Management Of Heart Failure Patients Research Articles

Risk of heart failure progression in patients with reduced ejection fraction: mechanisms and therapeutic options.

Transition from stage C to stage D of heart failure (HF) represents an irreversible process toward end-stage disease. Crucial interventions to be adopted in the attempt to interfere with this process are represented by the identification of patients at high risk to develop HF progression and by an effective and prompt management. Markers of worse prognosis and disease progression are well established and include recurrence of HF decompensation, intolerance to the neurohormonal standard pharmacological treatment, and resistance to loop diuretics. In addition, both NT-proBNP and sympathetic nervous system (SNS) overdrive are strong predictors of adverse clinical outcome and allow to identify high-risk HF patients even in the presence of mild symptoms. To counteract the deleterious effects of the SNS activation, new strategies such as a new drug combining angiotensin receptor and neprilysin inhibition and baroreceptor stimulation therapy (BAT) have been investigated. Inability to properly counteract the SNS overdrive leads to acute HF decompensation by different mechanisms. The leading ones are represented by the progressive sodium and water retention with fluid overload and by the blood volume redistribution between splanchnic and non-splanchnic regions. The correct understanding of these mechanisms, together with the availability of new therapeutic options such as peritoneal ultrafiltration, represent the rationale but not infrequently overlooked therapeutic options to improve congestion management in HF patients.

Pain Management in Patients with Heart Failure: A Survey of Nurses’ Perception

Background Over 50% of patients with heart failure (HF) report suffering from pain and pain related burdens; however, pain in HF patients has not been recognized and well treated. Few studies have comprehensively examined pain management in patients with HF from nurses’ perception. Aims To investigate nurses’ perception of pain management in HF patients. Methods Members of American Association of Heart Failure Nurses (AAHFN) were invited to participate in a cross-sectional on-line survey. Results A total of 147 nurses responded and completed the survey. The majority agreed that pain in HF patients was related to anxiety, depression, fatigue and unplanned hospitalization, and pain should be individually assessed and managed. More than 80% of them thought pain management practice in HF patients should be improved, 78.1% were interested in getting more information and online education module was the most preferable approach. Lack pain assessment tools, drug addiction, side effect, overuse, underuse, and contraindication with other medications were the main concerns regarding to opioid use in pain management in HF. The gaps of managing pain in HF patients included lack knowledge of opioid use, lack consideration and awareness of pain, no clinical guidelines of pain assessment and treatment, and complicated pain management with multiple chronic conditions. Conclusions The impact of pain, individually assessment and management of pain in HF patients were well perceived by nurses, whereas improvement in pain management practice in HF patients are needed. Concerns regarding to opioid use and gaps in pain management of HF patients should be addressed.

Persistent Intravascular Volume Expansion is Compensatory, Not Detrimental, in Post-Hospital Chronic Heart Failure Patients and Associated with Better Clinical Outcomes

Background Intravascular volume is largely regulated by the kidneys but how the relative extent of volume expansion impacts outcomes in post-hospital chronic heart failure (HF) patients has not been assessed. Our hypothesis was that greater rather than lesser volume expansion is compensatory and associated with better HF-related outcomes. Methods Blood volume (BV) was prospectively measured in 87 HF patients at the time of hospital discharge (post-diuretic therapy) using a standardized nuclear medicine radiolabeled albumin indicator-dilution technique (Daxor Corp., NY, NY). A volume cut-point of ≥+25% above normal BV defined greater from lesser volume expansion. The cohort was analyzed for 1-year composite outcome of HF-related mortality or 1st re-hospitalization. Results BV expansion ≥+25% was present in 53% of the cohort with RBC mass excess (polycythemia) being the predominant contributor (74% of this subgroup). In this volume expanded subgroup (N=46) the risk for the composite endpoint was significantly lower than in the subgroup with less volume expansion (N=41; 56% with normal BV, 44% with mild-moderate BV expansion) [Fig. 1, p=0.017, RR 0.41 (0.20-0.84)]. Further, the evaluation of RBC mass as a component of intravascular volume informs the higher risk associated with true anemia [p=0.006, RR 2.78 (1.37-5.55)], but also importantly the significant reduction in risk associated with RBC polycythemia [p Conclusions The findings of this analysis indicate that persistent intravascular volume expansion (≥+25% above normal volume) is common at the time of hospital discharge despite diuretic intervention in chronic HF patients, and importantly that in post-hospital follow up the greater extent of BV expansion (compared to normal volume or mild-moderate expansion) driven mainly by RBC polycythemia is compensatory, not detrimental, and associated with better HF-related outcomes including reduced mortality. These findings provide additional insight into the pathophysiology of chronic HF and also have implications for a more individualized approach to volume assessment and management in HF patients.

