Chronic Heart Failure Guidelines Research Articles

Problematic aspects of iron deficiency compensation in heart failure

The initial contradictions in the problem of anemia treatment in cardiac patients are highlighted. The issues of diagnosis and treatment of iron deficiency, presented in the updated National clinical guidelines for chronic heart failure, are analyzed in detail. Based on them, involving own research, the author aims to develop a treatment and diagnostic program for anemia.

Nt-probnp as a Prognostic Marker in Different Gold Classes in Patients with Chronic Obstructive Pulmonary Disease (COPD)

Chronic obstructive pulmonary disease (COPD) was the fifth leading cause for early death and disability in 2020 with approximately 2.75 million deaths per year, which was 4.8%in total from the general mortality. Right ventricular hypertrophy with preserved systolic function is the most common finding in patients with COPD. The development of pulmonary hypertension leads to DV (right ventricle) dilatation and DV heart failure during the course of the disease. Material and methods: The design of the research was a prospective-clinical cross-sectional study as we analyzed 94 patients with COPD. All patients were divided in groups according to the degree of obstruction and classified by the GOLD classification system into four groups from GOLD 1 – GOLD4. All of our patients were analyzed thoroughly on admission and during hospital stay. ECG was made, Nt-proBNP analysis and basic and advanced echocardiography evaluation. Natriuretic peptides were measured and processed by commercially available assays with excellent precision where cut-off value was 125pg/ml. Echo analysis was done by Vivid 7 echo machine with a special feature to right heart chamber characteristics. Results: In terms of risk factors, hypertension, diabetes mellitus and hyperlipidemia were examined in all 94 patients in our study. Arterial hypertension was present in half of the patients, 51.06%. Diabetes mellitus was present in 19.15% of analyzed patients. The analysis of Nt-proBNP level in our study showed that the average value of this natriuretic peptide was above reference range and it was 236.27pg/ml. The highest average values of NT-proBNP were registered in GOLD class 3, while the lowest average and maximum value of NT-proBNP was found in GOLD class 2. According to the results of the Tukey post-hoc test, there was a statistically significant difference in Nt-proBNP levels between GOLD class 2 and GOLD class 3. The average values of Nt-proBNP in the group of patients with acute exacerbation was far higher than in the group of chronically stable patients. The difference between the two groups was 3.5 times in GOLD class 3 and approximately 2 times in GOLD class 4. Conclusion: BNP and NT-proBNP are natriuretic peptides that are secreted under conditions of cardiac stress and weakness. They are established biomarkers and are listed in the guidelines for chronic heart failure as they are quantitative markers used for diagnosis and risk stratification. Still, more studies with a larger number of patients are needed to confirm the role of Nt-proBNP in patients with COPD in different stages of GOLD and progression of the disease.

New principles for the treatment of chronic heart failure: the phenomenon of sodium-glucose cotransporter type 2 inhibitors

Chronic heart failure (CHF) is one of the most important problems in clinical cardiology due to high morbidity, frequent hospitalizations and poor prognosis of patients. Quite unexpectedly, sodium-glucose cotransporter type 2 (SGLT2i) inhibitors dapagliflozin and empagliflozin, which were created for the treatment of diabetes mellitus, proved to be effective means of reducing the risk of an adverse outcome in patients with CHF, they were included in a new four-component therapy for CHF with a reduced left ventricular ejection fraction with a class of recommendations I and level of evidence A. The basis for changing the clinical guidelines for CHF was the results of large randomized trials of DAPA-HF and EMPEROR-Reduced. Despite the obvious clinical benefit of using SGLT2i in CHF, the mechanisms of the observed effects remain speculative and continue to be actively studied. In particular, the literature discusses the role of osmotic diuresis, lowering blood pressure and body weight, increasing erythropoietin production, influencing myocardial remodeling, modifying the energy metabolism of the heart, inhibiting the sodium-hydrogen exchanger, autophagy, and influencing leptin and adiponectin levels. SGLT2i has many of the qualities of an ideal agent for the treatment of CHF with reduced left ventricular ejection fraction, including a single dose without the need for titration, once daily administration, early positive effects on clinical outcomes and quality of life, a favorable safety and tolerability profile with a frequency of serious side effects not different from placebo. At the same time, the choice of medical tactics may be influenced by the features of the evidence base of SGLT2i, in particular, the reduction in cardiovascular mortality and death from any cause in a randomized trial of dapagliflozin.

