Many chronic heart failure (CHF) patients take β-blockers. When such patients are hospitalized for decompensation, it remains unclear how ongoing β-blocker treatment will affect outcomes of acute inotrope therapy. We aimed to assess outcomes of SURVIVE patients who were on β-blocker therapy before receiving a single intravenous infusion of levosimendan or dobutamine.
Methods and results
Cox proportional hazard regression revealed all-cause mortality benefits of levosimendan treatment over dobutamine when the SURVIVE population was stratified according to baseline presence/absence of CHF history and use/non-use of β-blocker treatment at baseline. All-cause mortality was lower in the CHF/levosimendan group than in the CHF/dobutamine group, showing treatment differences by hazard ratio (HR) at days 5 (3.4 vs. 5.8%; HR, 0.58, CI 0.33–1.01, P = 0.05) and 14 (7.0 vs. 10.3%; HR, 0.67, CI 0.45–0.99, P = 0.045). For patients who used β-blockers (n = 669), mortality was significantly lower for levosimendan than dobutamine at day 5 (1.5 vs. 5.1% deaths; HR, 0.29; CI 0.11–0.78, P = 0.01).
Levosimendan may be better than dobutamine for treating patients with a history of CHF or those on β-blocker therapy when they are hospitalized with acute decompensations. These findings are preliminary but important for planning future studies.
Levosimendan; Dobutamine; Heart failure, congestive; Cardiac output, low; β-blockers, adrenergic
Heart failure is a common health problem with poor prognosis. The gold standard for diagnosis is echocardiography but it is not always reachable, especially in emergency conditions. NT-pro-brain natriuretic peptide (NT-proBNP) is a novel indicator for the diagnosis of heart failure and is being used in routine tests in emergency rooms. This study was conducted to compare NT-proBNP levels between hospitalized congestive heart failure (CHF) patients and outpatients.
This study was designed as a single-centre, prospective, and controlled trial. Blood samples and data were collected from a total of 119 patients with shortness of breath admitted to Department of Emergency, School of Medicine, Marmara University. Patients were primarily diagnosed with decompensated heart failure according to the Framingham criteria and aged above 18 years. A total of 92 patients were included in the study after exclusions. NT-proBNP measurements were made by immune fluorescent method. Available data were compared between hospitalized patients and outpatients.
NT-proBNP levels were significantly higher in hospitalized patients compared to outpatients, and this finding was correlated with the clinical status of the patients. The mean NT-proBNP value of the patients was 9741.9 ± 8973 pg/ml (range: 245-35000) while the mean NT-proBNP value of patients diagnosed with non-decompensated congestive heart failure was 688.9 ± 284.5 pg/ml (range: 115-1450.65).
NT-proBNP can be used as an easy diagnostic method for congestive heart failure. A certain cut-off value may be determined in further multi-centre controlled trials with larger patient groups.
NT-Pro-Brain Natriuretic Peptide; Heart Failure; Emergency
Dronedarone is a new multichannel blocking antiarrhythmic drug for treatment of atrial fibrillation (AF). In patients with recently decompensated congestive heart failure (CHF) and depressed LV function, the drug was associated with excess mortality compared with a placebo group. The present study aimed to analyse in detail the effects of dronedarone on mortality and morbidity in AF patients CHF.
Methods and results
We performed a post hoc analysis of ATHENA, a large placebo-controlled outcome trial in 4628 patients with paroxysmal or persistent AF, to evaluate the relationship between clinical outcomes and dronedarone therapy in patients with stable CHF. The primary outcome was time to first cardiovascular (CV) hospitalization or death. There were 209 patients with NYHA class II/III CHF and a left ventricular ejection fraction ≤0.40 at baseline (114 placebo, 95 dronedarone patients). A primary outcome event occurred in 59/114 placebo patients compared with 42/95 dronedarone patients [hazard ratio (HR) 0.78, 95% CI = 0.52–1.16]. Twenty of 114 placebo patients and 12/95 dronedarone patients died during the study (HR 0.71, 95% CI = 0.34–1.44). Fifty-four placebo and 42 dronedarone patients were hospitalized for an intermittent episode of NYHA class IV CHF (HR = 0.78, 95% CI = 0.52–1.17).
In this post-hoc analysis of ATHENA patients with AF and stable CHF, dronedarone did not increase mortality and showed a reduction of CV hospitalization or death similar to the overall population. However, in the light of the ANtiarrhythmic trial with DROnedarone in Moderate to severe CHF Evaluating morbidity DecreAse study, dronedarone should be contraindicated in patients with NYHA class IV or unstable NYHA classes II and III CHF.
