Congestive Heart Failure Mortality Research Articles

Prevalence and Prognostic Significance of Apparent Treatment Resistant Hypertension in Chronic Kidney Disease: Report From the Chronic Renal Insufficiency Cohort Study.

The association between apparent treatment resistant hypertension (ATRH) and clinical outcomes is not well studied in chronic kidney disease. We analyzed data on 3367 hypertensive participants in the Chronic Renal Insufficiency Cohort (CRIC) to determine prevalence, associations, and clinical outcomes of ATRH in nondialysis chronic kidney disease patients. ATRH was defined as blood pressure ≥140/90 mm Hg on ≥3 antihypertensives, or use of ≥4 antihypertensives with blood pressure at goal at baseline visit. Prevalence of ATRH was 40.4%. Older age, male sex, black race, diabetes mellitus, and higher body mass index were independently associated with higher odds of having ATRH. Participants with ATRH had a higher risk of clinical events than participants without ATRH-composite of myocardial infarction, stroke, peripheral arterial disease, congestive heart failure (CHF), and all-cause mortality (hazard ratio [95% confidence interval], 1.38 [1.22-1.56]); renal events (1.28 [1.11-1.46]); CHF (1.66 [1.38-2.00]); and all-cause mortality (1.24 [1.06-1.45]). The subset of participants with ATRH and blood pressure at goal on ≥4 medications also had higher risk for composite of myocardial infarction, stroke, peripheral arterial disease, CHF, and all-cause mortality (hazard ratio [95% confidence interval], (1.30 [1.12-1.51]) and CHF (1.59 [1.28-1.99]) than those without ATRH. ATRH was associated with significantly higher risk for CHF and renal events only among those with estimated glomerular filtration rate ≥30 mL/min per 1.73 m(2). Our findings show that ATRH is common and associated with high risk of adverse outcomes in a cohort of patients with chronic kidney disease. This underscores the need for early identification and management of patients with ATRH and chronic kidney disease.

Evolution and Impact of a Regional Reperfusion System for ST-Elevation Myocardial Infarction

BackgroundWe describe the evolution of a regional system designed to provide primary percutaneous coronary intervention (pPCI) as the preferred method of revascularization for ST-elevation myocardial infarction (STEMI) and its impact on first medical contact (FMC)-to-device times and in-hospital outcomes. MethodsPatients with STEMI presenting to the Vancouver Coastal Health Authority between June 2007 and January 2015 (N = 2503) were categorized according to 3 sequential phases: phase 1 = standardization of reperfusion algorithms; phase 2 = use of prehospital electrocardiograms; phase 3 = expedited interfacility transfer for pPCI. In-hospital outcomes by phase and hospital type were analyzed using multivariable logistic regression techniques. ResultsRegional pPCI use increased across phases (55.0% vs 72.5% vs 86.7%; P < 0.001) and median FMC-to-device times shortened between phase 1 and later phases at both PCI-capable (117 minutes vs 92 minutes vs 97 minutes, respectively; P < 0.001) and non-PCI–capable hospitals (174 minutes vs 146 minutes vs 123 minutes, respectively; P < 0.001). Overall in-hospital mortality (9.4% vs 8.9% vs 10.3%, respectively; P = 0.54) and congestive heart failure (CHF) (15.8% vs 19.7% vs 22.0%, respectively; P = 0.056) were unchanged across phases. A trend toward increased mortality (9.0% vs 9.3% vs 12.9%, respectively; P = 0.079) and higher rates of CHF (15.7% vs 21.5% vs 25.9%, respectively; P = 0.014) were seen in PCI-capable hospitals. ConclusionsOur regional STEMI model increased access to pPCI and reduced median reperfusion times. However, FMC-to-device times remained prolonged in many patients and overall clinical outcomes were not improved—in particular at PCI-capable hospitals. A strategy of pPCI as the preferred method of reperfusion may not benefit all patients in a regional model of STEMI care.

