Heart Failure-related Hospitalizations Research Articles

Tailored telemonitoring in patients with heart failure: results of a multicentre randomized controlled trial

Recent increases in heart failure tend to overload the healthcare system. Consequently, there is a need for innovative strategies to reduce heart failure hospitalizations. A multicentre randomized controlled trial was carried out to test the hypothesis that telemonitoring reduces heart failure hospitalizations during 1 year follow-up. The mean age of the 382 participating patients was 71.5 (32-93) years; the mean left ventricular ejection fraction was 0.38, and in 61% it was ≤0.45%. Mean time to first heart failure-related hospitalization was 161 days for the intervention group and 139 days for the usual-care group; hospitalizations occurred in 18 (9.1%) compared with 25 (13.5%) patients, with a total number of 24 and 43 hospitalizations, respectively [Kaplan-Meier P = 0.151, hazard ratio (HR) 0.65, 95% confidence interval (CI) 0.35-1.17]. Subgroup analysis of the primary endpoint showed benefits for three subgroups: duration of heart failure, having a pacemaker, and co-habiting. The combined endpoint of heart failure admission and all-cause mortality was similar for both groups (Kaplan-Meier P = 0.641, HR 0.89, 95% CI 0.69-1.83). No differences were found regarding secondary endpoints, except for the reduced number of face to face contacts with the heart failure nurse (Mann-Whitney P < 0.001). Mortality was 18 (9.1%) in the intervention group and 12 (6.5%) in the usual-care group (Mann-Whitney P = 0.34, Cox regression analysis P = 0.82). No significant differences were found regarding the primary endpoint, possibly caused by a relative underpowering of the population combined with well-treated study groups. However, telemonitoring tends to reduce heart failure (re)admissions and significantly decreases contacts with specialized nurses. Further research with pre-specified groups, as found in the subgroup analysis, is needed. NCT00502255.

Is Adherence to Weight Monitoring or Weight-Based Diuretic Self-Adjustment Associated With Fewer Heart Failure-Related Emergency Department Visits or Hospitalizations?

BackgroundHeart failure (HF) self-care interventions can improve outcomes, but less than optimal adherence may limit their effectiveness. We evaluated if adherence to weight monitoring and diuretic self-adjustment was associated with HF-related emergency department (ED) visits or hospitalizations. Methods and ResultsWe performed a case-control analysis nested in a HF self-care randomized trial. Participants received HF self-care training, including weight monitoring and diuretic self-adjustment, which they were to record in a diary. We defined case time periods as HF-related ED visits or hospitalizations in the 7 preceding days; control time periods were defined as 7-day periods free of ED visits and hospitalizations. We used logistic regression to compare weight monitoring and diuretic self-adjustment adherence in case and control time periods, adjusted for demographic and clinical covariates. Among 303 participants, we identified 81 HF-related ED visits or hospitalizations (cases) in 54 patients over 1 year of follow-up. Weight monitoring adherence (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.23–0.76) and diuretic self-adjustment adherence (OR 0.44, 95% CI 0.19–0.98) were both associated with lower adjusted odds of HF-related ED visits or hospitalizations. ConclusionsAdherence to weight monitoring and diuretic self-adjustment was associated with lower odds of HF-related ED visits or hospitalizations. Adherence to these activities may reduce HF-related morbidity.

Tailored Telemonitoring in patients with heart failure: results from a multicentre randomized controlled trial (the TEHAF-study)

