Heart Failure In Primary Care Research Articles

Effectiveness of the Assessment of Burden of Chronic Conditions (ABCC)-tool in patients with asthma, COPD, type 2 diabetes mellitus, and heart failure: A pragmatic clustered quasi-experimental study in the Netherlands

Background The Assessment of Burden of Chronic Conditions (ABCC)-tool was developed to optimise chronic care. Objectives This study aimed to assess the effectiveness of the ABCC-tool in patients with COPD, asthma, type 2 diabetes, and/or heart failure in primary care in the Netherlands. Methods The study had a pragmatic, clustered, two-armed, quasi-experimental design. The intervention group (41 general practices; 176 patients) used the ABCC-tool during routine consultations and the control group (14 general practices; 61 patients) received usual care. The primary outcome was a change in perceived quality of care (PACIC; Patient Assessment of Chronic Illness Care) after 18 months. Secondary outcomes included change in the PACIC after 6 and 12 months, and in quality of life (EQ-5D-5L; EuroQol-5D-5L), capability well-being (ICECAP-A; ICEpop CAPability measure for Adults), and patients’ activation (PAM; Patient Activation Measure) after 6, 12, and 18 months for the total group and conditions separately. Results We observed a significant difference in the PACIC after 6, 12, and 18 months (18 months: 0.388 points; 95%CI: 0.089–0.687; p = 0.011) for the total group and after 6 and 12 months for type 2 diabetes. After 18 months, we observed a significant difference in the PAM for the total group but not at 6 and 12 months, and not for type 2 diabetes. All significant effects were in favour of the intervention group. No significant differences were found for the EQ-5D-5L and the ICECAP-A. Conclusion Use of the ABCC-tool has a positive effect on perceived quality of care and patients’ activation, which makes the tool ready for use in clinical practice. Healthcare providers (e.g. general practitioners and practice nurses) can use the tool to provide person-centred care. Trial registration number: ClinicalTrials.gov Registry (NCT04127383).

Use of sacubitril/valsartan in patients with heart failure in primary care in Germany: the AURORA-HF noninterventional study.

Sacubitril/valsartan (Sac/Val) is the first angiotensin receptor-neprilysin inhibitor indicated for symptomatic chronic heart failure (HF) with reduced ejection fraction (HFrEF). Given most patients with HF in Germany are managed by general practitioners, AURORA-HF investigated the baseline characteristics and 1‑year follow-up of patients starting Sac/Val in primary care in Germany. This was aprospective, multicenter, observational study, with all treatment decisions independent of participation. The only inclusion criteria were adults (age ≥ 18years) with symptomatic HFrEF. The study comprised four groups, depending on therapy on entry: initiation of (1)Sac/Val or (2)other HF therapy; and no change in HF regimen that (3)included or (4)did not include Sac/Val. Baseline data were captured for all groups; 1‑year follow-up was recorded in groups1 and2. Of 1278 patients in the baseline analyses, 513 (40.1%) had newly started Sac/Val (449 [87.5%] completing the 1‑year follow-up), 265 (20.7%) had newly started other HF regimens (245, 92.5%) with 1‑year follow-up, while 249 with Sac/Val (19.5%) and 251 without Sac/Val (19.6%) patients had unchanged therapies. Patients treated with Sac/Val had ahigher New York Heart Association (NYHA) class at baseline and more often aleft ventricular ejection fraction (LVEF) < 35%. The only baseline parameter significantly correlating with Sac/Val discontinuation during the 1‑year follow-up was diabetes mellitus (odds ratio: 2.44; 95% confidence interval: 1.14-5.24). In the Sac/Val group,30.7% of patients were in NYHA classI/II on study entry, improving to 51.0% at 1‑year follow-up. In the no Sac/Val group, the corresponding rates of NYHA I and II classes were 49.8% and 58.2%, respectively. The overall adverse event profile of Sac/Val was good, with only 6.0% patients experiencing serious adverse events leading to permanent discontinuation. In patients with symptomatic HFrEF treated in primary care, the group in whom Sac/Val was initiated was characterized by ahigher NYHA class and lower LVEF compared to patients in whom Sac/Val was not initiated. Sac/Val was well tolerated, with ahigh proportion completing 1year of therapy.