Severity of Mitral Valve Degeneration Is Associated with Chromosome 15 Loci in Whippet Dogs.

Mitral valve degeneration (MVD) is the most common form of heart disease in dogs, frequently leading to left-sided congestive heart failure and cardiac mortality. Although breed-specific disease characteristics and overrepresentation point towards a genetic origin for MVD, a causative mutation and complete molecular pathogenesis are unknown. Whippet dogs are overrepresented in incidence of MVD, suggesting an inherited component in this breed. Expressivity of this condition is variable with some dogs showing evidence of more severe disease at earlier ages than other dogs. This phenomenon makes a traditional case versus control genetic study prone to phenotyping error. This study sought to avoid these common pitfalls by identifying genetic loci associated with severity of MVD in Whippets through a genome-wide association study (GWAS). 138 Whippet dogs were characterized for MVD by echocardiographic examination and a novel disease severity score was developed and adjusted for age in each subject. Single nucleotide polymorphism (SNP) genotype data (170k Illumina CanineHD SnpChip) was obtained for DNA isolated from blood of each study subject. Continuous variable genome wide association was performed after correction for population stratification by efficient mixed model association expedited (EMMAX) in 130 dogs. A genome wide significant association was identified on chromosome 15 (peak locus 57,770,326; Padj = 0.049) and secondary loci of suggestive association were identified on chromosome 2 (peak locus 37,628,875; Padj = 0.079). Positional candidate genes were identified within the primary and secondary loci including follistatin-related protein 5 precursor (FSTL5) and Rho GTPase-activating protein 26 (ARHGAP26). These results support the hypothesis that severity of MVD in whippets has a genetic basis and warrants further study by either candidate gene sequencing or next-generation techniques.

The Role of I-123 Metaiodobenzylguanidine Imaging in Management of Patients With Heart Failure

Despite advances in evidence-based treatments, the morbidity and mortality of congestive heart failure remain exceedingly high. In addition, the costs associated with recurrent hospitalizations and advanced therapies, such as implantable cardiac defibrillators (ICDs), left ventricular assist devices, and heart transplantation, place a substantial financial burden on the health care system. The present criteria for risk stratification in patients with heart failure are inadequate and often prevent the allocation of appropriate treatment. Patients who have received ICDs as primary prevention for sudden cardiac death often receive no device therapy in their lifetime, whereas other patients with left ventricular dysfunction die suddenly without meeting criteria for ICD implantation.

Comparative risk of renal, cardiovascular, and mortality outcomes in controlled, uncontrolled resistant, and nonresistant hypertension

We sought to compare the risk of end stage renal disease (ESRD), ischemic heart event (IHE), congestive heart failure (CHF), cerebrovascular accident (CVA), and all-cause mortality among 470,386 individuals with resistant and nonresistant hypertension (non-RH). Resistant hypertension (60,327 individuals) was sub-categorized into 2 groups; 23,104 patients with cRH (controlled on 4 or more medicines) and 37,223 patients with uRH (uncontrolled on 3 or more medicines) in a 5 year retrospective cohort study. Cox proportional hazard modeling was used to estimate hazard ratios adjusting for age, gender, race, body mass index, chronic kidney disease (CKD), and co-morbidities. Resistant hypertension (cRH and uRH) compared to non-RH, had multivariable adjusted hazard ratios (95% confidence intervals) of 1.32 (1.27–1.37), 1.24 (1.20–1.28), 1.46 (1.40–1.52), 1.14 (1.10–1.19), and 1.06 (1.03–1.08) for ESRD, IHE, CHF, CVA, and mortality, respectively. Comparison of uRH to cRH had hazard ratios of 1.25 (1.18–1.33), 1.04 (0.99–1.10), 0.94 (0.89–1.01), 1.23 (1.14–1.31), and 1.01 (0.97–1.05) for ESRD, IHE, CHF, CVA, and mortality, respectively. Males and Hispanics had greater risk for ESRD within all 3 cohorts. Resistant hypertension had greater risk for ESRD, IHE, CHF, CVA, and mortality. The risk of ESRD and CVA and were 25% and 23% greater, respectively, in uRH compared to cRH supporting the linkage between blood pressure and both outcomes.