Background: Recent increasing prevalence of heart failure (HF) patients leads to an increasing burden to the health care system. Consequently, there is a need for innovative strategies to reduce HF hospitalizations. Methods: We performed a multicentre randomized controlled trial to test the hypothesis that telemonitoring in patients with HF, by means of the Health Buddy system (HB), will reduce HF hospitalizations and number of contacts with caregivers as compared to care as usual (CAU) during 1 year follow-up, from October 1, 2007, through December 31, 2008. Results: Among 382 patients—197 in the HB and 185 in the CAU-group—226 (59%) were male, mean age was 71.5 (SD 11.2), 45.5% being ≥75 years of age; 57% of the patients were in NYHA HF class 2, 40% in class 3 and 3% in class 4. Both study groups were similar for demographic and clinical characteristics. Mean time to first heart failure related hospitalization was 161 days for the intervention group and 139 days for the usual-care group; hospitalizations occurred in 18 (9.1%) compared to 25 patients (13.5%) respectively (Kaplan–Meier p=0.151, hazard ratio 0.65, CI 0.35–1.17). Combined endpoint of heart failure admission and all cause mortality was similar for both groups (Kaplan–Meier p=0.641 hazard ratio 0.89, CI 0.69–1.83). Cox regression analysis disclosed an important interaction between group assignment and heart failure duration, p=0.007, OR=0.983, CI 0.970–0.995 indicating a significant decrease in heart failure hospitalizations in the intervention group if heart failure duration was <18 months, p=0.026, hazard ratio 0.26, CI 0.07–0.94. Contacts with the heart-failure-nurse were mean 1.36 (range 0–11) in the intervention group vs. 1.74 (0–8) in the usual-care group (Mann-Whitney p<0.001). Mortality was 18 (9.1%) in the intervention-group and 12 (6.5%) in the usual-care-group (Mann–Whitney p=0.34, Cox-regression analysis p=0.82). Conclusion: Telemonitoring tends to reduce heart failure admissions and decreases contacts with specialized nurses. If heart failure duration is <18 months heart failure admissions and readmissions are significantly reduced.

Resource Utilization and Cost of Heart Failure associated with Reduced Ejection Fraction in Swedish Patients

Aim:The purpose of this study was to assess healthcare utilization and costs for heart failure patients with reduced ejection fraction (HF-REF) in Sweden.Methods and Results:This was a retrospective, population-based cohort study of patients diagnosed with HF-REF during a period of 18 months at 31 primary care centers in Uppsala County, Sweden. Data was obtained from computerized records from these centers, the Swedish Patient Registry, the Swedish Prescription Registry, the Cause of Death Registry, and a local echocardiography registry maintained by the Department of Physiology, Uppsala University Hospital. Main outcome measures were cardiovascular and heart-failure-related hospitalizations, outpatient visits, medication utilization, mortality (all-cause, cardiovascular, and heart-failure), and healthcare costs for HF-REF patients. During the index period, 252 heart failure patients had a left ventricular ejection fraction measurement ≤40% and were categorized as having HF-REF. More than half of the patients had ≥1 cardiovascular or heart failure-related hospitalization. On average, patients had >2 such hospitalizations annually. They also averaged ∼1 cardiovascular or heart-failure-related outpatient visit per year. All-cause mortality was high: 15.9% patients died within 1 year after the index date. The mean annual cost per patient for heart-failure-related hospitalizations was SEK 72,613 (EUR 7610). In contrast, annual prescription costs were low, on average 3% of total cost (SEK 3503, EUR 367 per patient)Limitations:The main limitations of this study include a short follow-up time and small sample size. Also, certain data were missing, such as echocardiograms (available for only 28% of patients), and information on patients’ New York Heart Association (NYHA) functional class, validity period for prescriptions or the units of medication prescribed, and medication dosing. Furthermore, the overall mortality could have been under-estimated, as only the primary cause of death was included in the analysis.Conclusions:The main burden associated with HF-REF is related to hospitalizations for heart-failure events. Effective treatment options that decrease hospitalization rates could reduce patients’ suffering and potentially offer considerable cost savings.

