Heart Failure In Community Research Articles

ANMCO/SIC Consensus Document: cardiology networks for outpatient heart failure care

Changing demographics and an increasing burden of multiple chronic comorbidities in Western countries dictate refocusing of heart failure (HF) services from acute in-hospital care to better support the long inter-critical out-of- hospital phases of HF. In Italy, as well as in other countries, needs of the HF population are not adequately addressed by current HF outpatient services, as documented by differences in age, gender, comorbidities and recommended therapies between patients discharged for acute hospitalized HF and those followed-up at HF clinics.The Italian Working Group on Heart Failure has drafted a guidance document for the organisation of a national HF care network. Aims of the document are to describe tasks and requirements of the different health system points of contact for HF patients, and to define how diagnosis, management and care processes should be documented and shared among health-care professionals.The document classifies HF outpatient clinics in three groups: (i) community HF clinics, devoted to management of stable patients in strict liaison with primary care, periodic re-evaluation of emerging clinical needs and prompt treatment of impending destabilizations, (ii) hospital HF clinics, that target both new onset and chronic HF patients for diagnostic assessment, treatment planning and early post-discharge follow-up. They act as main referral for general internal medicine units and community clinics, and (iii) advanced HF clinics, directed at patients with severe disease or persistent clinical instability, candidates to advanced treatment options such as heart transplant or mechanical circulatory support. Those different types of HF clinics are integrated in a dedicated network for management of HF patients on a regional basis, according to geographic features. By sharing predefined protocols and communication systems, these HF networks integrate multi-professional providers to ensure continuity of care and patient empowerment.In conclusion, This guidance document details roles and interactions of cardiology specialists, so as to best exploit the added value of their input in the care of HF patients and is intended to promote a more efficient and effective organization of HF services.

Is There a Role for Ivabradine in the Contemporary Management of Patients with Chronic Heart Failure in Academic and Community Heart Failure Clinics in Canada?

In patients with heart failure (HF) and reduced ejection fraction, increased heart rate (HR) is an independent risk factor for adverse outcomes. In systolic HF treatment with the If inhibitor ivabradine trial (SHIFT), Ivabradine improved survival when added to conventional treatment including β-blockers. However, the extent of benefit in the real world is unclear. We examined the characteristics of patients on guideline-directed therapy and determined who had SHIFT-like characteristics. A total of 1096 patients with chronic HF were reviewed from June 2014 to April 2015 in two HF clinics in Toronto: an academic institution (AI), and a community hospital (CH) clinic. SHIFT-like characteristics [left ventricular ejection fraction (LVEF) ≤35%; sinus rhythm; and HR≥70bpm] were described. For all patients, mean age was 75±13years, overall LVEF was 44±15%, AI less than CH (41.9±14.0% vs. 45.7±15.0%; p<0.0001). More than two-thirds of patients in both groups were on β-blockers; with less than one-third at target dose. The proportion of patients with SHIFT-like characteristics was 8.4% AI and 11.7% CH, respectively (p=0.0658). In HF clinics from both academic and community hospitals in Toronto, up-titration in the dose of β-blockers and other guideline therapy can be improved on. A small proportion of patients with HF and SHIFT-like characteristics may potentially benefit from the addition of Ivabradine, just approved in Canada; this number will be further reduced if target dosage for β-blockers is achieved. Servier Inc.

What proportion of patients with chronic heart failure are eligible for sacubitril-valsartan?