Atrial fibrillation; Congestive heart failure; Dronedarone
Risk stratification in congestive heart failure (CHF) patients is based on a variety of clinical and laboratory variables. We analysed renal function, BNP, water composition, echocardiographic and functional determinations in predicting mid-term outcome in CHF patients discharged after decompensation.
Material and methods
All subjects with NYHA class II-IV were enrolled at hospital discharge. NYHA class, BNP, water body composition, non-invasive cardiac output and echocardiogram were analysed. Death, cardiac transplantation and hospital readmission for CHF were scheduled.
Two-hundred and thirty-seven (64.5% males, age 71.1±10.1) patients were discharged after obtaining normal hydration; left ventricular ejection fraction (LVEF) was 43.2±16.2%, cardiac output was 3.8±1.1 l/min and BNP at discharge resulted 401.3±501.7 pg/ml. During the 14-month follow-up 15 patients (6.3%) died, 1 (0.4%) underwent cardiac transplantation and 18 (7.6%) were readmitted for CHF (event group); in 203 (85.6%) no events were observed (no-event group). Higher NYHA class (2.1±0.7 vs. 1.9±0.4, p=0.01), BNP at discharge (750.2±527.3 pg/ml vs. 340.7±474.3 pg/ml, p=0.002) and impaired LVEF (33.7±15.7% vs. 44.5±15.8%, p=0.0001) and creatinine (1.7±0.6 vs. 1.2±0.8 mg/dl, p=0.004) were noticed in the event group. At multivariate Cox analysis LVEF (p=0.0009), plasma creatinine (p=0.006) and BNP at discharge (p=0.001) were associated with adverse mid-term outcome. Kaplan-Meier survival curves demonstrated that adding cut-off points for creatinine 1.5 mg/dl and discharged BNP of 250 pg/ml discriminated significantly prognosis (p=0.0001; log rank 21.09).
In predicting mid-term clinical prognosis in CHF patients discharged after acute decompensation, BNP at discharge ≥ 250 pg/ml added with plasma creatinine > 1.5 mg/dl are strong adverse predictors.
congestive heart failure; prognosis; natriuretic peptide
Cardiac asthma is common, but has been poorly investigated. The objective was to compare the characteristics and outcome of cardiac asthma with that of classical congestive heart failure (CHF) in elderly patients.
Prospective study in an 1,800-bed teaching hospital.
Two hundred and twelve consecutive patients aged ≥ 65 years presenting with dyspnea due to CHF (mean age of 82 ± 8 years) were included. Findings of cardiac echocardiography and natriuretic peptides levels were used to confirm CHF. Cardiac asthma patients were defined as a patient with CHF and wheezing reported by attending physician upon admission to the emergency department. The CHF group (n = 137) and the cardiac asthma group (n = 75), differed for tobacco use (34% vs. 59%, p < 0.05), history of chronic obstructive pulmonary disease (16% vs. 47%, p < 0.05), peripheral arterial disease (10% vs. 24%, p < 0.05). Patients with cardiac asthma had a significantly lower pH (7.38 ± 0.08 vs. 7.43 ± 0.06, p < 0.05), and a higher PaCO2 (47 ± 15 vs. 41 ± 11 mmHg, p < 0.05) at admission. In the cardiac asthma group, patients had greater distal airway obstruction: forced expiratory volume in 1 second of 1.09 vs. 1.33 Liter (p < 0.05), and a forced expiratory flow at 25% to 75% of vital capacity of 0.76 vs. 0.99 Liter (p < 0.05). The in-hospital (23% vs. 19%) and one year mortality (48% vs. 43%) rates were similar.
Patients with cardiac asthma represented one third of CHF in elderly patients. They were more hypercapnic and experienced more distal airway obstruction. However, outcomes were similar.
Population-based secular trends in survival of patients with congestive heart failure (CHF) are central to public health research on the burden of the syndrome.
Patients 35–79 years old with a CHF discharge code in 1995 or 2000 were identified in 22 Minneapolis-St. Paul hospitals. A sample of the records was abstracted (50% of 1995 records; 38% of 2000 records). A total of 2,257 patients in 1995 and 1,825 patients in 2000 were determined to have had a CHF-related hospitalization. Each patient was followed for one year to ascertain vital status.