Relationship between plasma concentrations of N‐terminal pro brain natriuretic peptide and the characteristics and outcome of patients with a clinical diagnosis of diastolic heart failure: a report from the PEP‐CHF study

The aim of this study was to explore the relationships between plasma concentrations of N-terminal pro brain natriuretic peptide (NT-proBNP) and characteristics and prognosis of patients with heart failure and preserved (HFPEF) left ventricular ejection fraction (LVEF). No substantial trial has shown that treatment alters prognosis in patients with HFPEF due, in part, to much lower than anticipated event rates. The lack of a simple, objective test to identify patients with HFPEF at increased risk of cardiovascular events would be valuable. The Perindopril in Elderly People with Chronic Heart Failure Trial (PEP-CHF) was a randomized, controlled trial comparing perindopril and placebo in patients with symptoms and signs of heart failure who had an LVEF >40% and evidence of LV diastolic dysfunction. The primary endpoint was all-cause mortality or heart failure-related hospitalization. NT-proBNP was measured in 375 patients. Quartile thresholds were 176, 409, and 1035 pg/mL. Patients in the highest quartile of NT-proBNP were older, had lower body mass, more often had atrial fibrillation, had greater atrial and ventricular dimensions and a lower LVEF, and were more likely to receive loop diuretic therapy. Compared with the first quartile of NT-proBNP, the hazard ratios for the primary endpoint in the second {1.38 [95% confidence interval (CI) 0.64-2.99]}, third [2.84 (95% CI 1.42-5.72)], and fourth [4.47 (95% CI 2.30-8.72)] quartiles were increased. In a multivariable model, NT-proBNP, but not echocardiographic measures, was associated with outcome. NT-proBNP is a powerful prognostic marker in patients with HFPEF.

Prevalence, Morbidity, and Mortality of Heart Failure–Related Hospitalizations in Children in the United States: A Population-Based Study

BackgroundFew data exist on prevalence, morbidity, and mortality of pediatric heart failure hospitalizations. We tested the hypotheses that pediatric heart failure–related hospitalizations increased over time but that mortality decreased. Factors associated with mortality and length of stay were also assessed. Methods and ResultsA retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database was performed for pediatric (age ≤18 years) heart failure–related hospitalizations for the years 1997, 2000, 2003, and 2006. Hospitalizations did not significantly increase over time, ranging from 11,153 (95% confidence interval [CI] 8,898–13,409) in 2003 to 13,892 (95% CI 11,528–16,256) in 2006. Hospital length of stay increased from 1997 (mean 13.8 days, 95% CI 12.5–15.2) to 2006 (mean 19.4 days, 95% CI 18.2 to 20.6). Hospital mortality was 7.3% (95% CI 6.9–8.0) and did not vary significantly between years; however, risk-adjusted mortality was less in 2006 (odds ratio 0.70, 95% CI 0.61 to 0.80). The greatest risk of mortality occurred with extracorporeal membrane oxygenation, acute renal failure, and sepsis. ConclusionsHeart failure–related hospitalizations occur in 11,000–14,000 children annually in the United States, with an overall mortality of 7%. Many comorbid conditions influenced hospital mortality.

Abstract P238: Long-Term Survival Trends in Hospitalized Heart Failure Patients

Background: Long-term survival data on patients with heart failure (HF) in community-based populations are limited. Preserved ejection fraction (PEF) is present in 50-60% of HF patients. We examined whether trends in long-term survival differed between HF patients with preserved (ejection fraction &gt;/= 45) and reduced ejection fraction (REF) in the context of modern treatment. Methods: The Minnesota Heart Survey, a community-based population study conducted in the Minneapolis-St. Paul metropolitan area, abstracted a random sample of hospital records for patients aged 35-84 with a discharge diagnosis of HF in 1995 and 2000. In the absence of a gold standard diagnosis of HF, hospitalization records that met at least four of six published classification algorithm definitions were considered HF related. Mortality was ascertained from medical records and by linkage to death certificates from the Department of Health. Kaplan-Meier was used for unadjusted survival and Cox proportional hazards regression was used to calculate adjusted hazard ratios (HR). Results: In 1995 1269 HF patients (PEF, n = 423; REF, n = 846) and in 2000 1103 HF patients (PEF, n = 413; REF, n = 690) were identified. The prevalence of hypertension, diabetes mellitus and hyperlipidemia were significantly higher in 2000; the utilization of ACE-Inhibitors, beta-blockers and revascularization were also significantly greater in 2000. In 1995, the unadjusted 9-year survival was 21% in REF and 28% in PEF; in 2000 these numbers were 28% in REF and 29% in PEF (Figure). After adjustment for sex and age the HR for 9-year mortality in 1995 was 0.77 (95% CI: 0.68 - 0.89) for HF patients with PEF compared to REF, p = 0.0003; in 2000 the adjusted HR for 9-year mortality in patients with PEF compared to REF was 0.95 (95%CI: 0.82 - 1.10), p = 0.48. Conclusion: Survival after a HF related hospitalization is low with less than 30% of patients surviving nine years. The increased utilization of ACE-Inhibitors and beta-blockers may partially explain the improved survival among HF patients with REF.