Heart Failure Medications are Tolerated by Elderly Patients

Introduction Elderly patients with heart failure with reduced ejection fraction (HFrEF) were not included in the clinical trials of the common therapies used for the management of heart failure patients including ACE inhibitors, angiotensin receptor blockers (ARBs), angiotensin-receptor neprilysin inhibitors (ARNIs), beta blockers, and aldosterone antagonists. We have observed reluctance to prescribe these medications to these patients partly due to lack of demonstrated efficacy but more due to concerns of an increased incidence of adverse effects and less tolerability. The purpose of this study is to examine the tolerability of common heart failure medications in a patient population over the age of 80 years with an EF ≤40%. Methods All patients with HFrEF admitted between February 1, 2015 and December 31, 2017 over the age of 80 with documented follow-up were included. A similar group of patients aged 60-79 matched for gender, ejection fraction, and month of admission were abstracted as a comparator group. Medication tolerability was assessed within three months of hospital discharge. Tolerability was defined as continuation of the same dose or increased dose of each medication. Results There were 194 HFrEF patients included in the study, 97 in each cohort. Groups were fairly balanced in terms of baseline characteristics, with differences in ejection fraction, weight, race, and diastolic blood pressure. There were no significant differences for medications prescribed at hospital discharge in 60-79 years vs 80 years old. The two cohorts also demonstrated similar tolerability rates for all classes of medications: beta blockers (91.5% vs 88.6%, p=0.52), ACEi/ARB/ARNi (85.9% vs 85.7%, p=0.97), and aldosterone antagonists (83.3% vs 86.4%, p=1.0). The most common reasons for discontinuing or reducing the dose were consistent among the two groups of patients, with the most common reason being hypotension. Conclusions Evidence-based medications are tolerated well by patients over 80 years old with very low rates of discontinuing or reducing doses within three months. In addition, there were similar rates of tolerability among patients 60-70 years and those over 80 years old. From a safety and tolerability standpoint, these findings support the utilization of evidence-based medications in elderly patients.

Heart Failure Re-Admissions: Impact of a Specialized Resident Task Force in Year Two of a Performance Improvement Project

Background Heart failure (HF) is a complex disorder that imposes substantial patient burden and entails much health care costs. Nationwide, 30 day re-admissions for HF are tracked and serve as a measure of quality of care. Efforts to minimize HF related hospital re-admissions have generally had mixed results. Hypothesis Development of a specialized, experienced team of internal medicine residents trained to educate and counsel HF patients will enhance their knowledge of the disease, improve self-care and reduce hospital re-admissions in those admitted with acute decompensated HF. Methods In August 2017 a team of 9 Internal Medicine residents were recruited to create a Specialized Resident Force (SRF). The team was expanded to 20 residents in August 2018; they received individual hands-on training sessions in counseling hospitalized HF patients from a mentor weekly initially, later monthly. Patients with HF were counseled by the SRF on diet, activity, medication use, weight monitoring and outpatient follow-up. Demographic data, comorbidities and HF specific data was gathered. Patient's cognition was evaluated. If cognitively impaired, education was offered to caregiver, if available. A tool helped document data; a booklet on HF education, counseling by the resident and a 2 page summary script were offered to patients. Other disciplines (nurse, nutritionist, cardiologist, social worker) had roles in the project. Results Enhanced SRF education was provided to 171 patients with HF between August 2018 and January 2019. Education provided by SRF resulted in declines in 30 day all cause readmissions following index HF admission (Table 1). Observations by mentor suggested enhanced practical knowledge base of SRF trainees as a result of participation. Conclusions A Specialized Resident Force with support from other disciplines helped reduce and maintain low 30 day HF hospital re-admissions consistently over a 6 month period. The project help residents acquire expertise in PI activity while also enhancing their real life experience in managing HF patients.