The risk profile of the 2000 patient cohort was somewhat worse than that of the 1995 cohort in both sex groups, but the distributions of age and left ventricular ejection fraction were similar. Within one year of admission in 2000, 28% of male patients and 27% of female patients have died, compared to 36% and 27% of their counterparts in 1995, respectively. In various Cox regression models the average year effect (2000 vs. 1995) was around 0.75 for men and 0.95 to 1.00 for women. The use of angiotensin converting-enzyme inhibitors and beta-blockers was associated with substantially lower hazard of death during the subsequent year.
Survival of men who were hospitalized for CHF has improved during the second half of the 1990s. The trend in women was very weak, compatible with little to no change. Documented benefits of angiotensin converting-enzyme inhibitors and beta-blockers were evident in these observational data in both men and women.
Chronic heart failure (CHF) has a high morbidity and mortality. Chronic kidney disease (CKD) has consistently been found to be an independent risk factor for unfavorable cardiovascular (CV) outcomes. Early intervention on CKD reduces the progression of CHF, hospitalizations and mortality, yet there are very few studies about CKD as a risk factor in the early stages of CHF. The aims of our study were to assess the prevalence and the prognostic importance of CKD in patients with systolic CHF stages B and C.
This is a prospective cohort study, dealing with prognostic markers for CV endpoints in patients with systolic CHF (ejection fraction ≤ 45%).
CKD was defined as estimated glomerular filtration rate <60 mL/min/1.73 m2 and CV endpoints as death or hospitalization due to CHF, in 12 months follow-up. Eighty three patients were studied, the mean age was 62.7 ± 12 years, and 56.6% were female. CKD was diagnosed in 49.4% of the patients, 33% of patients with CHF stage B and 67% in the stage C. Cardiovascular endpoints were observed in 26.5% of the patients. When the sample was stratified into stages B and C of CHF, the occurrence of CKD was associated with 100% and 64.7%, respectively, of unfavorable CV outcomes. After adjustments for all other prognostic factors at baseline, it was observed that the diagnosis of CKD increased in 3.6 times the possibility of CV outcomes (CI 95% 1.04-12.67, p = 0.04), whereas higher ejection fraction (R = 0.925, IC 95% 0.862-0.942, p = 0.03) and serum sodium (R = 0.807, IC 95% 0.862-0.992, p = 0.03) were protective.
In this cohort of patients with CHF stages B and C, CKD was prevalent and independently associated with increased risk of hospitalization and death secondary to cardiac decompensation, especially in asymptomatic patients.
Congestive heart failure (CHF) is a leading cause of death in the United States affecting approximately 670,000 individuals. Due to the prevalence of CHF related issues, it is prudent to seek out methodologies that would facilitate the prevention, monitoring, and treatment of heart disease on a daily basis. This paper describes WANDA (Weight and Activity with Blood Pressure Monitoring System); a study that leverages sensor technologies and wireless communications to monitor the health related measurements of patients with CHF. The WANDA system is a three-tier architecture consisting of sensors, web servers, and back-end databases. The system was developed in conjunction with the UCLA School of Nursing and the UCLA Wireless Health Institute to enable early detection of key clinical symptoms indicative of CHF-related decompensation. This study shows that CHF patients monitored by WANDA are less likely to have readings fall outside a healthy range. In addition, WANDA provides a useful feedback system for regulating readings of CHF patients.
Health monitoring; Telemedicine; Wireless health; Congestive heart failure patients monitoring; Real-time feedback; Data integrity; Database backup
Rho kinases (ROCKs) are the best characterized effectors of the small G-protein RhoA, and play a role in enhanced vasoconstriction in animal models of congestive heart failure (CHF). This study examined if ROCK activity is increased in CHF and how it is associated with the outcome in CHF.
Methods and results
Patients admitted with CHF (n =178), disease controls (n =31), and normal subjects (n =30) were studied. Baseline ROCK activity was measured by phosphorylation of themyosin-binding subunit in peripheral leucocytes. The patients were followed up for 14.4 ± 7.2 months (range 0.5–26 months) or until the occurrence of cardiac death. The ROCK activity in CHF patients (2.93 ± 0.87) was significantly higher than that of the disease control (2.06 ± 0.38, P < 0.001) and normal control (1.57 ± 0.43, P < 0.001) groups. Similarly, protein levels of ROCK1 and ROCK2 as well as the activity of RhoA in CHF were significantly higher than in disease controls and normal controls (all P < 0.05). Dyspnoea at rest (β =0.338, P < 0.001), low left ventricular ejection fraction (β = –0.277, P < 0.001), and high creatinine (β =0.202, P =0.006) were independent predictors of the baseline ROCK activity in CHF. Forty-five patients died within 2 years follow-up (25.3%). Combining ROCK activity and N-terminal pro brain natriuretic peptide (NT-proBNP) had an incremental value (log rank χ2 =11.62) in predicting long-term mortality when compared with only NT-proBNP (log rank χ2 =5.16, P < 0.05).
