Innovative imaging methods in heart failure: a shifting paradigm in cardiac assessment. Position statement on behalf of the Heart Failure Association of the European Society of Cardiology

Myriad advances in all fields of cardiac imaging have stimulated and reflected new understanding of cardiac performance, myocardial damage and the mechanisms of heart failure. In this paper, the Heart Failure Association assesses the potential usefulness of innovative imaging modalities in enabling more precise diagnostic and prognostic evaluation, as well as in guiding treatment strategies. Many new methods have gradually penetrated clinical practice and are on their way to becoming a part of routine evaluation. This paper focuses on myocardial deformation and three-dimensional ultrasound imaging; stress tests for the evaluation of contractile and filling function; the progress of magnetic resonance techniques; molecular imaging and other sound innovations. The Heart Failure Association aims to highlight the ways in which paradigms have shifted in several areas of cardiac assessment. These include reassessing of the simplified concept of ejection fraction and implementation of the new parameters of cardiac performance applicable to all heart failure phenotypes; switching from two-dimensional to more accurate and reproducible three-dimensional ultrasound volumetric evaluation; greater tissue characterization via recently developed magnetic resonance modalities; moving from assessing cardiac function and congestion at rest to assessing it during stress; from invasive to novel non-invasive hybrid techniques depicting coronary anatomy and myocardial perfusion; as well as from morphometry to the imaging of pathophysiologic processes such as inflammation and apoptosis. This position paper examines the specific benefits of imaging innovations for practitioners dealing with heart failure aetiology, risk stratification and monitoring, and, in addition, for scientists involved in the development of future research.

Integration of imaging and circulating biomarkers in heart failure: a consensus document by the Biomarkers and Imaging Study Groups of the Heart Failure Association of the European Society of Cardiology

Circulating biomarkers and imaging techniques provide independent and complementary information to guide management of heart failure (HF). This consensus document by the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) presents current evidence-based indications relevant to integration of imaging techniques and biomarkers in HF. The document first focuses on application of circulating biomarkers together with imaging findings, in the broad domains of screening, diagnosis, risk stratification, guidance of treatment and monitoring, and then discusses specific challenging settings. In each section we crystallize clinically relevant recommendations and identify directions for future research. The target readership of this document includes cardiologists, internal medicine specialists and other clinicians dealing with HF patients.

Identification of novel splice mutation in SMAD3 in two Cypriot families with nonsyndromic thoracic aortic aneurysm. Two case reports

BACKGROUND

Thoracic aortic aneurysm and dissection (TAA/D) represents a potentially lethal disease group characterized by an increased risk of dissection or rupture. Only a small percentage (approximately 30%) of individuals with nonsyndromic familial TAA/D have a pathogenic variant in one of the genes that have been found to be associated with the disease.

METHODS

A targeted sequencing panel and direct sequencing approach were used to identify causative mutations in the index patients and other family members.

RESULTS

In this study we report two apparently unrelated Cypriot families with nonsyndromic familial TAA/D. The proband A is a female patient diagnosed with TAA/D and intracranial aneurysm and opted for an elective intervention. The proband B is a male patient who was diagnosed with TAA/D and underwent cardiac surgery. Sequencing analysis identified a novel splice site variant (c.871+1G>A) in SMAD3 which is shown to be associated with the disease. Analysis of mRNA from the patient's tissue confirmed aberrant splicing and exon 6 skipping.

CONCLUSION

Our findings expand the mutation spectrum of variants that have been shown to be associated with nonsyndromic familial TAA/D. This study demonstrates the importance of a comprehensive clinical and genetic evaluation aiming at early diagnosis and intervention.

[Genetic basis for malformation-associated uropathy and renal dysplasia]

The wide association between urinary tract malformations and dysplastic kidneys, known as CAKUT (Congenital Anomalies of the Kidney and Urinary Tract), could be caused by a single disorder of the embryonic development of the kidney and urinary tract. These complex patterns of development are under genetic control. A positive family history strongly suggests a genetic origin of these conditions. Linkage studies show an extreme genetic heterogenicity and an important phenotypic and clinical variability of the same mutation. Some urinary tract malformations have been investigated in the context of clinical syndromes. The renal-coloboma syndrome is an autosomal dominant human disease, secondary to mutation of the PAX2 transcription factor, characterized by optic nerve coloboma, renal anomalies and vesicoureteral reflux. However, most of the urinary tract anomalies can occur in isolation. Studies have shown the association of hereditary hydronephrosis with HLA antigens on chromosome 6 and the association of VUR with the mutations in a locus of chromosome 1. The higher frequency and severity of some uropathies in the male gender may be explained by a linkage-disequilibrium phenomenon or a X-linked transmission pattern. For example, the mutations in the AGTR2 gene on chromosome X were observed in animal models but not yet confirmed in human subjects. Finally, the ACE gene polymorphism is associated with a higher incidence of congenital hypo-dysplastic kidneys and represents a significant risk factor for the development of progressive renal damage.

