Cardiac Heart Failure Patients Research Articles

SMOOTHING THE MOVE FROM POST-ACUTE TO HOME CARE FOR OLDER CARDIAC PATIENTS: A SOCIAL WORK TRANSITIONS INITIATIVE

Transitioning across medical settings (e.g. from hospital to post-acute (PA) or PA to homecare (HC)) is a difficult time with numerous challenges, as critical information passes across sites, new systems are quickly established, and caretakers change. Older cardiac heart failure (CHF) patients, often with comorbidities and having fewer social supports, are especially vulnerable to rehospitalizations at that time. This study examines the impact of a Social Work Transitions (SWT) intervention, designed to ease older cardiac patients’ transition from a PA to HC setting, on rehospitalization rates. The SWT model for CHF patients was developed in a large healthcare system with a continuum of services for older adults including PA and HC. Once a patient enters PA from the hospital a transitions social worker (SW) remains the patient’s primary support and contact through PA discharge and the transition to HC. In HC, that same SW ensures needed services occur, conducts home visits, and provides additional follow-up via phone calls. Study 1: compared HC rehospitalization rates of CHF patients receiving SWT (N=28) with those not receiving SWT (N=26). This natural control group arose during the initial program months, as SW turnover occurred and some CHF patients were not accompanied by a transitions SW. SWT patients had half the rehospitalizations (25%) as controls (54%). Study 2 tracked 30 day rehospitalizations rates for the first 17 study months (N=257). Program rehospitalization rates (16.7%) were below the CMS benchmark (21%). These findings support using the SWT program to prevent unnecessary rehospitalizations in CHF patient.

ASSESSMENT OF CARDIAC HEART FAILURE AND CARDIAC ARTERY DISEASE BY THE HIGHER ORDER SPECTRA

Cardiac diseases are major reason of death in the world populace and the numeral of cases is upsurging every year. Due to cardiac artery disease (CAD), the strength of heart muscles becomes weak and heart pumping is disturbed which may eventually lead to abnormal heart beat and heart failure. Therefore, the beginning stage detection of CAD and cardiac heart failure (CHF) are of prime importance. In this work, we have used a non-invasive diagnosis method as higher order spectra (HOS) for assessment of cardiac diseases. The method indicates whether or not a cardiac heart disease is present, by assessing the cardiac health of subjects using extracted features from heart rate variability (HRV) signals. This assessment is based on 10 spectra nonlinear features. These features were extracted from HRV signals by using the HOS method. For this study, the R-R interval data (i.e. HRV signals) were taken from the standard database of cardiac heart failure (CHF), CAD patients, healthy young (YNG) and Self recorded of healthy young (SELF_YNG) subjects. Statistical assessments were performed on the group of database sets as YNG-CAD, YNG-CHF, SELF_YNG-CAD and Self_YNG-CHF subjects. A Wilcoxon rank sum test ([Formula: see text]-value) was used to statistically compare the features extracted by HOS for group of data sets. It indicates whether or not the same features of individual classes of HRV data sets are dissimilar. The results depicted that the all features are very significant ([Formula: see text]) except the phase entropy (PHE) feature which is not significant for CAD-CHF, SELF_YNG-CAD and SELF_YNG-CHF group of subjects. While in the case of YNG-CAD group of subjects, features like first-order spectral moment of amplitudes of diagonal elements (H3), PHE and logarithmic amplitudes of diagonal elements (H2) are significant ([Formula: see text]) and excluding these features, the remaining features are very significant except MM and H1 which are not significant. The results also depicted that the mean value of sum of logarithmic amplitude (H1), H2, normalized entropy (P1), normalized squared entropy (P2) and PHE features of healthy YNG subjects are having higher values than that of CAD and CHF patients. While weighted center of bi-spectrum (WCOB2) and FLAT spectrum features are lower than CAD and CHF patients compared to YNG subjects. In case of CAD and CHF patients, all the features of CAD patients are having higher values compared to CHF except P1, P2 and WCOB1.