ROCK activity is increased in CHF and it might be associated with the mortality in CHF. ROCK activity might be a complementary biomarker to CHF risk stratification.
Rho kinases; Congestive heart failure; Mortality
Congestive heart failure (CHF) is a common cause of hospitalization and has a poor prognosis. Specialized multidisciplinary clinics are effective in the management of CHF.
To measure time of admission to the specialized clinics and explore factors related to the time of admission to these clinics.
Patients who were newly admitted to one of six CHF multidisciplinary clinics in the province of Quebec were enrolled in the study. Data were collected from the common clinical database used at these clinics as well as from questionnaires administered to the patients.
A total of 531 patients with a mean age of 65.9 years were enrolled. Only 26% were women. The median duration of disease before admission to the CHF clinic was 1.2 years. The majority of patients (62%) were referred by a cardiologist or an internist, while 24% were referred by other specialists, and 14% by general practitioners. One-fifth of patients did not have regular follow-up for their CHF before being admitted to the clinic. Factors associated with shorter disease duration at admission to the clinic were referral by a specialist, not having regular medical follow-up for CHF, having a higher income and having visited the emergency room for CHF.
There may be a need to improve dissemination of information regarding availability and benefits of CHF clinics and criteria for referral.
Congestive heart failure; Multidisciplinary heart failure clinics; Referral
Congestive heart failure (CHF) is associated with cognitive deficits, particularly of memory and attention. The present study aims to clarify whether clinical treatment can reverse the attentional deficits of patients with CHF.
A convenience sample of 50 patients with CHF functional class IV and 30 elderly controls were recruited from a teaching hospital in Brazil. Participants received a clinical and cognitive examination that included the Mini-Mental State Examination (MMSE), Cambridge Cognitive Examination of the Elderly (CAMCOG), Digit Span, Digit-Symbol Substitution, and Letter Cancellation test. The cognitive performance of CHF patients was reassessed 6 weeks after the introduction of clinical treatment.
Twenty-seven CHF subjects had MMSE<24, compared to only 10 of the controls (p = 0.07). CHF patients also had lower CAMCOG scores (mean = 71.8) than controls (mean = 82.0; p < 0.01). Digit Span, Digit Symbol and Letter Cancellation scores were lower for patients with CHF than controls (p < 0.01). Similarly patients with CHF took longer to complete the Trail Making A (p = 0.07) and B (p < 0.01). CAMCOG scores and left ventricular ejection fraction were moderately correlated (rho = 0.4, p < 0.01). Nineteen patients were lost for follow-up (11 deceased). Clinical treatment was associated with significant improvement of cognitive scores, particularly on the Digit Symbol (p < 0.01) and Letter Cancellation Tests (p < 0.01). Digit Span, Digit Symbol, Letter Cancellation and Trail Making scores of treated CHF patients and controls were similar (p > 0.10).
CHF is associated with deficits in attention and psychomotor speed. These deficits improve with clinical treatment.
Dyspneic patients are commonly encountered by Emergency Medical Service (EMS). Frequent causes include Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). Measurement of peak expiratory flow rate (PEFR) has been proposed to help differentiate COPD from CHF. This prospective, cohort, pilot study was conducted to determine if PEFR in patients with an exacerbation of COPD were significantly different than CHF. Included were patients presenting with dyspnea plus a history of COPD and/or CHF. A PEFR was measured, values were compared to predicted average, and a percentage was calculated. Twenty-one patients were enrolled. Six had a diagnosis of COPD, 12 CHF; 3 had other diagnoses. Mean percentage of predicted PEFR with COPD was 26.36%, CHF 48.9% (P = 0.04). Patients presenting with acute COPD had significantly lower percentage of predicted PEFR than those with CHF. These results suggest that PEFR may be useful in differentiating COPD from CHF. This study should be expanded to the prehospital setting with a larger number of subjects.
Nesiritide is indicated in the treatment of acute decompensated heart failure. However, a recent meta-analysis reported that nesiritide may be associated with an increased risk of death. Our goal was to evaluate the impact of nesiritide treatment on four outcomes among adults hospitalized for congestive heart failure (CHF) during a three-year period.