Does a normal electrocardiogram exclude heart failure with reduced left ventricular ejection fraction?

Abstract Background In the ESC guidelines for chronic heart failure an electrocardiogram (ECG) is part of the diagnostic set-up (1). A normal ECG makes the diagnosis unlikely. But can a normal ECG exclude heart failure with reduced left ventricular ejection fraction (HFrEF) and be a gatekeeper to echocardiography? Methods Patients referred from primary care to the cardiac outpatient clinic with suspicion of heart failure were consecutively included in the study, during a period of one year. With the referral from primary care was included an ECG which was assessed by a senior cardiologist and divided into two groups: 1) Patients with normal ECG; 2) Patients with pathologically ECG. Subsequently, an echocardiographic examination was performed in a blinded fashion and left ventricular ejection fraction (LVEF) was measured. Results Overall, 403 patients were included in the study. A normal ECG was present in 155 (38%) patients and a pathological ECG was present in 248 (62%) patients. In total, an echocardiographic examination identified 55 (14%) patients with an LVEF below 60% and 33 patients (8%) with LVEF below 50%. In patients with a normal ECG, only two patients had heart failure with a mildly reduced ejection fraction (41–49%), Figure 1. Thus, the ECG had a sensitivity of 94% and a negative predictive value of 99%, Figure 2. Conclusion A normal electrocardiogram has a high diagnostic sensitivity and negative predictive value for excluding heart failure with reduced LVEF and could be a gatekeeping tool in the prioritization of patients referred to echocardiography examination from primary care. Funding Acknowledgement Type of funding sources: Private hospital(s). Main funding source(s): Department of Cardiovascular research, OUH, Svendborg Hospital

심부전 환자에서 엠파글리플로진의 유효성 및 안전성 검토

The United States (US) Food and Drug Administration (FDA) approved empagliflozin, which is a sodiumglucose cotransporter 2 (SGLT2) inhibitor used for type 2 diabetes, for the treatment of heart failure (HF) with reduced ejection fraction (HFrEF) in 2021. Earlier this year, empagliflozin became the only SGLT2 inhibitor approved for the treatment of HF with preserved ejection fraction (HFpEF) as well. These approvals were based on the studies that showed empagliflozin reducing hospitalization for HF and cardiovascular mortality. Based on these new findings, SGLT2 inhibitors, including empagliflozin, have been recently added to the heart failure treatment guidelines in the US and Europe. Although empagliflozin is approved for adults with HFrEF in South Korea, treatment guidelines for chronic heart failure have not been updated to include this drug and other SGLT2 inhibitors, yet. Therefore, the purpose of this review is to examine the studies on the efficacy and safety of empagliflozin in heart failure and its current place in clinical practice.

BLITZ-HF: a nationwide initiative to evaluate and improve adherence to acute and chronic heart failure guidelines.