The PARADIGM-HF trial showed that sacubitril-valsartan, an ARB-neprilysin inhibitor, is more effective than enalapril for some patients with heart failure (HF). It is uncertain what proportion of patients with HF would be eligible for sacubitril-valsartan in clinical practice. Between 2001 and 2014, 6131 patients consecutively referred to a community HF clinic with suspected HF were assessed. The criteria required to enter the randomized phase of PARADIGM-HF, including symptoms, NT-proBNP, and current treatment with or without target doses of ACE inhibitors or ARBs, were applied to identify the proportion of patients eligible for sacubitril-valsartan. Recognizing the diversity of clinical opinion and guideline recommendations concerning this issue, entry criteria were applied singly and in combination. Of 1396 patients with reduced left ventricular ejection fraction (≤40%, HFrEF) and contemporary measurement of NT-proBNP, 379 were on target doses of an ACE inhibitor or ARB at their initial visit and, of these, 172 (45%) fulfilled the key entry criteria for the PARADIGM-HF trial. Lack of symptoms (32%) and NT-proBNP <600 ng/L (49%) were common reasons for failure to fulfil criteria. A further 122 patients became eligible during follow-up (n = 294, 21%). However, if background medication and doses were ignored, then 701 (50%) were eligible initially and a further 137 became eligible during follow-up. Of patients with HFrEF referred to a clinic such as ours, only 21% fulfilled the PARADIGM-HF randomization criteria, on which the ESC Guidelines are based; this proportion rises to 60% if background medication is ignored.

Hemodynamic-guided heart-failure management using a wireless implantable sensor: Infrastructure, methods, and results in a community heart failure disease-management program.

The real-world impact of remote pulmonary artery pressure (PAP) monitoring on New York Heart Association (NYHA) class improvement and heart failure (HF) hospitalization rate is presented here from a single center. METHODS: Seventy-seven previously hospitalized outpatients with NYHA class III HF were offered PAP monitoring via device implantation in a multidisciplinary HF-management program. Prospective effectiveness analyses compared outcomes in 34 hemodynamically monitored patients to a group of similar patients (n = 32) who did not undergo device implantation but received usual care. NYHA class and 6-minute walk testing were assessed at baseline and 90 days. All hospitalizations were collected after 6 months of the implantation date (average follow-up, 15 months) and compared with the number of hospitalizations experienced prior to hemodynamic monitoring. Patients in both groups had similar distributions of age, sex, and ejection fraction. After 90 days, 61.8% of the monitored patients had NYHA class improvement of ≥1, compared with 12.5% in the controls (P < 0.001). Distance walked in 6 minutes increased by 54.5 meters in the monitored group (253.0 ± 25.6 meters to 307.4 ± 26.3 meters; P < 0.005), whereas no change was seen in the usual-care group. After implantation, 19.4% of the monitored group had ≥1 HF hospitalization, compared with 100% who had been hospitalized in the year prior to implantation. The monitored group had a significantly lower HF hospitalization rate (0.16; 95% confidence interval: 0.06-0.35 hospitalizations/patient-year) compared with the year prior (1.0 hospitalizations/patient-year; P < 0.001). Hemodynamic-guided HF management leads to significant improvements in NYHA class and HF hospitalization rate in a real-world setting compared with usual care delivered in a comprehensive disease-management program.

7 Association between low-dose aspirin use, monocyte biomarkers, matrix metalloproteinases and outcome in HFpEF

Introduction Most community heart failure patients present with preserved ejection fraction (HFpEF) associated with inflammation, monocytosis, endothelial dysfunction and platelet activation. We investigated the clinical relationship between low-dose aspirin and outcome in HFpEF and the effects of aspirin on monocyte function and cell-cell interactions in-vitro. Methods In a retrospective analysis of HFPEF patients, we identified 150 patients taking low-dose (75 mg/day) aspirin and age/sex-matched HFPEF controls not taking aspirin over a 3 year follow-up period. From this cohort, we also studied HFPEF age/sex-matched patients (14 aspirin, 14 non-aspirin) using primary monocyte isolation, monocyte qPCR, serum matrix metalloproteinase (MMP) and inflammatory marker assays. Finally, primary monocytes were isolated from 6 healthy volunteers, analysed using flow cytometry for monocyte-platelet complexes, monocyte chemotaxis assays, and co-cultured with platelet releasate (PR, 16h) with and without aspirin. Results Aspirin was associated with higher overall survival and lower HF hospitalisations over the 3-year follow up period (HR = 0.605, 95% confidence interval, 0.389–0.961). Serum MMP2 and sCD163 were significantly reduced in aspirin HFPEF versus matched HFPEF controls. The majority (88%) of donor monocytes were complexed with platelets. Monocyte incubation with PR caused cell activation, increased release of matrix metalloproteinas and MCP1 as well as increased monocyte invasiveness in an in-vitro transwell assay. Inflammatory cytokines (IL1alpha, IL1beta, CCL17) and gene expression of PSGL was reduced by aspirin as was monocyte invasion was reduced by 50% with aspirin treatment (p Conclusion This retrospective study shows an association between the use of low-dose aspirin and better clinical outcome in HFpEF, associated with reduced sCD163 and circulating matrix metalloproteinase. These effects may be related to antiplatelet mediated modulation of monocyte function. Further work is required to evaluate antiplatelet strategies in HFpEF.