Congestive Cardiac Heart failure patients in the community: successfully managing complexity and polypharmacy

An introduction: (comprising context and problem statement) Congestive heart failure (CHF) is a chronic progressive condition that affects the pumping power of heart muscles which results in fluid builds up around the heart and causes it to pump inefficiently. Patients who develop decompensated CHF need to attend daily clinics in the hospital and are frequently admitted to hospital for periods of at least 2 days. Short description of practice change implemented: In consultation with nurse specialists, consultant cardiologist and the Community Intervention Team (CIT) a care pathway is developed for the patient’s treatment in the community, supported by electronic health records. Sample case study to highlight practice change: Patient prescribed intravenous (IV) frusemide in Outpatients. Referral and prescription electronically sent to CIT. IV medication is administered in patients’ home 2 days a week. Only 1 visit per week is now required to the CHF clinic. Patient is monitored and educated on the efficiency of the medication. Patient and family / carers are educated in what to look for in case of worsening symptoms. There is frequent feedback from the CIT to the hospital on the patient’s condition. Achieving the objectives: Safe management of CHF patients in the community: Symptoms that previously required admission to the acute setting are observed earlier in the home and acted upon thus reducing the opportunity for problems to build up. Consequent reduction in admissions to acute settings: Quality of patients’ life improved significantly, measured by the reduction of IV treatment, massive reduction of oedema and related discomfort; independence gained in activities of daily living (ADL’s). Aim and theory of change: The close IT-enabled communication between hospital and community ensures that all clinicians involved with the patients’ treatment are aware of changes in condition and treatment. This holistic approach avoids admission to hospital. Targeted population and stakeholders: CHF patient population deemed suitable for management in the community as identified by cardiologist and CHF nurse. Stakeholders: Primary: community intervention team (CIT), GP, public health etc. Secondary: Cardiac Failure Nurse specialists, outpatient departments, consultants etc. Highlights: (innovation, Impact and outcomes) The integrated care approach for a CHF patient is the first of its kind in this community, with high patient and clinician satisfaction. CHF patients are often referred to as palliative as their medical condition is irreversible. However quality of life and longevity can be achieved on this programme through the close monitoring of the patient at home, compatibility with other medication, reduced chance of the patient acquiring hospital infection superimposing on top of their CHF condition thus weakening overall health This intervention is both sustainable and transferable to other CHF patients throughout the country. Discussion and conclusion: Problems arising from CHF are multi-faceted as they vary from shortness of breath, reduced mobility, to fatigue etc. Managing this complexity in the community requires excellent integrated care between primary and secondary providers. Lessons Learned: Communication between primary and secondary healthcare professionals is essential to keeping patients in the community.

Oxygen pulse profile do not predict the response to exercise training

The gain of peak VO 2 after exercise training has prognostic value in cardiac heart failure (CHF) patients. The predictive factors influencing this response remain debated. As oxygen pulse is correlated with the stroke volume, it could reflect cardiac adaptation during exercise. The aim of this study is to evaluate the cardiac function in benefits of exercise training (ET). We included prospectively 53 CHF patients (mean age 57 ± 12 years, LVEF 29 ± 6%) who underwent two cardiopulmonary exercises (CPX): before and after 20 endurance exercise training sessions. We analyzed for the two CPX heart rate, workload, VO 2 , oxygen pulse and calculated stroke volume and cardiac output at rest, anaerobic threshold (AT) and peak exercise. We measured BNP levels before and after the exercise-training program. Patients were considered as responders if the gain of peak VO 2 was > 10%. Mean change in peak VO 2 after exercise training is 17% for global population, 36% for responders ( n = 27) and –4% for non-responders ( n = 26). At baseline, responder patients have a lower workload at AT and at peak exercise (52.6 ± 19 vs. 62.2 ± 17 W, P = 0.035 and 68.9 ± 28 vs. 86.6 ± 27 W, P = 0.035); a lower peak oxygen uptake (14.8 ± 4.8 vs. 17.5 ± 4.6 mL/kg/min, P = 0.04), a chronotopic incompetence (max heart rate 99.8 ± 19.8 vs. 116 ± 2 beats/min, P = 0.01), a lower maximal cardiac output (6.6 ± 2.5 vs. 8.0 ± 2.3 L/min, P = 0.019) and a higher BNP serum level (median 506 vs. 279 pg/L, P = 0.019). However, oxygen pulse trends or left ventricular function do not influence changes in peak VO2 at any time and regardless of the training type (continuous vs. interval training). Cardiac adaptations in CHF patients do not seem to play a major role in the response to exercise. Benefits of exercise training on exercise tolerance in CHF patients are mainly due to peripheral improvements.