To assess adherence to guideline recommendations among a large network of Italian cardiology sites in the management of acute and chronic heart failure (HF) and to evaluate if an ad-hoc educational intervention can improve their performance on several pharmacological and non-pharmacological indicators. BLITZ-HF was a cross-sectional study based on a web-based recording system with pop-up reminders on guideline recommendations used during two 3-month enrolment periods carried out 3 months apart (Phase 1 and 3), interspersed by face-to-face macro-regional benchmark analyses and educational meetings (Phase 2). Overall, 7218 patients with acute and chronic HF were enrolled at 106 cardiology sites. During the enrolment phases, 3920 and 3298 patients were included, respectively, 84% with chronic HF and 16% with acute HF in Phase 1, and 74% with chronic HF and 26% with acute HF in Phase 3. At baseline, adherence to guideline recommendations was already overall high for most indicators. Among acute HF patients, an improvement was obtained in three out of eight indicators, with a significant rise in echocardiographic evaluation. Among chronic HF patients with HF and preserved or mid-range ejection fraction, performance increased in two out of three indicators: creatinine and echocardiographic evaluations. An overall performance improvement was observed in six out of nine indicators in ambulatory HF with reduced ejection fraction patients with a significant increase in angiotensin receptor-neprilysin inhibitor prescription rates. Within a context of an already elevated level of adherence to HF guideline recommendations, a structured multifaceted educational intervention could be useful to improve performance on specific indicators. Extending this approach to other non-cardiology healthcare professionals, who usually manage patients with HF, should be considered.

Regional Disparities in Adherence to Guidelines for the Treatment of Chronic Heart Failure.

Objective The incidence of chronic heart failure (CHF) is likely to keep increasing in Japan as the population ages, placing increased burdens on medical facilities, particularly on the limited numbers of rural hospitals. We explored the appropriateness of CHF treatment in rural areas in Japan. Methods We compared rates of adherence to therapeutic guidelines for CHF between residents with a left ventricular ejection fraction <35% living in urban areas (n = 207) and those in rural areas (n = 180). Treatments included pharmacological [beta-blockers, angiotensin-converting enzyme inhibitors (ACEi)/angiotensin II receptor blocker (ARB), mineralocorticoid receptor antagonist (MRA) and anticoagulants for atrial fibrillation] and non-pharmacological [implantable cardioverter defibrillator (ICD)/cardiac resynchronization therapy (CRT), cardiac rehabilitation and HF education] approaches. Patients This study included 387 patients with CHF, prior myocardial infarction or cardiomyopathy, and a left ventricular ejection fraction (LVEF) <35% as determined by echocardiography. Results The respective rates of treatments administered in urban and rural areas were as follows: beta-blockers, 91.3% vs. 61.7% (p<0.05); ACEi/ARB, 86.5% vs. 68.3% (p<0.05); MRA, 74.4% vs. 59.4% (p<0.01); anticoagulants, 100% vs. 86.5%, (p<0.05); ICD/CRT, 45.4% vs. 5.0% (p<0.05); cardiac rehabilitation, 32.4% vs. 13.3% (p<0.05) and HF education, 33.3% vs. 32.8% (p=0.75). Conclusion Regional disparities in treatment for CHF persist, even in Japan. Improvements in the use of guideline-directed treatment in rural areas might improve the outcomes for CHF patients.

2020 Clinical practice guidelines for Chronic heart failure

Endorsed by the Research and Practical Council of the Ministry of Health of the Russian Federation.

2020 Clinical practice guidelines for Chronic heart failure

Endorsed by the Research and Practical Council of the Ministry of Health of the Russian Federation.

Galectin-3: role in the formation of various hemodynamic phenotypes of heart failure and interaction with some neurohumoral factors