211 - Plasma Aldosterone, ANP, Hypertension and Stage A and B Heart Failure in the General Community

211 - Plasma Aldosterone, ANP, Hypertension and Stage A and B Heart Failure in the General Community

Does left ventricular diastolic dysfunction progress through stages? Insights from a community heart failure study

We performed a retrospective pilot study on a group of symptomatic patients attending our community heart failure clinic with left ventricular diastolic dysfunction (LVDD), rising or elevated LV end diastolic pressure, elevated brain natriuretic peptide (BNP), but with no clinical or radiographic evidence of heart failure; a group we hypothesised may be in the pre-HFPEF stage. MethodsThose with LVEF >45% and LV diastolic dysfunction were included and divided into two groups: E/e′ <15 and E/e′ ≥15 corresponding with rising and raised LVEDP, respectively. Clinical events (deaths and hospital admissions) were compared at 1year and were grouped into all-cause events or cardiovascular events. The total numbers of all-cause and cardiovascular events of the individual groups and the entire cohort were assessed at 1year. ResultsOut of 584 screened, 80 patients were included. Thirty five patients had E/e′ <15 and 45 had E/e′ ≥15. At 1year follow-up the 1year all-cause events in the E/e′ ≥15 group was higher compared to the E/e′ <15 group (p=0.03). At 12months, in the entire cohort there were a total of 45 clinical events (39 hospital admissions and 6 deaths) out of which 20 events were cardiovascular. ConclusionPatients in the pre-HFPEF stage had many events and those with elevated E/e′ ≥15 had a poor 1year outcome. As this was strongly influenced by comorbidities we suggest close monitoring of these patients in dedicated HFPEF clinics along with vigorous management of comorbidities.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Self-care and improved outcomes: an intervention by heart failure nurse specialists

Background: Heart failure is a prevalent, debilitating condition. Patients need to develop and maintain effective strategies and behaviours to care for themselves and manage their illness. Aim: The aim of this study was to evaluate whether or not an educational intervention carried out by a team of heart failure nurse specialists (HFNS), as part of usual care, enhanced self-care behaviour in patients with chronic heart failure. Methods: A quantitative survey was carried out using the ‘Looking After Yourself with Heart Failure Questionnaire (LAYHFQ)’, to determine levels of self-care behaviour pre- and post-HFNS intervention. All new patients registered to a community heart failure nursing service completed the questionnaire at initial assessment and 6 weeks later, following the nurse-led intervention (N=36). Paired t-tests (2-tailed) were carried out to determine if there were significant differences between total self-care scores before and after the intervention, and for each individual self-care behaviour. Results: Selfcare was improved overall (p=0.011), with five behaviours demonstrating a statistically significant improvement: namely, the uptake of flu and pneumonia vaccination (p=0.009), regular weighing (p=0.001), recognising changes in sleep patterns (p=0.014), recognising signs of fluid retention (p=0.001), and the wellbeing dimension of going out as much as possible (p=0.019). Conclusion: An educational intervention by an HFNS leads to enhanced self-care and may result in improved physical and psychological outcomes for patients with heart failure.