Targeted Left Ventricular Lead Placement to Guide Cardiac Resynchronization Therapy: The TARGET Study: A Randomized, Controlled Trial

This study sought to assess the impact of targeted left ventricular (LV) lead placement on outcomes of cardiac resynchronization therapy (CRT). Placement of the LV lead to the latest sites of contraction and away from the scar confers the best response to CRT. We conducted a randomized, controlled trial to compare a targeted approach to LV lead placement with usual care. A total of 220 patients scheduled for CRT underwent baseline echocardiographic speckle-tracking 2-dimensional radial strain imaging and were then randomized 1:1 into 2 groups. In group 1 (TARGET [Targeted Left Ventricular Lead Placement to Guide Cardiac Resynchronization Therapy]), the LV lead was positioned at the latest site of peak contraction with an amplitude of >10% to signify freedom from scar. In group 2 (control) patients underwent standard unguided CRT. Patients were classified by the relationship of the LV lead to the optimal site as concordant (at optimal site), adjacent (within 1 segment), or remote (≥2 segments away). The primary endpoint was a ≥15% reduction in LV end-systolic volume at 6 months. Secondary endpoints were clinical response (≥1 improvement in New York Heart Association functional class), all-cause mortality, and combined all-cause mortality and heart failure-related hospitalization. The groups were balanced at randomization. In the TARGET group, there was a greater proportion of responders at 6 months (70% vs. 55%, p = 0.031), giving an absolute difference in the primary endpoint of 15% (95% confidence interval: 2% to 28%). Compared with controls, TARGET patients had a higher clinical response (83% vs. 65%, p = 0.003) and lower rates of the combined endpoint (log-rank test, p = 0.031). Compared with standard CRT treatment, the use of speckle-tracking echocardiography to the target LV lead placement yields significantly improved response and clinical status and lower rates of combined death and heart failure-related hospitalization. (Targeted Left Ventricular Lead Placement to Guide Cardiac Resynchronization Therapy [TARGET] study); ISRCTN19717943).

Is Adherence to Weight Monitoring or Weight-Based Diuretic Self-Adjustment Associated With Fewer Heart Failure-Related Emergency Department Visits or Hospitalizations?

Is Adherence to Weight Monitoring or Weight-Based Diuretic Self-Adjustment Associated With Fewer Heart Failure-Related Emergency Department Visits or Hospitalizations?

Nursing professionalsʼ experiences of the facilitators and barriers to the use of telehealth applications: - a systematic review of qualitative evidence

Nursing professionalsʼ experiences of the facilitators and barriers to the use of telehealth applications: - a systematic review of qualitative evidence

Abstract 9185: Is Suboptimal Adherence to Weight Monitoring and/or Weight-Based Diuretic Self-Adjustment Associated with Heart Failure-Related Emergency Department Visits or Hospitalizations?