Renal Response in Patients with Chronic Kidney Disease Predicts Outcome Following Cardiac Resynchronization Therapy.

Chronic kidney disease (CKD) severity is associated with increased morbidity and mortality in congestive heart failure. There is a paucity of data regarding renal improvement after cardiac resynchronization therapy (CRT) and its potential impact on clinical outcomes, especially in patients with severe CKD. This was a retrospective analysis of a prospectively collected cohort of 260 patients with CKD undergoing CRT at a single center. Renal function was compared before and after CRT. The primary end point was a composite of death, heart transplant, and left ventricular assist device (LVAD), assessed at 5 years. Patients with more severe CKD demonstrated increased risk of death, transplant, or LVAD following CRT (P = 0.015). Renal response (estimated glomerular filtration rate improvement ≥10 mL/min/1.73 m(2) ) was observed in 14% of all patients and 28% of patients with stage IV CKD. Independent predictors of renal response included left ventricular ejection fraction improvement (odds ratio [OR] 1.06, confidence interval [CI] 1.01-1.10), angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use (OR 4.31, CI 1.08-17.23), and advanced CKD stage (OR 2.19, CI 1.14-4.23). Renal response independently decreased hazard of the primary outcome (HR 0.24, CI 0.08-0.73, P = 0.01). Renal responders with stage IV CKD had 80% 5-year event-free survival, compared to 0% for nonrenal responders in stage IV (P = 0.03). Although severity of CKD is associated with poorer outcome after CRT, improvement in renal function can occur in patients across all CKD stages. Renal responders, including those with stage IV CKD, demonstrate favorable 5-year outcomes. Assessment of renal response may help better prognostic outcomes following CRT.

Participation in a Structured Weight Loss Program and All-Cause Mortality and Cardiovascular Morbidity in Obese Patients With Chronic Kidney Disease

To determine if participation in a weight loss program impacted upon a composite end point of all-cause mortality and cardiovascular morbidity in obese patients with chronic kidney disease (CKD). Retrospective cohort study. All patients with a body mass index (BMI) >30kg/m(2) or >28kg/m(2) with at least 1 comorbidity (hypertension, diabetes, or dyslipidemia) referred to an established weight management program (WMP) from 2005 to 2009 at a metropolitan tertiary teaching hospital were eligible for inclusion in the study cohort. Twelve-month structured weight loss program. Combined outcome of all-cause mortality, myocardial infarction, stroke, and hospitalization for congestive heart failure; kidney transplantation waitlisting. A total of 169 obese patients with CKD commenced the WMP and 169 did not-becoming the observational control group (CON). There were no significant differences between groups for age, BMI, sex, ethnicity, smoking, hypertension, or kidney function at baseline, although CON included more patients with diabetes than WMP (49% vs. 38%, P=.03). Kaplan-Meier survival analysis with log-rank test differed between groups for the combined outcome (P=.03). Cox regression analysis with adjustment for age, sex, ethnicity, hypertension, diabetes, kidney function, baseline BMI, and smoking status, indicated that patients in WMP had a significantly longer event-free period for the combined outcome, than those in CON (adjusted hazard ratio 0.53; 95% confidence interval [CI] 0.29-0.97; P=.04). Participation in the WMP did not increase the likelihood of kidney transplantation waitlisting (odds ratio [OR] 1.06; 95% CI 0.39-2.87; P=.9). Lower baseline BMI and greater weight loss over 12months were the only factors related to kidney transplantation waitlisting (adjusted R(2)=0.426). Participation in a structured weight loss program may be associated with improved outcomes in obese patients with CKD.

Risk-Adjusted In-Hospital Mortality Models for Congestive Heart Failure and Acute Myocardial Infarction: Value of Clinical Laboratory Data and Race/Ethnicity.