Effects of combined exercise training and electromyostimulation treatments in chronic heart failure: A prospective multicentre study.

Background Exercise training as part of a comprehensive cardiac rehabilitation is recommended for patients with cardiac heart failure. It is a valuable method for the improvement of exercise tolerance. Some studies reported a similar improvement with quadricipital electrical myostimulation, but the effect of combined exercise training and electrical myostimulation in cardiac heart failure has not been yet evaluated in a large prospective multicentre study. Purpose The aim of this study was to determine whether the addition of low frequency electrical myostimulation to exercise training may improve exercise capacity and/or muscular strength in cardiac heart failure patients. Methods Ninety-one patients were included (mean age: 58 ± 9 years; New York Heart Association II/III: 52/48%, left ventricular ejection fraction: 30 ± 7%) in a prospective French study. The patients were randomised into two groups: 41 patients in exercise training and 50 in exercise training + electrical myostimulation. All patients underwent 20 exercise training sessions. In addition, in the exercise training + electrical myostimulation group, patients underwent 20 low frequency (10 Hz) quadricipital electrical myostimulation sessions. Each patient underwent a cardiopulmonary exercise test, a six-minute walk test, a muscular function evaluation and a quality of life questionnaire, before and at the end of the study. Results A significant improvement of exercise capacity (Δ peak oxygen uptake+15% in exercise training group and +14% in exercise training + electrical myostimulation group) and of quality of life was observed in both groups without statistically significant differences between the two groups. Mean creatine kinase level increased in the exercise training group whereas it remained stable in the combined group. Conclusions This prospective multicentre study shows that electrical myostimulation on top of exercise training does not demonstrate any significant additional improvement in exercise capacity in cardiac heart failure patients.

Benefits of Cardiovascular Rehabilitation of Insufficient Cardiac to the Institute of Cardiology of Abidjan

Objective: Our work aims to propose a simplified approach by the cardiovascular rehabilitation for the cardiac heart failure. Method and Patients: We realized an observational prospective study during 12-month period which included 85 cardiac heart failure patients at Abidjan Cardiology Institute. Results: 85 patients were included in our study; the average age was 45 ± 20 years. The ratio-sex (men/woman) was to 2. Six patients abandoned the study due to financial issues so that we continued the study with 79 patients. According to the stage of cardiac failure by New York Heart Association (NYHA): after the cardiac rehabilitation, the values of P (P = 0.000) confirmed that the rehabilitation improved considerably the potency tolerance. 60 patients (75%) were at the NYHA II, III stages. According to potency test results, rehabilitation improved significantly the patients potency in watt of the (P = 0.000). According to left ventricle ejection fraction: rehabilitation improved patients cardiac output. Variability rate was 50% for the cardiac output between 20% - 30% and 30% - 40%. Conclusion: In addition to drug therapy, cardiovascular rehabilitation is now recognized in the management of heart failure. Improvements of signs and patients’ life quality remain the major benefits of Cardiovascular Rehabilitation and the reduction of hospitalizations and mortality.

Can 123 I-MIBG cardiac scintigraphy predict functional recovery in heart failure after cardiac resynchronization?