Aim. To study the interaction of serum galectin-3 (Gal-3) with fibrogenic factors, cardiac remodeling, as well as parameters of central hemodynamics in various hemodynamic phenotypes of heart failure (HF). Material and methods . A total of 210 male and female patients with HF were examined (mean age 64,1±1,4 years). HF was established on the basis of patient complaints, medical history, physical examination and laboratory tests using the 2016 ESC Chronic Heart Failure Guidelines. In addition to standard diagnostic tests, enzyme immunoassays were performed: serum Gal-3, aldosterone, matrix metalloproteinase 1 (MMP1), tissue inhibitor of matrix metalloproteinase 1 (TIMP1). Results. Patients were divided into two groups: group I (n=59) — patients with HF with reduced ejection fraction (LVEF &lt;40%), group II (n=56) — patients with HF with midrange EF (LVEF 41-49%), group III (n=95) — patients with HF with preserved EF (LVEF &gt;50%). Reference values of studied substances were as follows: Gal-3 — 8,6 [3,7; 11,7] ng/ml; aldosterone — 86,8 [47,8; 199,1] pg/ml; MMP1 — 14,5 [8,5; 18,7] ng/ml; TIMP1 — 87,4 [68,6; 115,2] ng/ml. In patients with HF, the levels of Gal-3, aldosterone and TIMP1 increased with the disease functional class (FC). In patients of group I, it significantly increased by 1,7-2,5 (p&lt;0,01), 4,1-5,9 (p&lt;0,05) and 4,1-5,7 (p&lt;0,05); in group II, 1,8-2,8 (p&lt;0,01), 5,6-6,8 (p&lt;0,01) and 6,1-8,3 (p&lt;0,01); in group III, by 2,1-3,1 (p&lt;0,01), 6,1-6,9 (p&lt;0,01) and 6,8-9,3 times (p&lt;0,01), respectively. A positive correlation was established with FC: in groups I and II, Gal-3 had a significant negative relationship with LVEF (p&lt;0,001; p&lt;0,01, respectively); in group III, Gal-3 had a moderate positive relationship with LV posterior wall thickness (p&lt;0,05), interventricular septum thickness (p&lt;0,05), the left ventricle mass index (p&lt;0,01) and LV relative wall thickness (p&lt;0,01). Conclusion. Levels of Gal-3 and aldosterone increased with HF FC and had a relevant relationship with the activation of some other neurohumoral factors. Gal-3 can be used as an early biomarker of myocardial fibrosis and cardiac remodeling, in predicting and evaluating risk factors, clinical course and outcome of the disease, as well as to assess the effectiveness of treatment in patients with these HF phenotypes.

Care Right Where You Are: Treating in Place to Avoid an Emergency Department Visit or Hospitalization

Care Right Where You Are: Treating in Place to Avoid an Emergency Department Visit or Hospitalization

P2614Comparison of global longitudinal strain and ejection fraction in correlation to NT-proBNP in ischemic and non-ischemic heart failure

Abstract Background In chronic heart failure (CHF) NT-proBNP and left ventricular ejection fraction (LVEF) by echocardiography are standard diagnostic as well as follow-up markers and are known to correlate with prognosis. Speckle-tracking echocardiography is a more recent technique to quantify myocardial deformation as a measurement of left ventricular function with potential benefits over LVEF. Purpose The purpose of this investigation was to analyse the cross-sectional relationship between 2D speckle tracking-derived global longitudinal strain (GLS) and NT-proBNP plasma levels in a prospective cohort of ischemic and non-ischemic CHF patients. Methods We enrolled 205 patients with chronic heart failure. Major inclusion criteria were age over 18 years, stable disease with absence of unplanned hospitalization or change in medication or device therapy in the previous month or major surgery in the previous 3 months. CHF treatment had to be according to the recommendations of the ESC CHF guidelines 2016 and LVEF had to be below 50%. Patient history, physical examination and an extensive echocardiography exam were performed. Lab results included NT-proBNP. Manual longitudinal strain was calculated using EchoPAC (General Electric Medical Systems, Horten, Norway) by a single and blinded examiner. LVEF was measured using Simpson's biplane method. Results 205 patients included in the study. The baseline characteristics included mean age 65.0 years and 75% male. Mean GLS was −9.6% (SD ±4.5%) and median NT-proBNP 1269.5 (IQR 379.5–2759.5) ng/ml. The CHF aetiology was 70.0% ischemic vs 30.0% non-ischemic. There was a significant negative correlation between GLS and NT-proBNP (Pearson r=0.239, p=0.029), this was not significant for LVEF and NT-proBNP (Pearson r=0.149, p=0.228).In a multivariate regression analysis adjusted for age, sex, NYHA classification and HF aetiology, GLS remained significantly correlated with NT-proBNP (adjusted beta-coefficient= 0.289, p=0.011). Furthermore, in contrast to LVEF, GLS showed a significant correlation to NT-proBNP in patients with ischemic (Pearson r=0.266, p=0.049) as well as non-ischemic aetiology of heart failure (Pearson r=0.434, p=0.034). Conclusion Global longitudinal strain, not LVEF, was significantly correlated with NT-proBNP in patients with CHF, independently of age, sex, symptoms or heart failure aetiology. This shows that speckle-tracking might be superior to LVEF for the assessment of left ventricular function in CHF.