The Economic Impact of Mitral Regurgitation on Patients With Medically Managed Heart Failure

The objective of this study was to quantify the financial healthcare burden of mitral regurgitation (MR) on medically managed heart failure (HF) patients. Data from the Truven Health MarketScan Commercial Claims and Medicare Supplemental Databases were analyzed. Included patients had a minimum of 1 inpatient or 2 outpatient claims for HF with a 6-month preperiod (baseline). A 6-month postperiod (landmark) after HF index was used to capture MR diagnosis and severity. Following the landmark period, patients had to have 12 months of continuous medical and prescription drug plan enrollment with at least 2 records of HF medication refills. A therapeutic intensity score was calculated based on HF medication usage. Medically managed HF patients were separated into 3 cohorts: without MR (no MR), insignificant MR (iMR), and significant MR (sMR). Healthcare utilization and all-cause expenditures were modeled to quantify the burden of MR. All models controlled for baseline demographics, co-morbid conditions, and HF therapeutic intensity. Medically managed incident HF patients with sMR had significantly more hospital days (1.91 vs 1.72 days; p = 0.0096) and annual expenditures ($23,988 vs $21,530; p < 0.0001) compared with no MR patients. No differences were identified when comparing iMR and no MR. When evaluating HF admissions, sMR patients had an estimated 50% greater HF admissions rate (0.036 vs 0.024; p < 0.0001) compared with no MR patients. Additionally, HF admits for iMR were 23% more than those with no MR (0.029 vs 0.024; p = 0.0064). In conclusion, evidence of MR in retrospective claims significantly increases the healthcare impact of medically managed HF patients. Both utilization and financial burden is more pronounced when MR is clinically significant.

Heart Failure Phenotypes Require Sex-Specific Criteria Which Are Based on Ventricular Dimensions.

Ejection fraction (EF) is often used as a criterion to establish diagnostic phenotypes of heart failure (HF). Because EF is a derived metric based on end-systolic volume (ESV) and end-diastolic volume (EDV), it is more logical to consider ESV or EDV as cut-off marker. We concentrate on the impact of ESV, which has the advantage of being linearly related to EDV and nonlinearly with EF, both with highly significant correlations. In particular we also analyze if HF classification should distinguish between females and males.ESV and EDV were determined by biplane angiography in 197 HF patients (67 women). As body surface indexed (i) ESVi values for adult healthy females are smaller than for males, we employ classes of ESVi (bins of 10 mL/m2) to group preserved and reduced EF's (cut-off at 50%) for HF. Reference values regarding mean and standard deviation for ESVi are based on a control group (N=155, 65 women) without HF. For interpretation of the findings we use the documented universal relationship connecting EF to ESV: EF = 1 + c1 {ESV / (c2 - ESV)}, where c1 and c2 are population-based sex-independent constants. In the reference group ESVi (mL/m2) in women (27.4 ± 27.6) is smaller (P=0.0026) than in their male counterparts (43.6 ± 37.5). Similarly, for HF the ESVi in women (45.7 ± 41.4) is smaller (P=0.0033) than in men (64.2 ± 41.4). This signifies (see formula above) that women have higher values for EF, primarily resulting from smaller ventricular size related to their sex, and not exclusively reflecting disease state. Current phenotype classification based on pooled data for males and females may be inappropriate for either sex.The significantly smaller ESVi observed in women has direct consequences for the traditional classification based on EF cutoff values for HF. Sex-specific criteria (regarding ESVi or EF) for HF phenotypes are warranted, and expectedly have substantial consequences for identification, classification, and management of HF patients.

Curriculum heart failure : Task force curriculum heart failure of the working group on heart failure of the Austrian Cardiological Society.