Heart failure in India: The INDUS (INDia Ukieri Study) study

Introduction: There are few data on heart failure (HF) burden and none available on the community prevalence of HF in India. We conducted a study aimed at determining the HF prevalence in a rural community as well as tertiary hospital care setting in North India. We also reviewed the existing literature regarding the estimated and projected prevalence of HF in India. Methodology: All adults (>20 years) with chronic breathlessness in six villages under a primary health care center in Northern India were identified and evaluated with standardized questionnaire and physical examination by trained health care workers. HF was diagnosed by standardized criteria and a transthoracic echocardiogram was performed in all subjects. In the hospital study, 500 consecutive patients presenting to our tertiary referral hospital were evaluated for the diagnosis of HF. For the systematic review, all published studies addressing HF or the burden of risk factors in India were identified. Projections for the absolute HF burden were made using local data and global studies of HF incidence, morbidity, and mortality. Results: Among the surveyed rural adult population of 10,163 patients, chronic breathlessness was present in 128 (1.3%). HF was present in 9% (n = 12), of which 67% (n = 8) had preserved left ventricular (LV) systolic function and 33% (n = 4) had LV systolic dysfunction. Therefore, the prevalence of HF in this general community was 1.2/1000. All patients with HF and preserved ejection fraction had poorly controlled hypertension. In the hospital study, of 500 consecutive patients, 20.4% had HF. Rheumatic heart disease (52%) was the most common cause followed by ischemic heart disease (17%). The mean age of presentation was 39 ± 16 years. The prevalence of HF in the outpatient department patients was 22.5% below 30 years and 14.9% above 50 years, reflecting the young population of HF. For the estimates concerning HF burden in India, projections were made using both age-specific extrapolations from developing countries and data regarding development of HF in the presence of risk factors. The estimated prevalence of HF is about 1% of the total population or about 8–10 million individuals. The estimated mortality attributable to HF is about 0.1–0.16 million individuals per year. Conclusions: While our hospital data are consistent with the HF burden and etiology expected in a government tertiary hospital setting, our community-based study is the first of its kind reported from India. The community study demonstrates a surprisingly low prevalence of symptomatic HF in the surveyed villages. This could be partially explained by the rural farming-based community setting but is also likely due to under-reporting of symptoms. Our review of the projected national estimates suggests an alarming burden of HF in India despite a younger population than the developed nations. A significant proportion of this burden may be preventable with better screening and early and adequate treatment of the risk factors.

56 Comparison of morbidity, mortality and cost impact of stage B and stage C heart failure underline the clinical and economic need for national heart failure prevention strategy

Introduction Heart failure (HF) has hit the epidemic proportion and is incurring significant cost to the health care system. Given the major morbidity, mortality and economic burden of this condition, a prevention strategy needs careful assessment to determine its role in the future health care policy. The STOP-HF project has underlined the clinical and cost effectiveness of a biomarker driven risk stratification and intervention strategy in those at risk for HF. Supportive data to establish the widespread application of this strategy would come from a comparative analysis of patients at risk for HF and those of a new community diagnosis of HF followed in a disease management programme. To assess the importance of HF prevention, we report the morbidity, mortality and economic costs of an at-risk cohort compared to established community HF. Method 1566 patients attending the HF prevention unit and rapid access clinic for possible new onset HF from 2002 up to end of 2012 were selected for this analysis. Using Doppler echocardiography, patients were categorised to stage A (risk factors for HF with no structural or functional impairment of the heart), stage B (asymptomatic LV systolic dysfunction [B-LVSD], or isolated LV diastolic dysfunction [B-LVDD]), and stage C (symptomatic HF with reduce LVEF [C-REF] or preserved LVEF [C-PEF]). Follow-up time for events was until the end of 2014. Hospitalisations were collected, confirmed by HIPE records and categorised as HF event, other cardiovascular (other-CV) event, non-cardiovascular (non-CV) event and death. In the pre-specified cost analysis, direct costs associated with emergency hospitalisations were analysed using a case-mix approach from the perspective of the healthcare provider. Result 1097 patients were in stage A, 173 stage B (112 B-LVDD and 61 B-LVSD), and 296 stage C (181 C-PEF and 115 C-REF). BNP increased through the stages at 19.1 pg/mL, 62.8 pg/mL, 67 pg/mL, 185 pg/mL and 384.5 pg/mL. Figure 1 showed that the HF events and death rate increased across the spectrum. The other-CV events are higher in B-LVDD group compare to the B-LVSD group. C-REF has more other-CV events compared to C-PEF, but the non-CV events are similar. In the costing sub-study of 1,025 patients for whom detailed costing data were available, emergency CV hospitalisation costs per patient per annum were €313 ± 1222, €350 ± 1095 and €899 ± 1228 for stages A to C respectively. The data also show that emergency non-CV hospitalisation costs per patient per annum were €422 ± 1078, €560 ± 1316 and €2739 ± 4769 for stages A to C respectively, underlining a dramatic 4-fold increase emergency hospitalisation costs between stage B and C. Conclusion The clinical and costs impact of HF care escalate significantly with the development of the symptomatic phase of HF syndrome. These data along with the positive clinical and cost effectiveness analysis of the STOP-HF data underline the need for national activation of the STOP-HF strategy.