2203It is more than simple interventions needed to improve heart failure patients health related quality of life

Background

In order to improve health-related quality of life (HR-QoL) of heart failure (HF) patients, different disease management programs have been developed at the discharged and follow-up phase.

Aim

To determine the effectiveness of a three-month telephone follow-up, a telephone follow-up with education before discharge, or education only before discharge (all performed by nurse specialists) on HR-QoL in HF patients. The results of the randomized clinical trial (RCT) MEETinCY are presented.

Method

This is a multicenter RCT with 3 different intervention groups (IGs) and one control group (CG) The first IG included only patients' education before discharge (E). The second IG included patients' education and telephone follow-up after discharge for three months (ET). The third IG included only telephone follow-up for three months (T). The Greek version of the MLHFQ was used. The statistical analysis of the impact of the intervention was done using ANCOVA. The magnitude of the effect of the intervention was studied with the Cohen's d coefficient for repeated measurements. The exploration of clinical and demographic factors in the relationship of HR-QoL was done by using linear coefficients of regression. The investigation of the robustness of the results and the intention to treat was carried out by sensitivity analysis. The management of missing value of the MLHFQ was done by using multiple imputation.

Results

The study included 334 patients. The analysis demonstrated that the study groups differentiates the level of HR-QoL post-intervention measurement in terms of the Overall QoL (F=2.8, 47, p=0.04). The mean level of Overall HR-QoL adjusted for the pre-intervention measurement, in the T: 40.3 (SE=2.2) and ET: 42 (2.2) groups was higher than that of the E group: 39 (2.2) and the CG: 47 (2). Study group differences were also detected statistically in the Social dimension (F=3.4, p=0.02) but not in in the Physical dimension (F=1.9, p=0.11) or the Emotional dimension (F=0.99, p=0.40). However, in the ET and T groups, higher adjusted average levels of the Physical and Social dimension are observed compared to the E and Control group. Overall, IGs exhibited low to moderate effect size improvements (drm = 0.4) while the CG had negligible improvement (drm = 0.02). Women exhibit lower overall HR-QoL scores compared to men by 13.9 points in the MLHFQ scale (b=13.9, p<0.015). NYHA IV (38.5, p<0.001), NYHA III (29.5, p<0.001) and NYHA II (9.15, p<0.001) patients exhibit worse overall HR-QoL compared to NYHA I patients.

Conclusion

Patients' education before discharge was not found to have an important role over the three- months telephone follow-up after discharge. On the other hand, improvement was found in patients who had the telephone intervention and the possibility to call researchers (nurses) whenever they needed. Patients seem to need continuing communication and support and to feel the availability of contacting and seeking help when needed.

Acknowledgement/Funding

Cyprus University of Technology's state funded budget [Startup Fund EX2007 (04)]

Supportive care reinforces telemonitoring in heart failure patients: pilot results of the “SupportHeart”

Introduction

Disease management programs for HF are characterized by heterogeneity and different levels of complexity, thus the results regarding of their effectiveness are controversial. The trajectory of HF makes supportive care (SC) mandatory. The main feature of this framework is continuing communication addressing patient's support needs.

Aim

To evaluate the effectiveness of an individualized SC management program.

Study design

This was a pilot study of a randomized control trial (RCT) [control group (CG) and intervention group (IG)], the “SupportHeart” to assess a SC management program for HF patients. Patients allocated in the IG received written material for HF self-management and the first brief educational session was conducted by a nurse in the bedside.

The intervention was consisted by monthly meetings including educational sessions about the HF syndrome, pharmacological and non- pharmacological treatment, self-management and physical activity (PA). The evaluation of the intervention included health-related quality of life (HR-QoL), self-care management, adherence to PA, anxiety and depression and perceived support. Furthermore, acute events (readmissions and deaths) were measured. Monthly phone calls were also contacted by the research team and patients could call them whenever they needed to. Statistical comparisons were performed and Kaplan Meir curves and the log-rank test (LRT) were utilised to explore the time until the first acute event.

Results

Thirty-five patients with HF participated in the study and the intervention lasted for six months (mth). A better HR-QoL was found for both groups in the sixth mth period with a difference in the social dimension of the HR-QoL favoring the IG. IG: baseline = 4.8 (4.9)/1st mth = 3.3 (3.5)/6th mth=2.8 (3.1), CG: baseline = 2.3 (1,1)/1st mth = 3.4 (2,7)/6th mth = 2.7 (2.8)]. Also, a difference in the sub-scale of family/significant others was indicated where the IG followed an increased trend [IG baseline = 50.9 (5.4)/6th mth = 52.7 (3.4)] [CG baseline = 50.3 (8.9)/6th mth = 49.9 (4.2)]. No difference was found for self-care management, except of the sub-dimension of PA and recognition of deteriorating symptoms favoring IG. IG: baseline = 11.7 (3.4)/1st mth = 13.1 (2.0)/6th mth = 13.6 (1.7). The survival of the CG was lower than that of the IG in 30 days: (LRT, χ2(1)=5.7, p=0.02), 90 days: (LRT, χ2(1)=12.3, p&lt;0.001) and 180 days: (LRT, χ2(1)=6.8, p=0.009).