Adherence to guidelines in patients with chronic heart failure in primary health care

Objective: To describe adherence to international guidelines for chronic heart failure (CHF) management concerning diagnostics, pharmacological treatment and self-care behaviour in primary health care.Design: A cross-sectional descriptive study of patients with CHF, using data obtained from medical records and a postal questionnaire.Setting: Three primary health care centres in Sweden.Subjects: Patients with a CHF diagnosis registered in their medical record.Main outcome measures: Adherence to recommended diagnostic tests and pharmacological treatment by the European Society of Cardiology guidelines and self-care behaviour, using the European Heart Failure Self-care Behaviour Scale (EHFScBS-9). Results. The 155 participating patients had a mean age of 79 (SD9) years and 89 (57%) were male. An ECG was performed in all participants, 135 (87%) had their NT-proBNP measured, and 127 (82%) had transthoracic echocardiography performed. An inhibitor of the renin angiotensin system (RAS) was prescribed in 120 (78%) patients, however only 45 (29%) in target dose. More men than women were prescribed RAS-inhibition. Beta blockers (BBs) were prescribed in 117 (76%) patients, with 28 (18%) at target dose. Mineralocorticoidreceptor antagonists were prescribed in 54 (35%) patients and daily diuretics in 96 (62%). The recommended combination of RAS-inhibitors and BBs was prescribed to 92 (59%), but only 14 (9%) at target dose. The mean score on the EHFScBS-9 was 29 (SD 6) with the lowest adherence to daily weighing and consulting behaviour.Conclusion: Adherence to guidelines has improved since prior studies but is still suboptimal particularly with regards to medication dosage. There is also room for improvement in patient education and self-care behaviour.

An audit of adherence to heart failure guidelines in an Australian hospital: A pharmacist perspective

The Australian National Heart Foundation Guidelines have been developed to guide clinicians on how to best manage chronic heart failure (CHF) patients according to the current best available evidence. The primary aim of this study is to evaluate the proportion of patients prescribed evidence-based therapy (EBT) for CHF on discharge at this Australian metropolitan hospital and factors affecting its prescribing. The secondary aims are to examine the proportion of patients prescribed EBT on discharge on cardiac wards compared to medical wards and to explore the role of the pharmacist in the management of these patients. A retrospective audit of patients' medical notes who were admitted consecutively for CHF management was conducted over 6months to examine their management. The results showed at discharge, a total of 52% of patients were discharged on angiotensin converting enzyme inhibitors/angiotensin receptor blockers, 49% were discharged on β-blockers, 15% were on Aldosterone receptor antagonists, 90% were discharged on diuretics, and 29% were discharged on Digoxin. The main determinants of prescribing EBT on discharge were the presence of prescribing contraindications and patients' comorbidities. Patients discharged from cardiac wards were more likely to be prescribed EBT than if discharged on medical wards. Furthermore, in the subset of the cohort who was reviewed by a pharmacist during admission, a higher percentage of patients were discharged on EBT compared with those who did not have a pharmaceutical input. This study highlighted existing gaps between the National CHF Guidelines and clinical prescribing practice in this hospital. Patients who were discharged from cardiac wards were more likely to be prescribed medications concordant with the guidelines, and there is further opportunity for pharmacists to assist in closing gaps in prescribing practice by the promotion of adherence to these guidelines.

How robust are clinical trials in heart failure?