Background Heart failure (HF) self-care interventions that include daily weights and diuretic self-adjustment to manage volume status can improve outcomes, but suboptimal adherence may limit their effectiveness. We sought to evaluate the association of 1) adherence to weight monitoring, and 2) adherence to a weight-based diuretic self-adjustment plan (WBDSA) with HF-related Emergency Department (ED) visits or hospitalizations. Methods We performed a case-control analysis nested in a HF self-care clinical trial. Participants received HF education over one year that covered topics including daily weight monitoring and personalized WBDSA plans. All participants were to record daily weights and loop diuretic doses in a specialized diary. Cases were 7-day periods preceding HF-related ED visits or hospitalizations determined by masked outcome adjudication. Controls were 7-day periods free of ED visits or hospitalizations and were matched to cases 10:1 for age, gender, NYHA class, and study site. Weight monitoring adherence required recording a weight; WBDSA adherence required recording a correct diuretic dose based on the WBDSA plan. Weight monitoring and WBDSA adherence were determined over 7 days and dichotomized into &lt;6 versus &gt;= 6/7 days of adherence. We used logistic regression to evaluate the odds of weight monitoring and WBDSA adherence in cases compared to controls and adjusted for age, gender, NYHA class, study site, literacy, socioeconomic ladder, systolic HF, cardiovascular disease, and chronic kidney disease. Results Among 303 participants, we identified 81 eligible cases [12 ED visits (15%) and 69 hospitalizations (85%)] in 54 patients. Weight monitoring adherence (OR 0.43, 95% CI 0.23, 0.81) and WBDSA adherence (OR 0.36, 95% CI 0.16, 0.82) were both associated with lower adjusted odds of a HF-related ED visit or hospitalization. Results were similar in unadjusted models for both weight monitoring adherence (OR 0.54, 95% CI 0.31, 0.95) and WBDSA adherence (0.36, 95% CI 0.16, 0.81). Conclusions Adherence to daily weight monitoring and WBDSA was associated with lower odds of ED visits or hospitalizations related to HF. Enhancing adoption and adherence for these self-care behaviors may be an important step in reducing HF-related morbidity.

Abstract P270: Automating Processes to Expedite Medical Record Review in Research

Problem. Heart failure (HF) clinical trials often use medical record review data to determine HF related hospital events, such as emergency room visits and readmissions. However, reviewing medical records for each hospital event can be daunting. The purpose of this project was to expedite medical record review processes using an automated method for identifying potential HF related hospital events. Methods. A stepwise procedure was developed for obtaining electronic information of all consented HF clinical trial participants' hospital events. First, an electronic list of all study participants was generated from a study data base and electronically sent to the Medical Records department each month. Next, a list of all emergency room visits and hospitalizations, including admission and discharge dates, discharge disposition, and diagnosis and procedure codes was electronically generated by the Medical Records department. A trained cardiovascular research nurse reviewed the abstracted coding and billing data for each hospital event and identified specific codes potentially related to HF. Last, hospital events identified as meeting specific criteria were included in the medical record review. Results. Using the automated system, a total of 294 hospital events for 125 subjects were obtained from the Medical Records department during the initial 2 years of the clinical trial. Of these, 85 (29%) hospital events were identified as needing to undergo chart review. Thirty-three (39%) of the 85 charts that underwent blinded review were identified as being HF related hospital events. Conclusions. Automating procedures for obtaining hospital event information expedited both the systematic data review and chart review processes. In this study, combined use of automated processes for obtaining hospital event data and nurse review reduced the number of charts requiring blinded review by nearly 60%.