Health seeking behavior of patients with chronic heart failure in community

Total 1 500 subjects aged over 60 years were selected from 10 community health service centers with cluster sampling method. A questionnaire survey and physical examination were performed in all subjects. Sixty five patients with chronic heart failure were detected. The questionnaire showed that 77.6% (38/49) patients were diagnosed in tertiary hospitals, and 12.2% (6/49) were diagnosed in community hospitals. When heart failure occurred, most patients (37.7%, 20/53) chose to take a taxi to the tertiary hospital directly, and less patients (17.0%, 9/53) contacted community doctors. When a heart attack happened, 68.8%(33/48) of the patients could reach the hospital within 30 min, and 55.3% (26/47) within 60 min. 45.7% (21/46) elderly patients were hospitalized for heart failure once a year; 31.1% (14/45) were in hospital for less than 10 d each time. 46.0% (23/50) heart failure patients had received health education and 40.0%(16/40) had taken drugs under supervision; the majority health educators were community doctors and majority supervisors were family members. The results suggest that the confirmed diagnosis and treatment of heart failure patients still rely on tertiary hospitals, community health institutions play an important role in health education and management of heart failure patients outside hospitals. But the utilization of community health services is still not enough in community health service centers. Key words: Disease management; Heart failure

Plasma Aldosterone and Heart Failure in the General Community

and 687pg/ml, respectively. BNP decreased in both groups at discharge (60% for MSASV vs. 40% for standard care). However, after 3 days, BNP in the standard care group had increased to a median of 920pg/ml, while BNP in the MV-ASV group demonstrated a continued and marked decrease to a median of 353pg/ml. Compared to admission, the 3 day Likert Breathing scores demonstrated an average 52% increase in the MV-ASV group, versus a 24% increase in the standard care group. Conclusion: The use of MV-ASV in patients with ADHF resulted in a rapid early improvement in dyspnea as well as a marked drop in BNP levels, suggesting mitigations of pulmonary edema and neurohormonal activity.

Characterizing patients with chronic heart failure in community care after hospitalization: a potential role for ivabradine.

To identify the prevalence and characteristics of recently hospitalized chronic heart failure (CHF) patients in community care who meet the indication for ivabradine. A retrospective clinical audit of CHF patients recently hospitalized with acute decompensated heart failure (ADHF) and subsequently referred to the Tayside Heart Failure Nurse Liaison Service (THFNLS), a Scottish nurse-led community heart failure liaison service. Inclusion criteria were previous hospitalization with ADHF, subsequent referral to the THFNLS, data for ≥ 2 nurse visits, and a recorded pulse. The main outcome measure was the proportion of patients who meet the indicated criteria for ivabradine. In the UK, ivabradine is indicated for CHF with systolic dysfunction in patients in sinus rhythm, with a heart rate ≥ 75 bpm, and NYHA class II-class IV. After up-titration of a beta-blocker, 19.0% of patients in the full dataset (158 of 830) met the indication for ivabradine at the last visit. Of these "ivabradine-suitable" patients, 101 of 158 (63.9%) received bisoprolol "at any time" during the study period; 20 of 158 (12.7%) achieved the target dose (10 mg daily); 52 of 158 (32.9%) received 5 mg or 7.5 mg daily; and 93 of 158 (58.9%) received <5 mg daily. In this group of Scottish patients previously hospitalized with ADHF and under the care of a protocol-driven clinic, 19% met the indication for ivabradine and may benefit from the increased control of CHF that ivabradine can provide. Among these "ivabradine-suitable" patients, <15% achieved the target dose of beta-blockers, illustrating the substantial clinical need for a well-tolerated and effective therapy such as ivabradine.