Conclusion

This is the first RCT assessing the effectiveness of SC in HF and it seems to be a promising concept for HF management programs. There was a great effect in acute events as it was found a reduced risk by 87% for a patient receiving SC. Continuing communication which seems to be achievable through telehealth and phone follow-up incorporating patients' preferences, values, beliefs, illness understanding and information needs into the decision-making process and is shown to be a promising approach in the care of patients with HF.

Funding Acknowledgement

Type of funding sources: None.

Diabetes and female gender are found to increase the hazard of deterioration? Results from the MEETinCY trial

Background

Despite advances in the treatment of heart failure (HF), HF deteriorations are characterized by high hospital readmissions and linked with increased morbidity and mortality.

Aim

The aim of this study was to determine the effectiveness of a nurse-led management program on the reduction of the number of visits to ER, unplanned readmissions and mortality of patients with HF due to acute events of decompensation at 12 and 24-weeks post discharge. Secondary aim was to identify possible association between demographic or clinical characteristics and the hazard for acute events.

Methods

This study was designed as a multicenter single-blinded randomized clinical trial (RCT), The MEETinCY, with three different intervention groups (IGs) and one control group (CG) that received the usual care which did not include a structured educational programme. The first IG received only education (EE) before discharge, the second IG received only telephone follow-up (TT) for three months after discharge, the third IG included combination of education before discharge and telephone follow-up (ET) for three months after discharge. The efficacy of interventions on mortality and rehospitalization rates were estimated using a Kaplan Meier analysis and were compared with log rank test. The association of demographic and clinical characteristics to the hazard for acute events was explored using a multivariate Cox regression.

Results

Two hundred and forty-two (242) patients completed the study [CG n=68, EE n=57, ET n=59, TT n=58]. During the 90 and 180 days study periods, the intervention groups, although appearing to have a “better survival experience” than the CG, no statistically significant difference was found for the periods 90 (log-rank test, x2 = 3.7 p=0.28) and 180 (log rang x2=2.87, p=0.41) days. Regarding the incidence risk of acute events (Readmission, ER visit, HF death) at 3 months seems to be higher in the CG (N=28–41.2%) than the other groups [EE n:16 28.1%, ET n:20 33.9%, TT n:16 27.6%], but not statistically significant (p=0.32). Results at 6 months showed the frequency of acute events in the CG (N=34, 50%), to be lower compared to the other groups [EE N:23 40.4%, ET n:24 39%, TT n:25, 43.1%], but not statistically significant (p=0.59). The hazard of deterioration was found to be significantly higher in patients with diabetes and in females, where the acute event hazard increased by 72% [HR: 1.72 (95% CI: 1.047–2.844), p=0.033)], and 88% [HR: 1.88 (95% CI: 1.172–3.013), p=0.009)] respectively. In addition, NYHA status was found to be associated with increased hazard of acute events; NYHA IV patients had 2.6 times higher risk [HR: 2,637, (95% CI: 1,007 - 6,902)] than NYHA I patients.

Conclusions

This highlights the need for further investigation of educational and supportive programs to reduce the risk of incidence of acute events in HF. It is also important to identify possible associated factors that may be reversible or preventable.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Cyprus University of Technology State Funding

Age at diagnosis of vesicoureteric reflux after urinary infections: historical changes

AIM

Efforts are currently made to detect vesicoureteric reflux (VUR) early after urinary infections in order to limit secondary renal damage. This study investigated the extent to which recommendations for the detection of VUR are put into practice, and their influence on the age at diagnosis.

METHODS

The age at diagnosis of VUR after urinary tract infections was analysed in 126 patients (48M, 78F) referred to a tertiary centre in Milan between 1976 and 1999.

RESULTS

The median age at diagnosis was 34 mo in subjects born before and 8 mo (p < 0.001) in those born after 1988. The difference was statistically significant in female but not in male subjects. The figures from Milan were compared with those for 102 patients (35M, 65F) born between 1946 and 1970, treated in Melbourne and reported in 1976. In Melbourne the median age at diagnosis was 1-2 y for boys and 5-6 y for girls; in Milan, the corresponding figures were <1 y and 1-2 y. The difference between Melbourne and Milan was statistically significant for both genders.

CONCLUSION

In Milan VUR is now detected earlier than in the past. This trend is more marked in females than in males, but reflux is still detected earlier in boys.