To examine the impact of key laboratory and race/ethnicity data on the prediction of in-hospital mortality for congestive heart failure (CHF) and acute myocardial infarction (AMI). Hawaii adult hospitalizations database between 2009 and 2011, linked to laboratory database. Cross-sectional design was employed to develop risk-adjusted in-hospital mortality models among patients with CHF (n = 5,718) and AMI (n = 5,703). Results of 25 selected laboratory tests were requested from hospitals and laboratories across the state and mapped according to Logical Observation Identifiers Names and Codes standards. The laboratory data were linked to administrative data for each discharge of interest from an all-payer database, and a Master Patient Identifier was used to link patient-level encounter data across hospitals statewide. Adding a simple three-level summary measure based on the number of abnormal laboratory data observed to hospital administrative claims data significantly improved the model prediction for inpatient mortality compared with a baseline risk model using administrative data that adjusted only for age, gender, and risk of mortality (determined using 3M's All Patient Refined Diagnosis Related Groups classification). The addition of race/ethnicity also improved the model. The results of this study support the incorporation of a simple summary measure of laboratory data and race/ethnicity information to improve predictions of in-hospital mortality from CHF and AMI. Laboratory data provide objective evidence of a patient's condition and therefore are accurate determinants of a patient's risk of mortality. Adding race/ethnicity information helps further explain the differences in in-hospital mortality.

Rural congestive heart failure mortality among US elderly, 1999‐2013: Identifying counties with promising outcomes and opportunities for implementation research

Objective Describe modern trends in congestive heart failure (CHF) among elderly (>65 years of age) in the United States, to identify potentially successful rural areas. Compare CHF mortality using multiple- (MCOD) versus underlying-(UCOD) cause of death data. Methods U.S. Centers for Disease Control and Prevention mortality files (WONDER internet site). Results Using MCOD data, overall mortality rates/100,000 population (and 95% confidence intervals) for CHF among persons >65 years of age (1999–2013) were 482.0 (481.2–482.8) for large central and large fringe metropolitan (LCLF) counties, 549.6 (548.6–550.7) in small and medium metropolitan (SM) counties, and 652.6 (650.9–654.0) in micropolitan and non-core, non-metropolitan (MNCNM) counties. Twenty positive deviance NCNM counties (collectively including 198,581 residents >65 years of age) had an overall CHF rate of 300.9 (275.0–326.9) in 2013. This was significantly lower than the LCLF rate for 2013 (482.0 [481.2–482.8]), and represented a reduction of 47% since 1999. Overall CHF occurrence as estimated with MCOD was 3.4-fold higher than that obtained with UCOD. Conclusion These data illustrate underestimation of CHF by UCOD data and the importance of correct death certification. Rural CHF mortality rates are higher than urban rates, but some positive deviance counties demonstrate that this is not inevitable. Further research is needed to understand the relative contribution of research innovation, medical care, and public health to rural-urban disparities and the relative success of positive deviance counties.

Oral pharmacological treatment of congestive heart failure

Congestive heart failure (CHF) is a growing epidemiologic and clinical problem, and is increasing in incidence, prevalence and mortality. Therefore, the optimal treatment of heart failure (HF) is important to reduce hospitalization and mortality. In the treatment of CHF, diuretics are the first-line drug treatment for patients with fluid retention and are necessary to relieve symptoms but cannot halt progression or improve the prognosis of CHF. Angiotensin-converting enzyme inhibitors, beta-adrenergic receptor antagonists and mineralocorticoid/aldosterone receptor antagonist therapy have been shown to decrease mortality and progression of CHF and should be used early in HF with reduced ejection fraction. Angiotensin receptor antagonists are recommended in patients with current or prior symptoms who are angiotensin-converting enzyme inhibitor intolerant, unless contraindicated, to reduce morbidity and mortality. However, no treatment has been shown convincingly to reduce morbidity and mortality in patients with HF with preserved ejection fraction. Adequate treatment of hypertension and myocardial ischemia is also considered to be important, as is control of the ventricular rate in HF with preserved ejection fraction. For chronic HF with reduced ejection fraction, ivabradine and angiotensin receptor-neprilysin inhibition have been tested and may be used in evidence-based medicine in the near future. This review presents the evidence base for current drug treatments and their practical implications in chronic HF.