140 Exploring Heart Failure-Related Emergency Department Visits and Hospitalizations From the Patient Perspective

Low-income African-Americans with heart failure represent a vulnerable population that has poor clinical outcomes despite high rates of emergency department (ED) visits and hospitalizations. The patient-level factors that contribute to these high rates of health service utilization have not been clearly defined. The purpose of this study is to identify, among low-income African-Americans, patient-perceived medical and social challenges that contribute to poor heart failure-related clinical outcomes, avoidable ED visits, and avoidable hospitalizations. Semi-structured interviews were conducted with a convenience sample of African-American patients who presented to a high volume, inner-city, county-owned, teaching ED in Los Angeles. Patients were eligible for the study if they were being admitted to the hospital for a chronic heart failure exacerbation. The patients were interviewed in the ED or inpatient medicine ward. The interview incorporated questions to examine patients' experiences and beliefs regarding heart failure-related quality of life, general heart failure knowledge, patient-provider interactions, medication adherence, self-management skills, and health system navigation. Two follow-up interviews were performed by telephone with each study participant at 7 days and 30 days following discharge. The follow-up interviews included additional questions regarding patient satisfaction, the quality and comprehension of hospital discharge instructions, ease of new medication regimen, and outpatient follow-up care. Audio files of the interviews were transcribed and organized using Atlas.ti software. Themes were coded using grounded theory methods. Theme saturation was pre-defined as the identification of recurrent themes in greater than 70% of the interviews. Preliminary interviews were conducted with 7 African-American patients with a hospital admission diagnosis of chronic heart failure. The patients consisted of 5 men and 2 women, whose age ranged from 47 to 65 years old. One patient had Medicare insurance and the remaining patients were uninsured. All of the patients had a New York Heart Association classification of 3. Five salient themes were consistently identified that were believed by the patients to contribute to poor health and increased use of hospital-based care: 1) Competing demands due to economic or social stressors which results in medication noncompliance, 2) Dietary challenges and lack of nutrition education, 3) Poor patient-provider communication and/or interactions, 4) Unwarranted judgment by health providers and/or family, and 5) Lack of social support to make and maintain healthy lifestyle changes. All of the patients stated that they had adequate access to health care providers and heart failure related information. African-Americans with heart failure represent a vulnerable population that is subject to poor health outcomes despite costly health service utilization. However, lack of access to medical care is not a patient-perceived contributor to poor health. This qualitative study suggests that social and community factors may have a greater than expected impact on health behaviors and outcomes. The results from this study will be used to develop a community-based intervention to decrease avoidable ED visits and hospitalizations among low-income African-Americans with heart failure.

Cardiac Resynchronization Therapy for Drug-Refractory Heart Failure: -A Single-Center Experience

Background: Heart failure (HF) is associated with high mortality and morbidity rates even after pharmacological treatment. This retrospective study aimed at analyzing the clinical benefits and patient outcomes after cardiac resynchronization therapy (CRT). Methods: We enrolled 12 patients with New York Heart Association (NYHA) functional class Ⅲ or Ⅳ HF, a left ventricular ejection fraction (LVEF) of ≦35%, and an intrinsic QRS duration of ≧120 ms. These patients were refractory to pharmacological treatment and underwent CRT-device implantation. Results: After a mean follow-up of 6 months after device implantation, the mean values of NYHA functional class has decreased and the values of LV remodeling parameters, namely the LV end-diastolic diameter (LVEDD), LV end-systolic diameter (LVESD), and LVEF, had improved. The treatment resulted in a 58% reduction in the frequency of HF-related hospitalization, and cardiac-cause mortality was 8% for the entire study group; the corresponding values were 42.8% and 14.3% for patients with ischemic HF and 80% and 0% for those with non-ischemic HF. Both patients with ischemic and non-ischemic HF showed improvement in all the LV remodeling parameters. None of the patients developed any immediate complication of device implantation but 1 patient developed left subclavian vein thrombosis 2 months after device implantation and was treated successfully with anti-coagulant therapy. Conclusions: This small-scale, retrospective study of a drug refractory HF cohort revealed that CRT improves the quality of life, LVEF, LVEDD, and LVESD, and reduces cardiac-cause mortality and the frequency of HF related hospitalization both in ischemic and non-ischemic HF patients.