SummaryIt is well recognized that organized management of heart failure patients, including care by heart failure specialists, improves outcomes of these patients. In response to this, the Heart Failure Association of the European Society of Cardiology proposed a basic framework of a heart failure curriculum, which became a blueprint for training programs across Europe. The present curriculum for heart failure was well coordinated with the version issued by the German Society for Cardiology in order to achieve good comparability. Training in this Austrian curriculum takes two years, during which the predominant activity focuses on the care of patients with heart failure. The first year includes general (basic) training, while in the second year special modules (advanced chronic and acute heart failure with specific treatment, device treatment, interventional heart failure treatment, outpatient care or rehabilitation, heart failure diagnostics) must be chosen that impart in-depth knowledge, experience and/or skills. Of the five offered modules two must be completed for 6 months each. At least one specialist in internal medicine and cardiology with the additional qualification of heart failure must act as a supervisor at the training center. A certified Heart Failure Unit or a comparable structure should be available at the training center and integrated into the clinical routine of the cardiology department. Applications for recognition of curricular achievements in order to obtain the additional qualification “heart failure specialist” shall be evaluated by a dedicated committee of the nucleus of the Heart Failure Working Group of the Austrian Cardiological Society. The candidate will receive recognition of the additional qualification in heart failure, issued by the Austrian Cardiological Society.

Evaluation of procalcitonin in a fluorescent immunoassay AFIAS-6 analyzer

Biomarkers have become an integral part of practicing medicine, especially in heart failure. The natriuretic peptides are commonly used in the evaluation of heart failure, but their role extends beyond diagnosis and includes risk stratification and management of heart failure patients. Newer biomarkers have arrived and are becoming part of routine care of heart failure patients. Both ST2 and high-sensitivity troponin have significant prognostic value for mortality, but also may assist in the titration of medical therapy. Procalcitonin can help guide appropriate antibiotic use in patients with heart failure. The ability to appropriately use and interpret these biomarkers is imperative to the care of heart failure patients, especially as these newer biomarkers become widely used.

Value based innovation in heart failure patient management

Women with heart failure (HF) are more symptomatic than their male counterparts. Despite deriving similar benefits from both medical and devices therapies, women continue to be underrepresented in clinic trials. Important sex-based disparities exist in enrollment in clinical trials and access to medical and device-based therapies, in part stemming from differences in medical and psychosocial comorbidities. Disparities in access to beneficial interventions likely contribute to the greater symptom burden identified in women with HF. Improved focus on the enrollment of women in clinical trials will allow a better understanding of the underpinnings of these disparities and improve the care of women with HF.

PCV76 EFFECTS OF AGE ON THE ASSOCIATION BETWEEN COMORBIDITIES AND MORTALITY IN ADULTS WITH HEART FAILURE

Age and comorbidities are independent risk factors for mortality in adults with heart failure (HF). This study explored the modifying effect of age on the association between comorbidities and all-cause mortality among a national sample of adults with HF. This was a retrospective cohort study based on public-use data of the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2010, on adults who self-reported as having been diagnosed with HF. The outcome of the study was all-cause mortality. The primary independent variable was type of comorbidity (non-cardiovascular, cardiovascular and mixed). Descriptive statistics were used to describe the relationship between comorbidity and variables of interest. Age-stratified multivariate Cox Proportional Hazards models were used to assess the association of comorbidity with all-cause mortality overall and by age strata (≤60, 61–70,71–80, and >80 years old). The study included 926 HF subjects: mean age was 68 years, and 42% died during follow-up. The age-specific all-cause mortality rates of subjects ≤60, 61 – 70, 71 – 80, and > 80 years of age, were 20%, 28%, 48% and 82% respectively. In the overall cohort, subjects with non-cardiovascular and mixed comorbidities had a higher risk of all-cause mortality than those with cardiovascular comorbidities (HR=2.0,95%CI=1.2-3.2 and HR=1.6, 95% CI=1.1-2.2 respectively). The risk of all-cause mortality for mixed comorbidities compared to cardiovascular comorbidities was higher for subjects 61-70 years of age (HR=5.4, 95% CI=1.4-19.7), but lower for subjects >80 years of age (HR=0.5,95%CI=0.4-0.8). We found an association of higher risk of all-cause mortality with mixed and non-cardiovascular comorbidities compared to cardiovascular comorbidities in different age-groups. These findings may help to inform clinicians and health care providers on the management of HF patients with comorbidities and of different age groups.