慢性維持血液透析患者における腹部大動脈石灰化スコアとうっ血性心不全の発症および死亡との関連

慢性維持血液透析患者における腹部大動脈石灰化スコアとうっ血性心不全の発症および死亡との関連

Clinical and psychological telemonitoring and telecare of high risk heart failure patients

We conducted a trial of telemonitoring and telecare for patients with chronic heart failure leaving hospital after being treated for clinical instability. Eighty patients were randomized before hospital discharge to a usual care group (n = 40: follow-up at the outpatient clinic) or to an integrated management group (n = 40: patients learned to use a handheld PDA and kept in touch daily with the monitoring centre). At enrolment, the groups were similar for all clinical variables. At one-year follow-up, integrated management patients showed better adherence, reduced anxiety and depression, and lower NYHA class and plasma levels of BNP with respect to the usual care patients (e.g. NYHA class 2.1 vs 2.4, P < 0.02). Mortality and hospital re-admissions for congestive heart failure were also reduced in integrated management patients (P < 0.05). Integrated management was more expensive than usual care, although the cost of adverse events was 42% lower. In heart failure patients at high risk of relapse, the regular acquisition of simple clinical information and the possibility for the patient to contact the clinical staff improved drug titration, produced better psychological status and quality of life, and reduced hospitalizations for heart failure.

Exogenous midkine administration prevents cardiac remodeling in pacing-induced congestive heart failure of rabbits.

Midkine (MK), a heparin-binding growth factor, has been shown to prevent cardiac remodeling after ischemic injury through its anti-apoptotic effect. Cell apoptosis is central to the pathophysiology of cardiac remodeling in congestive heart failure (CHF) of ischemic as well as non-ischemic origin. We hypothesized that MK exerts the anti-apoptotic cardioprotective effect in CHF of non-ischemic etiology. MK protein or vehicle (normal saline) was subcutaneously administered in tachycardia-induced CHF rabbits (right ventricular pacing, 350 beats/min, 4 weeks). The vehicle-treated rabbits (n = 19, control) demonstrated severe CHF and high mortality rate, whereas MK (n = 16) demonstrated a well-compensated state and a lower mortality rate. In echocardiography, left ventricular (LV) end-diastolic dimension decreased in MK versus control, whereas LV systolic function increased. In histological analysis (picrosirius red staining), MK decreased collagen deposition area compared with control. TUNEL staining showed that MK prevented cell apoptosis and minimized myocyte loss in the CHF rabbit ventricle, associated with activation of PI3-K/Akt signaling, producing a parallel decrease of Bax/Bcl-2 ratio. MK prevented progression of cardiac remodeling in the CHF rabbit, likely by activation of anti-apoptotic signaling. Exogenous MK application might be a novel therapeutic strategy for CHF due to non-ischemic origin.

What is the prognostic significance of asymptomatic left bundle branch block (LBBB)?

Evidence-Based Answer In patients without congestive heart failure (CHF), LBBB is not associated with increased all-cause mortality when followed for 10 to 40 years (SOR: B, cohort studies). However, asymptomatic LBBB may be a risk factor for later diagnosis of CHF and CHF-specific mortality (SOR: B, retrospective and prospective cohort study). LBBB with left axis deviation (LAD) appears to carry a greater risk of adverse cardiovascular outcomes than LBBB without LAD (SOR: B, retrospective cohort study).