Heart failure awareness days: heart failure in primary care

In recognition of this year's heart failure awareness days, taking place between 29 April and 5 May, Nasa‑Marie Wright presents a case study of suspected heart failure in a primary care setting and suggests recommendations for improving diagnosis and management.

Diagnostic properties of natriuretic peptides and opportunities for personalized thresholds for detecting heart failure in primary care.

Heart failure (HF) is a prevalent syndrome with considerable disease burden, healthcare utilization and costs. Timely diagnosis is essential to improve outcomes. This study aimed to compare the diagnostic performance of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) in detecting HF in primary care. Our second aim was to explore if personalized thresholds (using age, sex, or other readily available parameters) would further improve diagnostic accuracy over universal thresholds. A retrospective study was performed among patients without prior HF who underwent natriuretic peptide (NP) testing in the Amsterdam General Practice Network between January 2011 and December 2021. HF incidence was based on registration out to 90 days after NP testing. Diagnostic accuracy was evaluated with AUROC, sensitivity and specificity based on guideline-recommended thresholds (125 ng/L for NT-proBNP and 35 ng/L for BNP). We used inverse probability of treatment weighting to adjust for confounding. A total of 15,234 patients underwent NP testing, 6,870 with BNP (4.5 % had HF), and 8,364 with NT-proBNP (5.7 % had HF). NT-proBNP was more accurate than BNP, with an AUROC of 89.9 % (95 % CI: 88.4-91.2) vs. 85.9 % (95 % CI 83.5-88.2), with higher sensitivity (95.3 vs. 89.7 %) and specificity (59.1 vs. 58.0 %). Differentiating NP cut-off by clinical variables modestly improved diagnostic accuracy for BNP and NT-proBNP compared with a universal threshold. NT-proBNP outperforms BNP for detecting HF in primary care. Personalized instead of universal diagnostic thresholds led to modest improvement.

Body mass index and survival in people with heart failure

AimsIn people with heart failure (HF), a high body mass index (BMI) has been linked with better outcomes (‘obesity paradox’), but there is limited evidence in community populations across long-term...

Prevalence of heart failure phenotypes and current use of therapies in primary care: results from a nationwide study.

Heart failure (HF) is an increasing concern worldwide. A rising HF burden is expected due to the prospected future demographic changes with aging populations. Consequently, the long-term follow-up and treatment will be performed increasingly by primary care physicians in the future. Contemporary data on HF patients in primary care are needed to plan and ensure an effective and safe follow-up of future patients. The electronic patient journals of 148 primary care clinics in Denmark were searched in a standardized manner to identify patients with HF [code K77 of the International Classification of Primary Care, Second Edition]. Prespecified variables including demographic information, clinical variables, co-morbidities, prescribed medications, and setting of follow-up were recorded. In total, 1111 patients were included in the study. The mean timepoint for the HF diagnosis was August 2018. In 95% of cases, the diagnosis of HF was made in a specialized setting. The echocardiogram data used for phenotyping were available in 1042 (94%) of the 1111 patients. HF with reduced ejection fraction (HFrEF) was present in 43%, recovered HFrEF in 31%, and HF with mildly reduced (HFmrEF) or preserved ejection fraction (HFpEF) in 26%. In patients with HFrEF or recovered HFrEF, fundamental treatments were prescribed in 86% for angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or angiotensin receptor neprilysin inhibitor (ARNI), in 82% for beta-blocker, in 38% for mineralocorticoid receptor antagonist (MRA), and in 12% for sodium-glucose co-transporter-2 inhibitor (SGLT2i). Older patients were treated to a significantly lesser extent than young patients for all drug classes [odds ratio (OR) point estimates 0.50 to 0.69, all P-values<0.05]. In patients with HFmrEF or HFpEF, an ACEI, ARB, or ARNI was prescribed in 67%, beta-blocker in 67%, MRA in 22%, and SGLT2i in 7.4% with significantly lower probability of treatment compared to patients with HFrEF or recovered HFrEF [OR point estimates 0.33 to 0.57, all P-values<0.05]. The setting of follow-up was available in 96% of patients. Irrespective of HF phenotype, follow-up was performed solely in primary care in 64%. These patients were generally treated to a lesser extent with HF therapies compared with patients where follow-up included specialized care, yet differences were generally small. HFrEF is the most common phenotype of HF in primary care followed by recovered HFrEF and fundamental therapies are markedly underutilized. Initiatives to increase the use of recommended therapies are needed to improve the future care of patients with HF.