Guidelines for the management of chronic heart failure (CHF) cite the results of randomized controlled trials (RCTs) to support treatment recommendations. The significance of an observed treatment-effect relies on the use of a boundary P-value, most commonly P < 0.05. There is concern about relying on arbitrary threshold P-values to report results as 'statistically significant'. The 'fragility index' (FI) has been proposed as an additional measure of the robustness of trial findings. FI is the minimum number of events needing to change from a non-event to an event in order to render a significant result non-significant. We calculated the FI to examine the robustness of statistically significant RCTs in CHF. Two reviewers extracted data from RCTs supporting treatment recommendations in CHF guidelines. Twenty-five eligible trials were identified with a median sample size of 2331 patients (range 129-8399) and a median number of primary endpoints of 688.5 (range 88-2031). For the primary endpoint (analysed for 20 trials), the median FI was 26 (range 0-118). The FI was ≤10 in 7 (35%) of these 20 trials, and in 4 (20%) trials the number of patients lost to follow-up in the treatment group exceeded the FI. The results of some large RCTs in CHF hinge on a small number of events. The FI offers an additional, easy to understand metric, which augments the standard reporting of boundary P-values for statistical significance. The FI helps in the interpretation of the robustness of the results of RCTs.

Impact of Ivabradine on Health-Related Quality of Life of Patients with Ischaemic Chronic Heart Failure.

Chronic heart failure (CHF) remains a major health problem, with high levels of morbidity and mortality and a low health-related quality of life (HRQoL). We assessed the impact on HRQoL of adding the If channel blocker, ivabradine, to a standard treatment regimen of patients with ischaemic CHF (I-CHF) and heart rate (HR) ≥70 beats/min (bpm). A randomized prospective study of 100 consecutive patients presenting with stable I-CHF, left ventricular ejection fraction (LVEF) <40% and a sinus HR ≥70 bpm. New York Heart Association (NYHA) class, overall summary score (OSS) and clinical summary score (CSS) of the Kansas City Cardiomyopathy Questionnaire (KCCQ) were used to assess HRQoL. The patients were randomized into 2 groups: carvedilol only (group I (n=50)) and carvedilol + ivabradine (group II (n=50)). The patients were followed up for 12 weeks and their HRQoL scores were monitored and compared. The overall mean age of the cohort was 63±10 years with 70% (n=70) males. HRQoL scores had significantly improved in group II after 12 weeks of follow-up. The net proportion of patients with a 5-point improvement in CSS was 30% higher in group II (p=0.002), whereas that for the OSS, it was 24% (p=0.001), when compared with group I. These improvements were accompanied by a significant HR reduction (69 vs 78 bpm; p=0.002). Adding ivabradine to the standard drug regimen, currently advocated by guidelines for CHF with a heart rate ≥70 bpm, resulted in a significant improvement in HRQoL.

Audit of a tertiary heart failure outpatient service to assess compliance with NICE guidelines

The National Institute for Health and Care Excellence (NICE) updated its guidelines for chronic heart failure (HF) in 2010. This re-audit assessed interim improvement as compared with an audit in 2011. Patients with HF (preserved and reduced ejection fraction) attending a tertiary cardiac centre over a 2-year period (January 2013-December 2014) were audited. The data collected included demographics, HF aetiology, medications, clinical parameters and cardiac rehabilitation. In total, 513 patients were audited. Compared with 2011, male preponderance (71%) and age (68±14years, (Mean ± SD)) were similar. 73% of patients lived outside of London. HF aetiologies included ischaemic heart disease (37% versus 40% in 2011), dilated cardiomyopathy (26% versus 20%) primary valve disease (13% versus 12%). For patients with left ventricular systolic dysfunction (n=434, 85% of patients audited) 89% were taking beta-blockers (compared with 77% in 2011), 91% an angiotensin converting enzyme inhibitor or angiotensin receptor blocker (86% in 2011) and 56% a mineralocorticoid receptor antagonist (44% in 2011); 6% were prescribed ivabradine. All patients were reviewed at least 6-monthly. Although 100% of patients were educated about exercise, only 21 (4%) enrolled in a supervised exercise programme. This audit demonstrated high rates of documentation, follow-up and compliance with guideline-based medical therapies. A consistent finding was poor access to cardiac rehabilitation.