Background: Cardiac heart failure patients may benefit from cardiac resynchronization, but around 30% do not respond. Several parameters have been studied to evaluate possible positive predictive factors. Aim: To evaluate if baseline 123 I-MIBG cardiac scintigraphy parameters can predict functional capacity modification after cardiac resynchronization (CRT), assessed by cardiopulmonary testing, in patients (P) with chronic heart failure (CHF). Methods: We prospectively assessed 49 consecutive CHF P referred to CRT, mean age 68±14 (34-82 years old), 68% male, LVEF<35%; 28% ischemic cardiomyopathy P and 72% nonischemic cardiomyopathy P; 37% diabetic P; 43% P class III and 57%≤ class II (NYHA). All patients underwent, before CRT and 6 months post-CRT, echocardiogram for left ventricular ejection fraction (LVEF), cardiopulmonary testing, CPT, for peak oxygen consumption (VO2p), and 123 I-MIBG cardiac scintigraphy, for early heart-mediastinum rate (HMR), late HMR and washout (WO). Results: Our preliminary results showed, mean LVEF 27±8%; VO2p mean value 14.8±5.5 ml/kg/min. Regarding 123 I-MIBG scintigraphy parameters, we found early HMR mean value 1.5±0.17 (75% P with early HMR < 1.6); late HMR mean value 1.4+/0.16, (94% P with late HMR<1.6); washout (WO) mean value 41±27. VO2 change after CRT at 6 months was positive in 68% of the P (mean variation +4.3+/2.7 ml/kg/min), group A, and negative in 32% of the P (mean variation -3.4+/2.3), group B. There was a very significant difference between VO2 variation in group A and B (p 1.6 (100%) had a positive VO2 variation (group A); P with baseline early HMR <1.6, had negative VO2 variation in 60% (group B) and positive in 40% (group A).Considering early HMR<1.5, 88% P had negative VO2 variation (group B). No significant differences were found in the late HMR, WO and LVEF. Conclusion: In this heart failure patients group, ischemic and nonischemic, baseline MIBG early heart-mediastinum rate was predictive of functional capacity modification: early HMR superior to 1.6 was always associated to VO2 increase after CRT (100% P); contrarly, early HMR inferior to 1.5 was mostly associated to VO2 decrease (88% P).

Acute effects of cardiac resynchronization therapy on arterial distensibility and serum norepinephrine levels in advanced heart failure

Cardiac resynchronization therapy (CRT) has become an accepted method for treating refractory heart failure (HF). Arterial distensibility is an index of arterial stiffness and a surrogate marker for atherosclerosis. The present study aims to assess the acute effects of ventricular resynchronization therapy with biventricular stimulation on arterial distensibility, echocardiographic parameters and serum norepinephrine levels in patients with drug refractory HF. Fourteen cardiac HF patients (53.6 ± 9.1; 39-67 years, 7 woman) were enrolled for CRT. Patients had an advanced cardiac HF (NYHA III-IV functional class) due to non-ischemic dilated cardiomyopathy, with a left ventricular ejection fraction (LVEF) < 35% and QRS duration ≥120 ms. Blood samples for norepinephrine and B-type natriuretic peptide were collected before 24 h biventricular implantation and after 48 h of CRT. Transthoracic echocardiography was used to evaluate arterial distensibility and cardiovascular condition. Although systolic blood pressure, diastolic blood pressure, LV end-diastolic diameter, LV end-systolic diameter, serum B-type natriuretic peptide, and serum norepinephrine levels significantly decreased after CRT implantation; EF and aortic distensibility significantly increased (p < 0.05). There was no significance in the hemodynamic and echocardiographic values, norepinephrine and B-type natriuretic peptide levels in pre- and post-CRT between man and woman. The major findings of this study are that in patients with cardiac HF in acute period, after implantation of CRT serum norepinephrine levels decrease and the arterial distensibility improves.