CHF patients discharged between 1/1/2002 and 12/31/2004 from the Adventist Health System, a national, not-for-profit hospital system, were identified. 25,330 records were included in this retrospective study. Nesiritide odds ratios (OR) were adjusted for various factors including nine medications and/or an APR-DRG severity score.
Initially, treatment with nesiritide was found to be associated with a 59% higher odds of hospital mortality (Unadjusted OR = 1.59, 95% confidence interval [CI]: 1.31–1.93). Adjusting for race, low economic status, APR-DRG severity of illness score, and the receipt of nine medications yielded a nonsignificant nesiritide OR of 1.07 for hospital death (95% CI: 0.85–1.35). Nesiritide was positively associated with the odds of prolonged length of stay (all adjusted ORs = 1.66) and elevated pharmacy cost (all adjusted ORs > 5).
In this observational study, nesiritide therapy was associated with increased length of stay and pharmacy cost, but not hospital mortality. Randomized trials are urgently needed to better define the efficacy, if any, of nesiritide in the treatment of decompensated heart failure.
Obesity predisposes individuals to congestive heart failure (CHF) and cardiovascular disease (CVD). Leptin regulates energy homeostasis, is elevated in obesity, and influences ventricular and vascular remodeling. We tested the hypothesis that leptin levels are associated with greater risk of CHF, CVD, and mortality in elderly individuals.
RESEARCH DESIGN AND METHODS
We evaluated 818 elderly (mean age 79 years, 62% women) Framingham Study participants attending a routine examination at which plasma leptin was assayed.
Leptin levels were higher in women and strongly correlated with BMI (P < 0.0001). On follow-up (mean 8.0 years), 129 (of 775 free of CHF) participants developed CHF, 187 (of 532 free of CVD) experienced a first CVD event, and 391 individuals died. In multivariable Cox regression models adjusting for established risk factors, log-leptin was positively associated with incidence of CHF and CVD (hazard ratio [HR] per SD increment 1.26 [95% CI 1.03–1.55] and 1.28 [1.09–1.50], respectively). Additional adjustment for BMI nullified the association with CHF (0.97 [0.75–1.24]) but only modestly attenuated the relation to CVD incidence (1.23 [1.00–1.51], P = 0.052). We observed a nonlinear, U-shaped relation between log-leptin and mortality (P = 0.005 for quadratic term) with greater risk of death evident at both low and high leptin levels.
In our moderate-sized community-based elderly sample, higher circulating leptin levels were associated with a greater risk of CHF and CVD, but leptin did not provide incremental prognostic information beyond BMI. Additional investigations are warranted to elucidate the U-shaped relation of leptin to mortality.
Objectives: To determine clinical and prognostic differences between preserved and deteriorated systolic function (defined as left ventricular (LV) ejection fractions ⩾ 50% and < 50%, respectively) in patients with heart failure satisfying modified Framingham criteria.
Patients and methods: Records were studied of 1252 patients with congestive heart failure (CHF) (mean (SD) age 69.4 (11.7) years; 485 women, 767 men) who had been admitted to a cardiology service for CHF in the period 1991–2002 and whose LV systolic function had been echocardiographically evaluated within two weeks of admission. Data were collected on the main clinical findings, supplementary examinations, treatment, and duration of hospitalisation. Whether the patient was alive in the spring of 2003 was evaluated by searching the general archives of the hospital and by telephone survey.
Results: LV systolic function was preserved in 39.8% of patients. Age, female to male sex ratio, and prevalence of atrial fibrillation, valve disease, and other non-ischaemic, non-dilated cardiopathies were all significantly greater in the group with preserved systolic function. New York Heart Association functional class IV, third heart sound, jugular vein congestion, cardiomegaly, radiological signs of lung oedema, pathological Q waves, left bundle branch block, sinus rhythm, ischaemic cardiopathy, and dilated cardiomyopathy were all significantly more prevalent in the group with deteriorated systolic function, as was treatment with angiotensin converting enzyme inhibitors and most other antihypertensive drugs on discharge from hospital. There was no significant difference in survival between the groups with preserved and deteriorated systolic function (either survival regardless of age at admission or in subgroups aged < 75 and ⩾ 75 years at admission). In the whole group, survival rates after one, three, and five years were 84.0%, 66.7%, and 50.9%, respectively.