A Physician Advisory System for Chronic Heart Failure management based on knowledge patterns

AbstractManagement of chronic diseases such as chronic heart failure (CHF) is a major problem in health care. A standard approach followed by the medical community is to have a committee of experts develop guidelines that all physicians should follow. These guidelines typically consist of a series of complex rules that make recommendations based on a patient's information. Due to their complexity, often the guidelines are ignored or not complied with at all. It is not even clear whether it is humanly possible to follow these guidelines due to their length and complexity. For instance, for CHF, the guidelines run nearly eighty pages. In this paper we describe a physician-advisory system for CHF management that codes the entire set of clinical practice guidelines for CHF using answer set programming (ASP). Our approach is based on developing reasoning templates, that we call knowledge patterns, and using them to systemically code the clinical guidelines for CHF as ASP rules. Use of the knowledge patterns greatly facilitates the development of our system. Given a patient's medical information, our system generates a recommendation for treatment just as a human physician would, using the guidelines. Our system works even in the presence of incomplete information.

General practitioners' adherence to chronic heart failure guidelines regarding medication: the GP-HF study.

The adherence to the guidelines for pharmacotherapy of chronic heart failure (HF)-patients improves prognosis. Although general practitioners (GPs) treat the majority of HF-patients, information about GPs' current guideline adherence and their typical prescription rationales is sparse. A three-stage study design was employed. In Stage I, 206 patient records from 15 randomly chosen GP practices were analysed; 76% of patients were prescribed ACE-inhibitors or angiotensin receptor blockers (ACEIs/ARBs), 73% beta blocker (BBs), but only 18% mineralocorticoid receptor antagonists (MRAs). ACEI doses were at 62% of the guideline recommended target doses, BBs at 46%, while MRAs were sufficiently highly dosed. The guideline adherence indicator (GAI-3) was only 22%. In Stage II, GPs in all 15 practices were interviewed, and health record documentation deficits and patients' contraindications were taken into account. This increased the percentage of patients correctly prescribed ACEIs/ARBs to 87%, BBs to 84% and GAI-3 to 56%. MRAs exhibited the most frequent contraindications, but remained underprescribed. Many GPs seemed not to be aware of the therapeutic value of MRAs or the need to reach target doses of the indicated drug classes. Patients-interviewed in Stage III-reported good tolerability of HF-drugs and generally good compliance, although 11% discontinued HF-medication on their own. Guideline adherence of GPs was higher than expected from literature and might be further improved by highlighting MRAs as the third prognostically relevant drug class beside ACEIs/ARBs and BBs and stronger emphasis on target doses.

Detecting cardiac events - state-of-the-art.

Cardiac biomarker measurement currently addresses two key questions in patient management: the differential diagnosis of chest pain and the differential diagnosis of the patient with breathlessness. There are currently three major themes in the strategies for the differential diagnosis of chest pain. The first is to undertake troponin measurement in patients selected to be at lower risk, hence to have a low prior probability of disease. The second is the introduction of high-sensitivity cardiac troponin (hs cTn) assays into routine clinical use with measurement at 0 and 3 h from admission. Two other approaches that utilize the diagnostic characteristics of these assays have also been suggested. The first is to use the limit of detection or limit of blank of the assay as the diagnostic discriminant. The second approach is to use the low imprecision of the assay within the reference interval and combine a discriminant value with an absolute rate of change (delta value). The third is the use of additional biomarkers to allow early discharge from the emergency department. The concept is to measure high-sensitivity cardiac troponin plus the extra marker on admission. The role of measurement of B-type natriuretic peptide or its N-terminal prohormone, N-terminal pro-B-type natriuretic peptide, has been accepted and incorporated into guidelines for chronic heart failure for some time. More recently, guidelines for acute heart failure can also recommend a single measurement of B-type natriuretic peptide or N-terminal pro-B-type natriuretic peptide in people presenting with new suspected acute heart failure.