Prescribing Patterns to Optimize Heart Rate: Analysis of 1,000 Consecutive Outpatient Appointments to a Single Heart Failure Clinic Over a 6-Month Period

ObjectivesThis study sought to characterize patients attending a community heart failure (HF) clinic and identified those who were eligible for optimization of beta-blockers (BB) or ivabradine. BackgroundAmong patients with HF due to left ventricular systolic dysfunction in sinus rhythm, those with higher resting heart rate have a worse prognosis. Reducing sinus rate to 50 to 60 beats/min might improve outcomes. MethodsA total of 1,000 consecutively scheduled HF clinic follow-up appointments over a 6-month period were reviewed. Demographic, clinical, and echocardiographic data were collected for patients who attended (824 unique patients; 555 men). Mean age was 74 ± 11 years, median N-terminal pro–B-type natriuretic peptide levels were 1,002 ng/l (interquartile range: 367 to 2,151 ng/l), and the mean left ventricular ejection fraction (LVEF) was 44 ± 11%. A total of 202 (25%), 252 (31%), and 370 (45%) patients had LVEFs of ≤35%, 36% to 49%, and ≥50%, respectively. Of patients with LVEF ≤35%, 142 (70%) were in sinus rhythm. ResultsAt 70 clinic visits, 58 patients with LVEFs of ≤35% were in sinus rhythm and had heart rates ≥70 beats/min. Of these, 13 patients had their BB dose increased, 20 were potentially eligible for, but did not have, BB uptitration, 15 were already taking target doses of BBs, and 10 patients were reported to be intolerant of higher doses. Thus, 25 patients were potentially eligible for ivabradine according to European Society of Cardiology guidelines; this number dropped to 14 when the United Kingdom National Institute for Health and Care Excellence guidelines were applied. ConclusionsAmong patients with LVEFs of ≤35%, most are treated with BBs and have a heart rate at rest of <70 beats/min; 12% of these patients might be eligible for ivabradine.

An article examining the changes in age, health complexity and disease type in people seen by a heart failure outreach service in Sydney from 2002-2014

Introduction: Since 2001 the heart failure service at Prince of Wales Hospital, Randwick has evolved to enhance specialist multidisciplinary outreach care. Over time changes in service delivery have been necessary to meet the demands of increased utilisation of the service, growing health complexities and ageing of the population. Objectives: To identify the changes in characteristics and complex health needs of patients referred to and seen by the heart failure service between 2001 to 2005 and 2012 to 2014. Methods: A retrospective analysis of data available for all patients referred to the heart failure service in 2001-2005 and 2012-2014 examining patient age, heart failure with reduced versus preserved ejection fraction and number of serious comorbidities. Results: Data from all 870 patients referred and reviewed by the service from 2001-2005 (n=545) and 2012-2014 (n=325) were included for analysis. Significant changes were found between the two time periods in patients age (mean {SD}) from 76.8{10.7} vs 78.4{12.2} (p=0.04) and the number of serious comorbidities (3.2{1.6} vs 4.4{1.9}, p=<.01). The proportion of patients with heart failure preserved ejection fraction was also significantly higher over time (30.8% vs 51.3%, p=<.01.) Conclusion: Demand for community heart failure services appears to be increasing, with patients older in age, a higher prevalence of preserved ejection fraction heart failure and more comorbid conditions. To continue to ensure best practice as per national and international heart failure guideline recommendations, service provision and funding will need to be regularly reviewed and adapted to meet the changes in demand.

Medicines management in the community: An HF specialist nurse prescriber's experience

Heart failure (HF) is a complex clinical syndrome of signs and symptoms resulting from structural or functional impairment of the heart to effectively deliver oxygen to meet the body's metabolic demands. It is associated with considerable mortality and morbidity and an uncertain disease trajectory. A significant part of the multifaceted care delivered by a community HF specialist nurse involves medicines management in relation to improving prognosis and managing symptoms. The prescribing process involves complex clinical and organisational decision-making to achieve safe and effective outcomes for patients. As part of, often small, HF specialist nurse services that work collaboratively with other health-care teams, their challenges can be less well understood within wider health and commissioning services. This practice-centred case study describes the profile of patients on a community HF specialist nurse's caseload and the nature and process of prescribing decisions made over a 3-month period and their subsequent effects on the prescribing practice, interdisciplinary working and related patient outcomes.