Usefulness of N-Terminal Pro–B-Type Natriuretic Peptide Levels for Stroke Risk Prediction in Anticoagulated Patients With Atrial Fibrillation

Oral anticoagulation is highly effective in reducing stroke and mortality in atrial fibrillation (AF). Several risk stratification schemes have been developed using clinical characteristics. Elevated levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) are important markers of increased mortality and morbidity in congestive heart failure and general community population. The aim of our study was to assess the predictive value of NT-proBNP levels in an unselected real-world cohort of anticoagulated patients with AF. We studied 1172 patients (49% male; median age, 76 years) with permanent AF who were well stabilized on oral anticoagulation (international normalized ratio, 2.0-3.0). Plasma NT-proBNP levels were quantified at baseline. We recorded thrombotic and vascular events, mortality, and major bleeding. The best cutoff points were assessed by receiver-operating characteristic curves. Median levels (interquartile range) of NT-proBNP were 610 (318-1037) pg/mL. Median follow-up was 1007 (806-1279) days. On multivariate analysis, high NT-proBNP was significantly associated with the risk of stroke (hazards ratio, 2.71; P=0.001) and composite vascular events (acute coronary syndrome or acute heart failure; hazards ratio, 1.85; P=0.016), as well as a significant association with mortality (adjusted hazards ratio, 1.66; P=0.006). No association with bleeding was found (P=0.637). The integrated discrimination improvement (IDI) analysis demonstrated that NT-proBNP improved the Congestive heart failure, Hypertension, Age≥75 (doubled), Diabetes mellitus, Stroke (doubled)-Vascular disease and Sex category (female); CHA2DS2-VASc score for predicting embolic events (relative IDI, 2.8%; P=0.001) and all-cause death (relative IDI, 1.8%; P=0.001). In real-world cohort of anticoagulated patients with AF, NT-proBNP provided complementary prognostic information to an established clinical risk score (CHA2DS2-VASc) for the prediction of stroke/systemic embolism. NT-proBNP was also predictive of all-cause mortality, suggesting that this biomarker may potentially be used to refine clinical risk stratification in anticoagulated patients with AF.

The influence of sex on cardiovascular outcomes associated with diabetes among older black and white adults

AimsIt is unknown whether sex differences in the association of diabetes with cardiovascular outcomes vary by race. We examined sex differences in the associations of diabetes with incident congestive heart failure (CHF) and coronary heart disease (CHD) between older black and white adults. MethodsWe analyzed data from the Cardiovascular Health Study (CHS), a prospective cohort study of community-dwelling individuals aged ≥65 from four US counties. We included 4817 participants (476 black women, 279 black men, 2447 white women and 1625 white men). We estimated event rates and multivariate-adjusted hazard ratios for incident CHF, CHD, and all-cause mortality by Cox regression and competing risk analyses. ResultsOver a median follow-up of 12.5years, diabetes was more strongly associated with CHF among black women (HR, 2.42 [95% CI, 1.70–3.40]) than black men (1.39 [0.83–2.34]); this finding did not reach statistical significance (P for interaction=0.08). Female sex conferred a higher risk for a composite outcome of CHF and CHD among black participants (2.44 [1.82–3.26]) vs. (1.44 [0.97–2.12]), P for interaction=0.03). There were no significant sex differences in the HRs associated with diabetes for CHF among whites, or for CHD or all-cause mortality among blacks or whites. The three-way interaction between sex, race, and diabetes on risk of cardiovascular outcomes was not significant (P=0.07). ConclusionsOverall, sex did not modify the cardiovascular risk associated with diabetes among older black or white adults. However, our results suggest that a possible sex interaction among older blacks merits further study.