Detecting heart failure using novel bio-signals and a knowledge enhanced neural network

BackgroundClinical decisions about Heart Failure (HF) are frequently based on measurements of left ventricular ejection fraction (LVEF), relying mainly on echocardiography measurements for evaluating structural and functional abnormalities of heart disease. As echocardiography is not available in primary care, this means that HF cannot be detected on initial patient presentation. Instead, physicians in primary care must rely on a clinical diagnosis that can take weeks, even months of costly testing and clinical visits. As a result, the opportunity for early detection of HF is lost. Methods and resultsThe standard 12-Lead ECG provides only limited diagnostic evidence for many common heart problems. ECG findings typically show low sensitivity for structural heart abnormalities and low specificity for function abnormalities, e.g., systolic dysfunction. As a result, structural and functional heart abnormalities are typically diagnosed by echocardiography in secondary care, effectively creating a diagnostic gap between primary and secondary care. This diagnostic gap was successfully reduced by an AI solution, the Cardio-HART™ (CHART), which uses Knowledge-enhanced Neural Networks to process novel bio-signals. Cardio-HART reached higher performance in prediction of HF when compared to the best ECG-based criteria: sensitivity increased from 53.5% to 82.8%, specificity from 85.1% to 86.9%, positive predictive value from 57.1% to 70.0%, the F-score from 56.4% to 72.2%, and area under curve from 0.79 to 0.91. The sensitivity of the HF-indicated findings is doubled by the AI compared to the best rule-based ECG-findings with a similar specificity level: from 38.6% to 71%. ConclusionUsing an AI solution to process ECG and novel bio-signals, the CHART algorithms are able to predict structural, functional, and valve abnormalities, effectively reducing this diagnostic gap, thereby allowing for the early detection of most common heart diseases and HF in primary care.

Body mass index and survival in people with heart failure

Abstract Background People with obesity are twice as likely to develop heart failure (HF) compared to people with a healthy body mass index (BMI) [1]. However, among people with HF a higher BMI has been linked to a reduced risk of all-cause mortality, a concept known as the “obesity paradox” [2]. Purpose To examine the association between BMI and survival in patients with chronic HF among a large primary care cohort. Methods We extracted data from the Clinical Practice Research Datalink of primary care records from 1st January 2000 to 31st December 2017 and included 47,531 patients with an incident diagnosis of HF, who were aged 45 years and over and who had a recorded BMI. Patients were stratified into categories of baseline BMI as underweight (BMI &amp;lt;18.5 kg/m2), healthy weight (BMI 18.5 to 24.9 kg/m2), overweight (BMI 25.0 to 29.9 kg/m2) or obese, with obesity split into class I (30.0–34.9 kg/m2), class II (35.0–39.9 kg/m2) and class III (40 kg/m2 and over). The primary outcome was all-cause mortality. We used Kaplan-Meier curves and log rank tests to compare survival in people with HF, based on baseline BMI. We also report a Cox regression model for risk of all-cause mortality among people with HF comparing BMI categories. Results There were 25,013 deaths during the study follow-up. The average age of participants was 77.1 years (SD 10.6) and mean BMI was 27.9 (SD 6.1). In an age- and sex-adjusted analysis, people who were underweight were at increased risk of all-cause mortality compared to people with healthy weight (HR 1.52, 95% CI 1.41 to 1.64). People with overweight (HR 0.81, 95% CI 0.79 to 0.84), obesity class I (HR 0.79, 95% CI 0.76 to 0.82) and obesity class II (HR 0.78, 95% CI 0.74 to 0.82) were at decreased risk of all-cause mortality. People with obesity class III had no difference in risk of death compared to people with healthy weight (HR 0.95, 95% CI 0.88 to 1.02). In a Kaplan-Meier analysis, there was an inverse relationship between body weight and risk of death, even within the first year of follow-up. Conclusion In our large community cohort of people with HF, we found an inverse relationship between BMI and survival. Underweight people with HF have the poorest prognosis and should be identified as high-risk. Conversely, people with HF who are overweight or obese (class I and II) are at lower risk of death confirming the obesity paradox in a real-world primary care population. These findings suggest a more cautious approach to weight management in overweight and obese patients may be needed for people with HF in primary care. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The SurviveHF study was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Oxford at Oxford Health NHS Foundation Trust and the Wellcome Institutional Strategic Fund. The funders did not have any role in the design of the study, analysis and interpretation of the data, or writing of the results for publication.