High-sensitivity troponin I and amino-terminal pro--B-type natriuretic peptide predict heart failure and mortality in the general population.

High-sensitivity cardiac troponin assays have potent prognostic value in stable cardiovascular disease cohorts. Our objective was to assess the prognostic utility of a novel cardiac troponin I (cTnI) high-sensitivity assay, independently and in combination with amino-terminal pro-B-type natriuretic peptide (NT-proBNP), for the future development of heart failure and mortality in the general community. A well-characterized community-based cohort of 2042 participants underwent clinical assessment and echocardiographic evaluation. Baseline measurements of cTnI with a high-sensitivity assay and NT-proBNP were obtained in 1843 individuals. Participants were followed for new-onset heart failure and mortality with median (25th, 75th percentile) follow-up of 10.7 (7.9, 11.6) and 12.1 (10.4, 13.0) years, respectively. When measured with a high-sensitivity assay, cTnI greater than the sex-specific 80th percentile was independently predictive of heart failure [hazard ratio 2.56 (95% confidence interval 1.88-3.50), P < 0.001] and mortality [1.91(1.49-2.46), P < 0.001] beyond conventional risk factors in this community-based cohort, with significant increases in the net reclassification improvement for heart failure. The prognostic utility of cTnI measured with a high-sensitivity assay goes beyond NT-proBNP, yet our data suggest that these 2 assays are complementary and most beneficial when evaluated together in identifying at-risk individuals in the community. Our findings lay the foundation for prospective studies aimed at identification of individuals at high risk by use of a multimarker approach, followed by aggressive prevention strategies to prevent subsequent heart failure.

Elevated pulmonary artery systolic pressure predicts heart failure admissions in African Americans: Jackson Heart Study.

Although elevated pulmonary artery systolic pressure (PASP) is associated with heart failure (HF), whether PASP measurement can help predict future HF admissions is not known, especially in African Americans who are at increased risk for HF. We hypothesized that elevated PASP is associated with increased risk of HF admission and improves HF prediction in African American population. We conducted a longitudinal analysis using the Jackson Heart Study cohort (n=3125; 32.2% men) with baseline echocardiography-derived PASP and follow-up for HF admissions. Hazard ratio for HF admission was estimated using Cox proportional hazard model adjusted for variables in the Atherosclerosis Risk in Community (ARIC) HF prediction model. During a median follow-up of 3.46 years, 3.42% of the cohort was admitted for HF. Subjects with HF had a higher PASP (35.6±11.4 versus 27.6±6.9 mm Hg; P<0.001). The hazard of HF admission increased with higher baseline PASP (adjusted hazard ratio per 10 mm Hg increase in PASP: 2.03; 95% confidence interval, 1.67-2.48; adjusted hazard ratio for highest [≥33 mm Hg] versus lowest quartile [<24 mm Hg] of PASP: 2.69; 95% confidence interval, 1.43-5.06) and remained significant irrespective of history of HF or preserved/reduced ejection fraction. Addition of PASP to the ARIC model resulted in a significant improvement in model discrimination (area under the curve=0.82 before versus 0.84 after; P=0.03) and improved net reclassification index (11-15%) using PASP as a continuous or dichotomous (cutoff=33 mm Hg) variable. Elevated PASP predicts HF admissions in African Americans and may aid in early identification of at-risk subjects for aggressive risk factor modification.

47 Knowsley Trigger Tool - A Tool to Aid Identification of Heart Failure Patients Nearing End of Life and Promote Communication Between Heart Failure Specialist Nurses and Primary Care

IntroductionDespite advanced in diagnosis and medical therapies heart failure remains an incurable long term condition; with an increasing prevalence it has arguably the greatest impact on quality of life.The disease...