Conclusion: In view of the poor prognosis of patients with CHF with preserved LV systolic function, who are currently treated empirically, it is to be hoped that relevant controlled clinical trials under way will afford information allowing optimisation of their treatment.
heart failure; prognosis; preserved systolic function; deteriorated systolic function
Congestive heart failure (CHF) affects more than five million people in the US, and results in considerable morbidity, mortality, and economic costs. Patients with Class III and IV CHF have a 40–50% probability of dying 5 years after symptom onset despite optimal therapy, a prognosis worse than many cancers. A variety of drugs and devices have improved survival – the 50% survival time in 1980 was just eighteen months – but the outlook for patients remains dismal and the prevalence of CHF continues to increase. This unmet medical need underscores the importance of developing new approaches for the treatment of CHF. This brief review focuses on data from preclinical experiments regarding the effects of increased adenylyl cyclase type 6 (AC6) expression on cellular and cardiac function, and possible mechanisms for the unexpected favorable effects of increased AC6 content on the failing heart.
To study the feasibility of using electronic medical record (EMR) data from the Deliver Primary Healthcare Information (DELPHI) database to measure quality of care for patients with congestive heart failure (CHF) in primary care and to determine the percentage of patients with CHF receiving the recommended care.
Items listed on the Ontario Ministry of Health and Long-Term Care Heart Failure Patient Care Flow Sheet (CHF flow sheet) were assessed and measured using EMRs of patients diagnosed with CHF between October 1, 2005, and September 30, 2008.
Ten primary health care practices in southwestern Ontario.
Four hundred eighty-eight patients who were considered to have CHF because at least 1 of the following was indicated in their EMRs: an International Classification of Diseases billing code for CHF (category 428), an International Classification of Primary Care diagnosis code for heart failure (ie, K77), or “CHF” reported on the problem list.
MAIN OUTCOME MEASURES
Number of CHF flow sheet items that were measurable using EMR data from the DELPHI database. Percentage of patients with CHF receiving required quality-of-care items since the date of diagnosis.
The DELPHI database contained information on 60 (65.9%) of the 91 items identified using the CHF flow sheet. The recommended tests and procedures were recorded infrequently: 55.5% of patients with CHF had chest radiographs; 32.6% had electrocardiograms; 32.2% had echocardiograms; 30.5% were prescribed angiotensin-converting enzyme inhibitors; 20.9% were prescribed β-blockers; and 15.8% were prescribed angiotensin II receptor blockers.
Low frequencies of recommended care items for patients with CHF were recorded in the EMR. Physicians explained that CHF care was documented in areas of the EMR that contained patient identifiers, such as the encounter notes, and was therefore not part of the DELPHI database. Extractable information from the EMR does not provide a complete picture of the quality of care provided to patients with CHF.
Newer non-pharmacological therapies for heart failure are being evaluated for patients of congestive heart failure (CHF). Mechanical support with left ventricular assist devices and heart transplantation are reserved for the minority of patients who have severely decompensated heart failure. Despite these therapeutic advances, it is generally accepted that current therapies do not adequately address the clinical need of patients with heart failure, and additional strategies are being developed. Cardiac resynchronization therapy (CRT) is a new modality that involves synchronization of ventricular contraction and has shown a lot of promise in managing symptomatic patients of CHF who are on optimal medical therapy and have interventricular conduction delay (IVCD). It has improved exercise tolerance and NYHA functional class in such patients in sinus rhythm and a recent meta-analysis has also shown mortality benefits in CHF. Recently benefits of CRT have also been observed in CHF patients who do not have wide QRS complexes on electrocardiogram (EKG). It has also been shown to benefit drug refractory angina in CHF. Recent studies have also focused on the combined use of CRT and implantable cardioverter defibrillator (ICD) and it has shown encouraging results. Our aim in this descriptive review is to define practice guidelines and to improve clinicians' knowledge of the available published clinical evidence, concentrating on few randomized controlled trials.
Study objective: To describe seasonal congestive heart failure (CHF) mortality and hospitalisations in Quebec, Canada between 1990–1998 and compare trends in CHF mortality and morbidity with those in France.
Design: Population cohort study.
Setting: Province of Quebec, Canada.
Patients: Mortality data were obtained from the Quebec Death Certificate Registry and hospitalisation from the Quebec Med-Echo hospital discharge database. Cases with primary ICD-9 code 428 were considered cases of CHF.
Results: Monthly CHF mortality was higher in January, declined until September and then rose steadily (p<0.05). Hospital admissions for CHF declined from May until September (moving averages analysis p<0.0001). Seasonal mortality patterns observed in Quebec were similar to those observed in France.