Machine learning optimization of an electronic health record audit for heart failure in primary care.

AimsThe diagnosis of heart failure (HF) is an important problem in primary care. We previously demonstrated a 74% increase in registered HF diagnoses in primary care electronic health records (EHRs) following an extended audit procedure. What remains unclear is the accuracy of registered HF pre‐audit and which EHR variables are most important in the extended audit strategy. This study aims to describe the diagnostic HF classification sequence at different stages, assess general practitioner (GP) HF misclassification, and test the predictive performance of an optimized audit.Methods and resultsThis is a secondary analysis of the OSCAR‐HF study, a prospective observational trial including 51 participating GPs. OSCAR used an extended audit based on typical HF risk factors, signs, symptoms, and medications in GPs' EHR. This resulted in a list of possible HF patients, which participating GPs had to classify as HF or non‐HF. We compared registered HF diagnoses before and after GPs' assessment. For our analysis of audit performance, we used GPs' assessment of HF as primary outcome and audit queries as dichotomous predictor variables for a gradient boosted machine (GBM) decision tree algorithm and logistic regression model. Of the 18 011 patients eligible for the audit intervention, 4678 (26.0%) were identified as possible HF patients and submitted for GPs' assessment in the audit stage. There were 310 patients with registered HF before GP assessment, of whom 146 (47.1%) were judged not to have HF by their GP (over‐registration). There were 538 patients with registered HF after GP assessment, of whom 374 (69.5%) did not have registered HF before GP assessment (under‐registration). The GBM and logistic regression model had a comparable predictive performance (area under the curve of 0.70 [95% confidence interval 0.65–0.77] and 0.69 [95% confidence interval 0.64–0.75], respectively). This was not significantly impacted by reducing the set of predictor variables to the 10 most important variables identified in the GBM model (free‐text and coded cardiomyopathy, ischaemic heart disease and atrial fibrillation, digoxin, mineralocorticoid receptor antagonists, and combinations of renin‐angiotensin system inhibitors and beta‐blockers with diuretics). This optimized query set was enough to identify 86% (n = 461/538) of GPs' self‐assessed HF population with a 33% reduction (n = 1537/4678) in screening caseload.ConclusionsDiagnostic coding of HF in primary care health records is inaccurate with a high degree of under‐registration and over‐registration. An optimized query set enabled identification of more than 80% of GPs' self‐assessed HF population.

PRospective Evaluation of natriuretic peptide-based reFERral of patients with chronic heart failure in primary care (PREFER): a real-world study

ObjectiveTo assess current management practice of heart failure with reduced ejection fraction (HFrEF) in multinational primary care (PC) and determine whether N-terminal-pro-B-type natriuretic peptide (NT-pro-BNP)-guided referral of HFrEF patients from...

Primary care heart failure service identifies a missed cohort of heart failure patients with reduced ejection fraction.

AimsWe explored whether a missed cohort of patients in the community with heart failure (HF) and left ventricular systolic dysfunction (LVSD) could be identified and receive treatment optimization through a primary care heart failure (PCHF) service.Methods and resultsPCHF is a partnership between Inspira Health, National Health Service Cardiologists and Medtronic. The PCHF service uses retrospective clinical audit to identify patients requiring a prospective face-to-face consultation with a consultant cardiologist for clinical review of their HF management within primary care. The service is delivered via five phases: (i) system interrogation of general practitioner (GP) systems; (ii) clinical audit of medical records; (iii) patient invitation; (iv) consultant reviews; and (v) follow-up. A total of 78 GP practices (864 194 population) have participated. In total, 19 393 patients’ records were audited. HF register was 9668 (prevalence 1.1%) with 6162 patients coded with LVSD (prevalence 0.7%). HF case finder identified 9725 additional patients to be audited of whom 2916 patients required LVSD codes adding to the patient medical record (47% increase in LVSD). Prevalence of HF with LVSD increased from 0.7% to 1.05%. A total of 662 patients were invited for consultant cardiologist review at their local GP practice. The service found that within primary care, 27% of HF patients identified for a cardiologist consultation were eligible for complex device therapy, 45% required medicines optimization, and 47% of patients audited required diagnosis codes adding to their GP record.ConclusionA PCHF service can identify a missed cohort of patients with HF and LVSD, enabling the optimization of prognostic medication and an increase in device prescription.