The left atrium and the right ventricle: two supporting chambers to the failing left ventricle.

Heart failure (HF) is mainly caused by left ventricular (LV) impairment of function, hence detailed assessment of its structure and function is a clinical priority. The frequent involvement of the left atrium (LA) and the right ventricle (RV) in the overall cardiac performance has recently gained significant interest with specific markers predicting exercise intolerance and prognosis being proposed. The LA and RV are not anatomically separated from the LV, while the LA controls the inlet the RV shares the interventricular septum with the LV. Likewise, the function of the two chambers is not entirely independent from that of the LV, with the LA enlarging to accommodate any rise in filling pressures, which could get transferred to the RV via the pulmonary circulation. In the absence of pulmonary disease, LA and RV function may become impaired in patients with moderate-severe LV disease and raised filling pressures. These changes can often occur irrespective of the severity of systolic dysfunction, thus highlighting the important need for critical assessment of the function of the two chambers. This review evaluates the pivotal role of the left atrium and right ventricle in the management of HF patients based on the available evidence.

Investigating self-care in a sample of patients with decompensated heart failure: A cross-sectional study

BackgroundThere is scarce evidence relating to self-care of heart failure (HF) in Spain. In particular, there is a need to establish patients’ level of understanding of HF, as well as their ability to recognize signs and symptoms of decompensation. Patients and methodsCross-sectional study to determine the level of self-care in a population of Spanish patients admitted to hospital with a primary diagnosis of decompensated HF. A convenience sample of 108 patients (50 women and 58 men) aged 83±8 were recruited to participate in this study. ResultsThe Self-Care of Heart Failure Index version 6.2 was used to quantify self-care in our sample. Mean and standard deviation from the Self-Care of Heart Failure Index self-care maintenance subscale were: (a) “exercise for 30 minutes”, 1±1; (b) “forget to take one of your medicines”, 2±2; (c) “ask for low-salt items when eating out or visiting others”, 2±1. A percentage of 67.6 had experienced shortness of breath or ankle swelling in the past month. However, the vast majority of our patients were unlikely to independently implement a remedy: (a) reduce salt, 2±1; (b) reduce fluid intake, 1±1; (c) take an extra diuretic, 1±1. Over 50% of our sample felt confident or very confident at following professional advice (3±1), keeping themselves free of symptoms (3±1), recognizing changes in their condition (3±1) and evaluating the significance of such changes (3±1). ConclusionsHF patients have a significantly low level of self-care when compared with HF patients from other countries, especially when it comes to managing their condition. Self-care promotion should be a priority for all healthcare professionals involved in the care and management of HF patients.

Point-of-Care Testing Devices for Heart Failure Analyzing Blood and Saliva Samples.

Heart failure (HF) is the most rapidly growing cardiovascular condition with an estimated prevalence of >37.7 million individuals globally. HF is associated with increased mortality and morbidity and confers a substantial burden, in terms of cost and quality of life, for the individuals and the healthcare systems, highlighting thus the need for early and accurate diagnosis of HF. The accuracy of HF diagnosis, severity estimation, and prediction of adverse events has improved by the utilization of blood tests measuring biomarkers. The contribution of biomarkers for HF management is intensified by the fact that they can be measured in short time at the point-of-care. This is allowed by the development of portable analytical devices, commonly known as point-of-care testing (POCT) devices, which exploit the advancements in the area of microfluidics and nanotechnology. The aim of this review paper is to present a review of POCT devices used for the measurement of biomarkers facilitating decision making when managing HF patients. The devices are either commercially available or in the form of prototypes under development. Both blood and saliva samples are considered. The challenges concerning the implementation of POCT devices and the barriers for their adoption in clinical practice are discussed.