Conclusion: CHF mortality in Quebec is highest during the winter and declines in the summer, similar to observations in France and Scotland. This suggests that absolute temperatures may not necessarily be that important but increased CHF mortality is observed once environmental temperatures fall below a certain "threshold" temperature. Alternatively better internal heating and warmer clothing required for survival in Quebec may ameliorate mortality patterns despite colder external environments.
In patients with congestive heart failure (CHF), a high prevalence of sleep-disordered breathing has been described. Cheyne-Stokes respiration (CSR) is present in up to 40% of patients with CHF. During the last decade, the medical treatment has been substantially improved. This study was designed to analyze the prognosis of CSR in modern-treated patients with CHF. For this purposes, in 57 patients with CHF who received modern treatment, a 5-year follow-up after initial full night polysomnography was performed. The mean follow-up period was 38 ± 18 months. Mean age was 62 ± 13 years and the mean ejection fraction was 25 ± 7 percent. Respiratory polygraphy revealed CSR with a respiratory disturbance index >5 per hour of sleep in 39 of 57 patients. Twelve patients died. CSR was only characterized by a tendency of worsening (log-rank test, p = 0.25). However, there was a significant difference toward positive outcome for patients who received cardiac resynchronization therapy (log-rank test, p = 0.036). Using Multivariate Cox’s proportional hazard regression with the factors resynchronization and CSR, the effect of resynchronization was almost significant (p = 0.08). In conclusion, no significant change of Cheyne-Stokes prevalence can be found in our small group of modern-treated patients with CHF. Cardiac resynchronization therapy was associated with improved patient outcome.
Cheyne-Stokes respiration; Chronic heart failure; Prognosis; Cardiac; Resynchronization therapy
Acute decompensation heart failure (ADHF) remains a cause of hospitalization in patients with end-stage congestive HF. The administration of levosimendan in comparison with a standard therapy in CHF patients admitted for ADHF was analysed.
Consecutive patients admitted for ADHF (NYHA class III–IV) were treated with levosimendan infusion 0.1 μg/kg/min or with furosemide infusion 100–160 mg per day for 48 hours (control group). All subjects underwent determination of brain natriuretic peptide (BNP), non-invasive cardiac output (CO), and echocardiogram at baseline, at the end of therapy and 1 week after therapy.
Seven patients admitted for 20 treatments in 16 months (age 66 years; mean admission/year 5.4) were treated with levosimendan and compared with 7 patients admitted for 15 treatments (age 69.1 years; mean admission/year 6.1). At the end of levosimendan therapy, BNP decreased (from 679.7±512.1 pg/ml to 554.2±407.6 pg/ml p=0.03), and 6MWT and LVEF improved (from 217.6±97.7 m to 372.2±90.4 m p=0.0001; from 22.8±9.1% to 25.4±9.8% p=0.05). Deceleration time, E/A, E/E’, TAPSE, pulmonary pressure and CO did not change significantly after levosimendan therapy and after 1 week. At follow-up, only 6-min WT and NYHA class showed a significant improvement (p=0.0001, p=0.001 respectively). The furosemide infusion reduced NYHA class and body weight (from 3.4±0.6 to 2.3±0.5 p=0.001; from 77.5±8.6 kg to 76±6.6 kg p=0.04), but impaired renal function (clearances from 56.3±21.9 ml/min to 41.2±10.1 ml/min p=0.04).
Treating end-stage CHF patients with levosimendan improved BNP and LVEF, but this effect disappeared after 1 week. The amelioration of 6MWT and NYHA class lasted longer after levosimendan infusion.
brain natriuretic peptide; end-stage heart failure; levosimendan
Studies on clinical features, treatment and prognosis of patients with congestive heart failure (CHF) and preserved left ventricular ejection fraction (LVEF) are few and their results frequently conflicting.
To investigate the characteristics and long term prognosis of patients with CHF and preserved (≥ 45%) LVEF.
Methods and Results:
We conducted a prospective multicentre study with 4720 patients attended in 62 heart failure clinics from 1999 to 2003 in Spain (BADAPIC registry). LVEF was preserved in 30% patients. Age, female gender, prevalence of atrial fibrillation, hypertension and non-ischaemic cardiopathy were all significantly greater in patients with preserved LVEF. Mean follow-up was 40±12 months. Mortality and other cardiovascular complication rates during follow up were similar in both groups. On multivariate analysis ejection fraction was not an independent predictor for mortality. Survival at one and five years was similar in both groups (79% and 59% for patients with preserved LVEF and 78% and 57% for those with reduced LVEF, respectively).