Diagnosing heart failure in primary care: individual patient data meta‐analysis of two European prospective studies

AimsNatriuretic peptides are helpful in detecting chronic heart failure (HF) in primary care; however, there are a lack of data evaluating thresholds recommended by clinical guidelines. This study assesses the diagnostic accuracy of N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) using combined individual patient data from two studies in the UK and the Netherlands.Methods and resultsRandom effects methods were used to estimate the performance characteristics of NT‐proBNP thresholds recommended by the European Society of Cardiology (ESC) and the UK National Institute for Health and Care Excellence (NICE) guidelines. New onset HF was diagnosed in 313 of 1073 (29.2%) participants. Age, sex, and atrial fibrillation‐adjusted NT‐proBNP was a better predictor of HF with reduced ejection fraction (HFrEF) than HF preserved ejection fraction (HFpEF), with area under receiver operating characteristic curve of 0.82 95% CI (0.78 to 0.86) vs. 0.71 (0.66 to 0.75). In persons aged 70 years and over, the ESC threshold at 125 ng/L for detection of all‐cause HF had summary negative predictive value (NPV) of 84.9% (81.6 to 88.2), positive predictive value (PPV) 68.1% (63.1 to 73.3), sensitivity 74.9% (69.5 to 80.3), and specificity 80.1% (76.9 to 83.4); the NICE threshold at 400 ng/L had summary NPV of 74.7% (72.1 to 77.2), PPV 81.8% (73.3 to 89.5), sensitivity 43.5% (37.2 to 49.8), and specificity 94.5% (92.3 to 96.7).ConclusionsN‐terminal pro‐B‐type natriuretic peptide is better at detecting HFrEF than HFpEF in a primary care setting. In persons aged 70 and over, the ESC threshold of 125 ng/L is more accurate at detecting and excluding HF than the higher level suggested in NICE guidelines. More prospective data are required to establish the optimal NP threshold for detecting chronic HF in general practice.

Heart failure epidemiology and treatment in primary care: a retrospective cross-sectional study.

AimsHeart failure is one of the leading causes of morbidity and mortality worldwide, but little is known on heart failure epidemiology and treatment in primary care. This study described patients with heart failure treated by general practitioners, with focus on drug prescriptions and especially on the only specific treatment for heart failure with reduced ejection fraction, namely sacubitril/valsartan.Methods and resultsThis was a retrospective cross‐sectional study using data from an electronic medical record database of Swiss general practitioners from 2016 to 2019. Multilevel logistic regression was used to find determinants of sacubitril/valsartan prescription; odds ratios (ORs) and 95% confidence intervals (CIs) were reported. We identified 1288 heart failure patients (48.5% women; age: median 85 years, interquartile range 77–90 years) by means of diagnosis code, representing 0.5% of patients consulting a general practitioner during the observation period. About 73.6% received a renin–angiotensin–aldosterone system inhibitor, 67.8% a beta‐blocker, 34.6% a calcium channel blocker, 86.1% a diuretic, and 40.1% another cardiac drug. Sacubitril/valsartan was prescribed in 6% predominantly male patients (OR 2.10, CI 1.25–3.84), of younger age (OR 0.59 per increase in 10 years, CI 0.49–0.71), with diabetes mellitus (OR 1.76, CI 1.07–2.90). The recommended starting dose for sacubitril/valsartan was achieved in 67.1% and the target dose in 28.6% of patients.ConclusionsPrevalence of heart failure among patients treated by general practitioners was low. Considering the disease burden and association with multimorbidity, awareness of heart failure in primary care should be increased, with the aim to optimize heart failure therapy.