Sarcopenia, Cachexia and Congestive Heart Failure in the Elderly

Skeletal muscle abnormalities and loss are frequently present in patients with mild or moderate cardiac heart failure (CHF) and may contribute to fatigue and dyspnea. These muscle abnormalities may be associated with age related body composition changes, such as sarcopenia. Muscle damage has also been observed in subjects with cardiac cahexia, a serious CHF complication, associated with poor prognosis independently of functional disease severity, age, and measures of exercise capacity and cardiac function. Loss of muscle mass is a feature of cachexia, whereas most sarcopenic subjects are not cachectic. Individuals with no weight loss, no anorexia, and no measurable systemic inflammatory response may be sarcopenic. Patients with severe CHF show multiple marked histological abnormalities of skeletal muscle, such as muscle fiber atrophy. These abnormalities are different in sarcopenia and cachexia. The majority of mechanisms involved in sarcopenia play a role even in the determination of cachexia and they are amplified in cachexia where they may induce both muscle damage as well as other abnormalities, such as fat and weight loss, through activation of lypolisis or anorexia. To distinguish cachexia and sarcopenia in CHF patients, even if not easy, should be clinically relevant, because no specific treatment is available for cachectic patients whereas treatment options are possible for sarcopenia.

Myocardial scar sizing and characterization predicts ventricular arrhythmia in cardiac resynchronization therapy candidates

Methods A standard Contrast-enhanced Cardiac Magnetic Resonance (ce-CMR) was performed pre-implantation of CRT device in 78 cardiac heart failure patients (64±11 years) with ischemic and non-ischemic dilated cardiomyopathy. Systolic function was assessed by cine imaging. Myocardial scar was characterized by a standard 2D segmented gradient echo inversion-recovery sequence applied in sequential short axis slices. Total scar was expressed as percentage of LV mass and the core and border zone as percentage of total scar). Patients were followed every 6 months to look for appropriate ICD therapy episodes. Results During a mean follow up of 25 months (percentile 25 th 75 th =15-34 months), appropriate therapy of ICD devices occurred in 11.5% of patients. The analysis showed that the percentage of total scar was a strong predictor of VA (ventricular fibrillation or ventricular tachycardia) needing ICD therapy (HR 1.096 [1.053 to 1.143], p <0.001). In a Cox regression model adjusted for systolic function, etiology and type of prevention, the predictive value of the size of the scar remained unchanged (HR 1.156 [1.063 to 1.257], p = 0.001). The percentage of border zone of the scar was also associated with the occurrence of VA (HR 1.063 [1.022 to 1.101], p <0.001). However, the proportion of core was not significant (p = 0.662). The area under the ROC curve of total scar to predict VA was 0.94, and a cut-off value of <16% of LV mass had a 100% negative predictive value to exclude VA during follow-up. Conclusions In TRC candidates with dilated cardiomyopathy of any etiology the extent of myocardial scar and the proportion of border zone predict the occurrence of VA. Assessment of scar burden and scar characterization using ce-CMR may be helpful to decide when combined ICD/CRT devices are indicated among CRT candidates.

Heart Failure and Hyperphosphorylation

The ryanodine receptor 2 (RyR2) provides the major source of calcium for excitation-contraction coupling in the heart. This receptor consists of four RyR2 subunits and four FKBP12.6 subunits. Marx et al . show that the RyR2 subunits are phosphorylated in vitro and in vivo by protein kinase A (PKA), which leads to dissociation of the FKBP12.6 subunits, which results in alterations in the electrophysiological properties of these calcium-release channels. Furthermore, the same altered biophysical properties occur in cardiac heart failure and are associated with hyperphosphorylation of the RyRs and decreased association with the regulatory subunit FKBP12.6. The authors demonstrate that the RyRs are in a large macromolecular complex that includes the RyR, FKBP12.6, PKA, protein phosphatases (PPA and PP2A), and the anchoring protein mAKAP. The mechanism described for physiological regulation of the RyR2 by PKA-controlled FKBP12.6 binding and the discovery of PKA-hyperphosphorylated RyRs in cardiac heart failure patients has important implications for using drugs that alter β-adrenergic receptor signaling in the treatment of this life-threatening disease. Marx, S.O., Reiken, S., Hisamatsu, Y., Jayaraman, T., Burkhoff, D., Rosemblit, N., and Marks, A.R. (2000) PKA phosphorylation dissociates FKBP12.6 from the calcium release channel (ryanodine receptor): Defective regulation in failing hearts. Cell 101 : 365-376. [Online Journal]