Brain natriuretic peptide gene polymorphism in patients with congestive heart failure

Aim. To study the influence of brain natriuretic peptide gene polymorphism (polymorphic locus Т-381С) on brain natriuretic peptide serum level and congestive heart failure onset risk and clinical features in patients with coronary heart disease. Methods. 412 patients with congestive heart failure were examined. Genotyping was performed by polymerase chain reaction. Brain natriuretic peptide N-terminal fragment level was assessed by ELISA. The control group included 211 healthy controls with no signs of cardiovascular pathology on examination. Results. In healthy people with C/C genotype the level of brain natriuretic peptide N-terminal fragment was significantly higher in comparison with people carrying T/T genotype. It was found that the T allele and T/T genotype of the T-381C natriuretic peptide gene polymorphic locus was associated with high risk, severity and unfavorable clinical course of congestive heart failure in patients with coronary heart disease. At the same time, the C allele and C/C genotype emerged as a protective factor regarding the risk, severity and clinical course of the disease. Conclusion. T/T genotype carriers of the of the T-381C natriuretic peptide gene polymorphic locus are a special subgroup associated with high risk of congestive heart failure onset and unfavorable clinical course. Therefore these patients with coronary heart disease should be considered as a group requiring an out-patient control and preventive measures targeted on congestive heart failure and premature mortality prevention.

Diuretics

Diuretics have been recommended as first-line treatment of hypertension and are also valuable in the management of hypervolemia and electrolyte disorders. This review summarizes the key features of the most commonly used diuretics. We then provide an update of clinical trials for diuretics during the past 5 years. Compared to other classes of medications, thiazide diuretics are at least as effective in reducing cardiovascular events (CVEs) in patients with hypertension and are more effective than β-blockers and angiotensin-converting enzyme inhibitors in reducing stroke. Observational cohort data and a network analysis have shown that CVEs are lowered by one-fifth from chlorthalidone when compared to the commonly used thiazide, hydrochlorothiazide. Relative to placebo, chlorthalidone increases life expectancy. In those aged 80 years and older, the diuretic, indapamide, lowers CVEs relative to placebo. The aldosterone antagonist, eplerenone, lowers total mortality in early congestive heart failure. The benefit of eplerenone following acute myocardial infarction (MI) is limited to administration within 3 to 6 days post-MI. Aldosterone antagonists have been shown to lower the incidence of sudden cardiac death and to reduce proteinuria. In the setting of heart failure, long acting loop diuretics azosemide and torasemide are more effective in improving heart failure outcomes than the far more commonly used short acting furosemide. Evening dosing of diuretics appears to lower CVEs relative to morning dosing. In conclusion, diuretics are a diverse class of drugs that remain extremely important in the management of hypertension and hypervolemic states.

A Quality Improvement Project to Reduce Congestive Heart Failure Mortality With Intensive Case Management

A Quality Improvement Project to Reduce Congestive Heart Failure Mortality With Intensive Case Management

The epidemiology of heart failure, based on data for 2.1 million inhabitants in Sweden

The epidemiology of congestive heart failure (CHF) is likely to have changed due to changes in demography, risk factors, diagnostic procedures, and medical care. Prevailing information is in part old, incomplete, and to some extent contradictory. We determined the current prevalence, incidence, mortality, and 5-year survival rate of CHF, and possible temporal changes in Sweden. This was a cross-sectional study on individual patient data from an administrative health data register in the Stockholm region, Sweden, comprising 2.1 million inhabitants. This contained all recorded diagnoses on all consultations in primary and secondary care (defined as specialist outpatient care), and on all hospitalizations. Prevalence, incidence, and mortality were estimated for the entire Swedish population, adjusted for demographic composition in 2010. The study population consisted of 88 038 patients (51% women). The prevalence was 2.2% (both women and men), the incidence was 3.8/1000 person-years (both women and men), and mortality was 3.2/1000 person-years in women and 3.0/1000 person-years in men (P < 0.001); the 5-year survival rate was 48%. Mortality (age adjusted; hazard ratio and 95% confidence intervals) was higher in men, 1.29, 1.24-1.34; P < 0.001. Prevalence remained essentially unchanged from 2006 to 2010, while incidence decreased by 24% (P < 0.001) and mortality by 19% (both women and men; P < 0.001). The estimated prevalence of CHF in Sweden is 2.2%, incidence 3.8/1000 person-years, and mortality 3.1/1000 person-years. There has been a decrease in incidence and mortality from 2006 to 2010 in both women and men, with no major change in prevalence over time.