In the BADAPIC registry, a high percentage of heart failure patients had preserved LVEF. Although clinical differences were seen between groups, morbidity and mortality were similar in both groups.
Heart failure; preserved systolic function; multicentre study.
Congestive Heart Failure (CHF) is common and costly, and despite pharmacologic and technical advances, outcomes remain suboptimal.
To examine whether hospitals that have more experience caring for patients with CHF provide better, more efficient care.
We used national Medicare claims data from 2006–2007 to examine the relationship between hospitals’ case volume and quality, outcomes, and costs for patients with CHF.
4,095 U.S. hospitals
Medicare fee-for-service patients with a primary discharge diagnosis of CHF
Hospital Quality Alliance (HQA) CHF process measures, 30-day risk-adjusted mortality rates, 30-day risk-adjusted readmission rates, and costs per discharge.
Hospitals in the lowest volume group had lower performance on HQA measures than medium- or high-volume hospitals (80.2% versus 87.0% versus 89.1%, p<0.001). Within the low volume group, being admitted to a hospital with a higher case volume was associated with lower mortality, lower readmission, and higher costs. For example, in the lowest volume group of hospitals, an increase of 10 cases of CHF was associated with 1% lower odds of mortality, 1% lower odds of readmissions and $22 higher costs per case. We found similar though smaller relationships between case volume and both mortality and costs in the medium and high-volume hospital cohorts.
Our analysis was limited to Medicare patients 65 years of age or older; risk adjustment was performed using administrative data.
Experience with managing CHF, as measured by an institution’s volume, is associated with higher quality of care and better outcomes for patients, but at a higher cost. Understanding which practices employed by high-volume institutions account for these advantages can help improve quality of care and clinical outcomes for all CHF patients.
Congestive heart failure (CHF) is a common disease requiring admission to hospital among elderly people and is associated with a high mortality rate. The objective of this study was to examine trends in CHF mortality and admissions to hospital in Montreal between 1990 and 1997 for individuals aged 65 years or more.
We obtained information about deaths from the Quebec Death Certificate Registry database and information about admissions to hospital from the Québec Med-Écho database. Patients with a primary diagnosis that was classified as ICD-9 code 428 were considered cases of CHF.
Although age-adjusted rates of mortality from CHF did not change significantly between 1990 and 1997, the annual rate of admission to hospital for CHF increased from 92 per 10 000 population in 1990/91 to 124 per 10 000 population in 1997/98 (p < 0.01). Deaths due to CHF, expressed as a proportion of all cardiovascular deaths, increased among women from 5.6% in 1990 to 6.2% in 1997 (p = 0.01). The rate of readmission for all causes following a first admission for CHF during that year rose over the study period from 16.6% to 22.0% within one month (p < 0.001) and from 46.7% to 49.4% within 6 months (p = 0.03). Conversely, mean annual length of stay per admission decreased from 16.4 days in 1990/91 to 12.2 days in 1997/98.
The increase in rates of admission to hospital for CHF and the stable rates of CHF mortality suggest that the management of CHF and its antecedents has improved in recent years.
It is recommended that persons recently diagnosed with heart failure consult with a specialist in heart failure.
To determine whether patients who were diagnosed with new-onset chronic heart failure (CHF) by a noncardiologist consulted with a cardiologist, and identify the factors associated with delayed consultation.
Physician reimbursement administrative data were obtained for all adults with suspected new-onset CHF in the year 2000 in Quebec, defined operationally as a physician visit for CHF (based on the International Classification of Diseases, 9th Revision diagnostic codes), with no previous physician visit code for CHF in the preceding three years. Among those first diagnosed by a noncardiologist, Cox regression modelling was used to identify patient and physician characteristics associated with time to cardiology consultation.
Of the 13,523 persons coded as having incident CHF, 54.9% consulted a cardiologist within the next 2.5 to 3.5 years, and 67.4% were seen by an internist or cardiologist. Older patients, women, and those with lower comorbidity and socioeconomic status had significantly longer times to cardiology consultation.
The data suggest that many patients with suspected new-onset CHF do not receive prompt cardiology care, as stipulated by current recommendations. Equity of access for women and those with lower socioeconomic status appears to be problematic.
Congestive heart failure; Health policy; Referral to cardiologists