Prevalência de diagnósticos de enfermagem prioritários em indivíduos segundo fatores de risco para insuficiência cardíaca na atenção primária

Introdução: a insuficiência cardíaca é um grave problema de saúde pública com elevada morbimortalidade, com estimativa de 23 milhões ao redor do mundo. Objetivo: estimar a prevalência de diagnósticos de enfermagem prioritários nos indivíduos com fatores de risco para insuficiência cardíaca na atenção primária. Metodologia: trata-se de análise secundária de uma amostra de 603 indivíduos do Estudo Digitalis, para os quais foi selecionado pelo método delphi, 25(vinte e cinco) diagnósticos de enfermagem prioritários. Resultados: dos 603 participantes, identificou-se 437 hipertensos, 380 diabéticos, 180 obesos e 52 com doença arterial coronariana, e ainda predominância feminina e faixa etária de 45 a 69 anos. E ainda a associação significativa com variáveis sociodemográficas, hábitos de vida e fatores de risco deu-se com onze diagnósticos. Conclusão: a identificação destes diagnósticos de enfermagem associados principalmente aos fatores de risco trouxe a perspectiva do planejamento de ações em saúde aos indivíduos com fatores de risco para o desenvolvimento da insuficiência cardíaca na atenção primária.

Current and Emerging Issues in the Management of Heart Failure in Primary Care

Describe the epidemiology of heart failure in people with diabetes mellitus. Implement evidence-based nonpharmacologic and pharmacologic therapies for heart failure with preserved ejection fraction and heart failure with reduced ejection fraction as recommended in current guidelines. Characterize the role of glucose-lowering medications, focusing on the sodium glucose cotransporter-2 inhibitors, for the treatment of people with type 2 diabetes mellitus.

Lung Ultrasound for Heart Failure Diagnosis in Primary Care

Lung ultrasound (LUS) is useful for diagnosing pulmonary congestion, but its value in primary care remains unclear. We investigated whether LUS improved diagnostic accuracy in outpatients with heart failure (HF) suspicion. LUS was performed on 2 anterior (A), 2 lateral (L), and 2 posterior (P) areas per hemithorax. An area was positive when ≥3 B-lines were observed. Two diagnostic criteria were used: for LUS-C1, 2 positive areas of 4 (A-L) on each hemithorax; and for LUS-C2, 2 positive areas of 6 (A-L-P) on each hemithorax. A cardiologist blinded to LUS validated HF diagnosis. 162 patients were included (age 75.6 ± 9.4 years, 70.4% women). Both LUS criteria, alone and combined with other HF diagnostic criteria, were accurate for identifying HF. LUS-C2 outperformed LUS-C1, showing remarkable specificity (0.99) and positive predictive value (0.92). LUS-C2, together with Framingham criteria, N-terminal pro-B-type natriuretic peptide, and electrocardiogram, added diagnostic value (area under the receiver operating characteristic curves 0.90 with LUS-C2 vs 0.84 without; P = .006). In the absence of N-terminal pro-B-type natriuretic peptide, LUS-C2 significantly reclassified one-third of patients above Framingham criteria and electrocardiogram (net reclassification improvement 0.65, 95% confidence interval 0.04-1.1). LUS was accurate enough to rule-in HF in a primary care setting. The accuracy of diagnostic workup for HF in primary care is enhanced by incorporating LUS, irrespective NT-proBNP availability.

An evidence-based structured one-year programme to sustain physical activity in patients with heart failure in primary care: A non-randomized longitudinal feasibility study.

AimThe primary objective of this non‐randomized feasibility study was to test a 1‐year model programme for sustaining/increasing patients’ motivation to perform daily physical activity.DesignNon‐randomized longitudinal feasibility study with a one‐group repeated measures design.MethodsThe study took place at a primary care centre in mid‐Sweden in 2017–2018. The model programme included individual and group‐based support, individualized physical activity prescriptions, a wrist‐worn activity tracker and an activity diary. The main outcomes were the participants’ perceptions of programme feasibility and scores on the Exercise Self‐Efficacy Scale.ResultsSeven patients were recruited. Six patients completed the programme that was perceived to imply learning, motivation and support. Compared with baseline, the median score of the Exercise Self‐Efficacy Scale improved 3 months after participants completed the programme.

Association of depression and anxiety with adherence in primary care patients with heart failure-cross-sectional results of the observational RECODE-HF cohort study.