Hand Carried Ultrasound Utilization in Acute Heart Failure Patients, Does It Correlate with Physical Examination?

Purpose Evaluation of intravascular volume is an essential component of clinical management of acute heart failure (HF) patients. Correlation between physical examination and ultrasound measurements has not been well studies and was the focus of this investigation. Methods We prospectively studied patients admitted to the medical floor with acute heart failure exacerbation between January 2017 to October 2018. Assessment of volume status by physical examination (PE) was performed by heart failure team, and classified patient's volume status into (0- euvolemic, 1- Mildly overloaded, 2- Moderately overloaded, 3- Severely overloaded), then central venous pressure (CVP) was measured using hand carried US (assessment of inferior vena cava size and respiratory variation, right and left jugular veins size, respiratory variation and compressibility). Spearman's correlation was used to correlate between PE findings and US-estimated CVP. Finally, the distribution of CVP for each PE category was provided (Figure). Results A total of 186 (Age 64±15,42% females) patients were included during study duration. (34%) patients had HF with preserved ejection fraction (HFpEF), and 104 (66%) patients had HF with reduced ejection fraction (HFrEF). The correlation between PE and US-estimated CVP was moderate at best (rho=0.41, p Conclusion Physical exam is moderately correlated with US-estimated CVP and is unreliable in directing therapy for acute HF exacerbation. Further investigations are needed to integrate hand carried US in the daily management of heart failure patients.

Investigando el autocuidado en una muestra de pacientes con insuficiencia cardiaca descompensada: un estudio transversal

BackgroundThere is scarce evidence relating to self-care of heart failure (HF) in Spain. In particular, there is a need to establish patients’ level of understanding of HF, as well as their ability to recognise signs and symptoms of decompensation. Patients and methodsCross-sectional study to determine the level of self-care in a population of Spanish patients admitted to hospital with a primary diagnosis of decompensated HF. A convenience sample of 108 patients (50 women and 58 men) aged 83±8 were recruited to participate in this study. ResultsThe Self-Care of Heart Failure Index version 6.2 was used to quantify self-care in our sample. Mean and standard deviation from the Self-Care of Heart Failure Index self-care maintenance subscale were: a) “exercise for 30 minutes”, 1±1; b) “forget to take one of your medicines”, 2±2; c) “ask for low-salt items when eating out or visiting others”, 2±1. A percentage of 67.6 had experienced shortness of breath or ankle swelling in the past month. However, the vast majority of our patients were unlikely to independently implement a remedy: a) reduce salt, 2±1; b) reduce fluid intake, 1±1; c) take an extra diuretic, 1±1. Over 50% of our sample felt confident or very confident at following professional advice (3±1), keeping themselves free of symptoms (3±1), recognizing changes in their condition (3±1) and evaluating the significance of such changes (3±1). ConclusionsHF patients have a significantly low level of self-care when compared with HF patients from other countries, especially when it comes to managing their condition. Self-care promotion should be a priority for all healthcare professionals involved in the care and management of HF patients.

Biomarker developments in heart failure: 2016 and beyond.

Biomarkers play a fundamental role in the management of heart failure. Both new and old biomarkers are evaluated every year with new information gained for their use in heart failure. Major advancements have been made in the past 2 years in key biomarkers that will surely become part of standard clinical management of heart failure. This review will focus on major developments since 2016. Soluble suppression of tumorigenicity 2 has had multiple breakthrough studies solidifying its prognostic use in both acute and chronic heart failure and with multiple studies showing a strong benefit with serial monitoring. High-sensitivity troponin has also recently been demonstrated to be a powerful prognostic biomarker in heart failure. Additionally, it may serve as a novel screening tool to identify patients at high risk for incident heart failure. Natriuretic peptides continue to show their resilience as the main prognostic biomarker in heart failure. Recent studies suggest natriuretic peptides may help identify certain patient populations that benefit from specific therapies and they can predict prognosis beyond in diseases other than heart failure. Although natriuretic peptides are well-established biomarkers in heart failure, the weight of evidence for soluble suppression of tumorigenicity 2 and high-sensitivity troponin has significantly grown since 2016 that these two biomarkers should be incorporated into regular practice and management of heart failure patients.

Safety of centrifugal left ventricular assist device in patients previously treated with MitraClip system

IntroductionNo data regarding the safety of continuous-flow left ventricular assist device (CF-LVAD) implantation in patients with previous MitraClip have been reported. Thus, it remains unknown whether an initial treatment strategy with MitraClip therapy might complicate future heart failure management in patients who are also considered for CF-LVAD. MethodsWe retrospectively identified 6 patients (median age of 62 years; 2 women) who had been treated with MitraClip, that were eventually implanted with a CF-LVAD (all Heartware HVAD) in 3 hospitals between 2013 and 2018. ResultsPatients were treated in 4 cases with 2 clips, and in 2 cases with 1 clip. Median time from MitraClip implantation to CF-LVAD implant was 282 days (interquartile range 67 to 493), and median time on CF-LVAD support was 401 days (interquartile range 105 to 492 days). Two patients underwent a heart transplant, 3 patients died on support, and 1 is alive on support. In all cases, there was a reduction of functional mitral regurgitation without MitraClip-related complications. ConclusionsBased on this small case series, implantation of a CF-LVAD appears safe in patients with a previously positioned MitraClip system, at least, with 1 or 2 clips in place, with no need for additional mitral valve surgery.

Impact of cardiac magnetic resonance imaging on heart failure patients referred to a tertiary advanced heart failure unit: improvements in diagnosis and management

The clinical use of cardiac magnetic resonance (CMR) in Australian heart failure (HF) patients has limited evidence. To examine how CMR, compared with routine echocardiography, affects the diagnosis and management of patients with HF. Single-centre retrospective study of HF patients newly referred to the Advanced Heart Failure and Transplant unit at The Prince Charles Hospital, Brisbane. Between January 2010 and December 2014, all patients clinically referred for both CMR and echocardiography in the workup of HF were analysed. Imaging results, electronic records and medical charts were reviewed for final diagnosis and changes in clinical management. A total of 114 new HF referrals was included. Evaluation of HF of uncertain aetiology (70%) was the most common indication for CMR. In 20% of cases, CMR led to a completely new diagnosis or diagnostic confirmation of suspicions raised by echocardiography. Clinical decision-making was altered in 48%, with the greatest impact on decisions regarding revascularisation. Overall, CMR had a significant impact on 50% of patients. In a multivariable model, the only independent variable significantly associated with clinical impact was the presence/absence of late gadolinium enhancement (P < 0.001). Importantly, body mass index, echocardiography image quality and the presence of sinus rhythm did not show statistical significance in the multivariate analysis. CMR makes a substantial contribution to both the diagnosis and management of HF patients over and above standard echocardiography. This study provides evidence of its clinical utility in the HF population in Australia and supports the role of CMR in the routine assessment of this cohort.

The diagnostic value of circulating microRNAs in heart failure.

Heart failure (HF) is a complex clinical syndrome, characterized by inadequate blood perfusion of tissues and organs caused by decreased heart ejection capacity resulting from structural or functional cardiac disorders. HF is the most severe heart condition and it severely compromises human health; thus, its early diagnosis and effective management are crucial. However, given the lack of satisfactory sensitivity and specificity of the currently available biomarkers, the majority of patients with HF are not diagnosed early and do not receive timely treatment. A number of studies have demonstrated that peripheral blood circulating nucleic acids [such as microRNAs (miRs), mRNA and DNA] are important for the diagnosis and monitoring of treatment response in HF. miRs have been attracting increasing attention as promising biomarkers, given their presence in body fluids and relative structural stability under diverse conditions of sampling. The aim of the present review was to analyze the associations between the mechanisms underlying the development of HF and the expression of miRs, and discuss the value of using circulating miRs as diagnostic biomarkers in HF management. In particular, miR-155, miR-22 and miR-133 appear to be promising for the diagnosis, prognosis and management of HF patients.