Psychological distress has a negative impact on the prognosis and quality of life for patients with heart failure. We investigated the association between psychological distress and the patients' adherence to medical treatment (medication adherence) and self-care advice (lifestyle adherence) in heart failure. We further examined whether there are different factors associated with low medication compared to low lifestyle adherence. This secondary analysis of the RECODE-HF cohort study analyzed baseline data of 3099 primary care heart failure patients aged 74 ± 10 years, 44.5 % female. Using multivariable regression, factors relating to medication and lifestyle adherence were investigated in order to estimate the extent to which these factors confound the association between psychological distress and adherence. Psychological distress was significantly associated with poorer medication adherence but not with lifestyle adherence after controlling for confounders. We identified different factors associated with medication compared to lifestyle adherence. A higher body mass index, a less developed social network, living alone, fewer chronic co-morbidities and unawareness of the heart failure diagnosis were only related to lower lifestyle adherence. Higher education was associated with poorer medication adherence. Male sex, younger age, lower self-efficacy and less familiar relation with the general practitioner were common factors associated with both lower medication and lifestyle adherence. Promising factors for increasing medication adherence (reduction of psychological distress) and lifestyle adherence (explaining the patient his/her heart failure diagnosis more than once and increase in the patients' self-efficacy), which were found in this cross-sectional study, must be further investigated in longitudinal studies.

Tissue Doppler indices of diastolic function as prognosticator in patients without heart failure in primary care

BackgroundTissue Doppler imaging (TDI) indices of left ventricular (LV) diastolic function provide incremental prognostic information on mortality and morbidity in the general population and in several clinical scenarios. Their independent, additional role in outpatients with normal LV ejection fraction (LVEF) and without heart failure (HF) is undefined. MethodsWe reviewed clinical and echocardiographic records of 2628 consecutive outpatients 52.8% male, median age 71 years) with LVEF > 50% without concurrent or prior HF, from the Cardiovascular Center of Trieste. We analyzed septal early mitral annular velocity (e’) and its combination with mitral peak early filling velocity (E/e’) in relation to the composite end-point of death and cardiovascular hospitalizations. ResultsDuring follow-up of 26 months (interquartile range: 12–41), 392 (15%) patients experienced the endpoint (88 deaths). Increasing E/e’ showed an overall association with the clinical end-point (log rank p < 0.02), but with no prognostic difference between the middle and upper tertile. Decreasing e’ also showed an association with the end-point, with a more balanced stepwise risk increase for increasing tertiles (log rank p < 0.01 for all contrasts). At multivariable analysis, E/e’ (either in tertiles or dichotomized according to the threshold of 15) was no longer associated with clinical outcome, whereas e’ independently predicted the combined endpoint [hazard ratio 0.73 (0.53-0.94), p = 0.04]. The prognostic value of e’ was incremental to that of other clinical and echocardiographic variables (p = 0.04). ConclusionsIn outpatients with normal LVEF and without HF, e’ and E/e’ are both associated with clinical end-points, though only e’ is an independent and incremental predictor of outcome. These findings suggest a potential role for e’ as a prognosticator, and spread a cautionary word about the utilization of septal E/e’ alone as a surrogate for a comprehensive assessment of diastolic function in this context.

Diagnostic accuracy and clinical impact of natriuretic peptide screening for the detection of heart failure in the community: a protocol for systematic review and meta-analysis

Introduction: Patients diagnosed with heart failure in primary care have a better prognosis than those diagnosed in hospital. However, most cases are missed in the community. Recent attention has focussed on the potential of early detection through screening. Natriuretic peptides (NPs) are tested by GPs and used to rule out heart failure in patients presenting with symptoms. Evidence is now emerging that they may also have a role in screening but their accuracy in this context and the associated optimal thresholds, have not been established. The impact that NP screening would have on patients and health care systems also remains unclear. Methods: We aim to undertake a systematic search of the following sources: Ovid Medline, Embase, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials. Screening, data extraction and critical appraisal will be carried out independently and in duplicate by two reviewers. We will include studies based in the community with &gt;100 participants that recruited a screened population. We will not add a study design filter and there will be no language restriction. The primary outcome will be the sensitivity and the specificity of NP screening and optimal thresholds for screening will be explored. Outcomes of interest for the impact analysis will include mortality, hospital admissions and cost effectiveness. This protocol has been developed in accordance with guidelines from the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P). Discussion: This systematic review will identify how accurately NP screen for heart failure in the community and explore where NP screening thresholds should be set. It also aims to summarise the clinical impact of this strategy. Together, these results should inform future interventions that may provide an alternative pathway to facilitate improved detection of heart failure in the community. Registration: PROSPERO CRD42018087498; registered on 11 May 2018.