High-Normal Albuminuria and Risk of Heart Failure in the Community

Albuminuria has been associated with cardiovascular risk, but the relationship of high-normal albuminuria to subsequent heart failure has not been well established. Prospective observational study, the Atherosclerosis Risk in Communities (ARIC) Study. 10,975 individuals free from heart failure were followed up from the fourth ARIC Study visit (1996-1998) through January 2006. Urinary albumin-creatinine ratio (UACR), analyzed continuously and categorically as optimal (<5 mg/g), intermediate-normal (5-9 mg/g), high-normal (10-29 mg/g), microalbuminuria (30-299 mg/g), and macroalbuminuria (≥300 mg/g). Incident heart failure was defined as a heart failure-related hospitalization or death. Cox proportional hazard models were used to calculate the HR of heart failure after adjustment for age, race, sex, estimated glomerular filtration rate (eGFR), and other cardiovascular risk factors. Individuals were followed up for a median of 8.3 years and experienced 344 heart failure events. Compared with normal UACR, albuminuria was associated with a progressively increased risk of heart failure from intermediate-normal (adjusted HR, 1.54; 95% CI, 1.12-2.11) and high-normal UACR (adjusted HR, 1.91; 95% CI, 1.38-2.66) to microalbuminuria (adjusted HR, 2.49; 95% CI, 1.77-3.50) and macroalbuminuria (adjusted HR, 3.47; 95% CI, 2.10-5.72). Results were similar in secondary analyses of participants censored at the time of coronary heart disease event and along a range of eGFRs. UACR was measured as a single random sample. Albuminuria is associated with subsequent heart failure, even in individuals with few cardiovascular risk factors and UACR within the normal range. Our results suggest that the association between albuminuria and heart failure may not be mediated fully by ischemic heart disease or kidney disease, measured using eGFR.

Race, Sex, and Age Differences in Heart Failure-Related Hospitalizations in a Southern State

Background— Because heart failure (HF) is the final common pathway for most heart diseases, we examined its 10-year prevalence trend by race, sex, and age in Tennessee. Methods and Results— HF hospitalization data from the Tennessee Hospital Discharge Data System were analyzed by race, sex, and age. Rates were directly age-adjusted using the Year 2000 standard population. Adult (age 20+ years) inpatient hospitalization for primary diagnosis of HF (HFPD) increased from 4.2% in 1997 to 4.5% in 2006. Age-adjusted hospitalization for HF (per 10 000 population) rose by 11.3% (from 29.3 in 1997 to 32.6 in 2006). Parallel changes in secondary HF admissions were also noted. Age-adjusted rates were higher among blacks than whites and higher among men than women. The ratios of black to white by sex admitted with HFPD in 2006 were highest (9:1) among the youngest age categories (20 to 34 and 35 to 44 years). Furthermore, for each age category of black men below 65 years, there were higher HF admission rates than for white men in the immediate older age category. In 2006, the adjusted rate ratios for HFPD in black to white men ages 20 to 34 and 35 to 44 years were odds ratio, 4.75; 95% confidence interval, 3.29 to 6.86 and odds ratio, 5.10; 95% confidence interval, 4.15 to 6.25, respectively. Hypertension was the independent predictor of HF admissions in black men ages 20 to 34 years. Conclusions— The higher occurrence of HF among young adults in general, particularly among young black men, highlights the need for prevention by identifying modifiable biological and social determinants to reduce cardiovascular health disparities in this vulnerable group.

Heart Failure Prevention Is the Best Option To Stem High Costs and Disease Burden

In this issue of Circulation: Cardiovascular Quality and Outcomes , Okin and colleagues1 report on the incidence of heart failure in a cohort of patients with hypertension enrolled in the Losartan Intervention for End Point Reduction in Hypertension (LIFE) study. This study, an international randomized trial, demonstrated that losartan, when compared with atenolol, provided superior reduction of events in high-risk patients with hypertension and no history of heart failure before enrollment.2 Over a 5-year follow-up period, the incidence of heart failure in blacks was 7%, significantly higher than the 3.1% incidence rate found in nonblack patients. This difference persisted even when appropriately adjusted for differences such as the heavier risk factor burden, younger age, sex, renal disease, diabetes mellitus, randomized treatment, incident myocardial infarction, in-treatment QRS duration, strain and left ventricular hypertrophy as measured by ECG, and diastolic and systolic pressure. Additionally, an echocardiographic substudy demonstrated adverse differences in left ventricular structure and performance after 2 years of antihypertensive therapy in blacks compared to nonblacks. Article see p 157 These findings are consistent with several previous reports detailing heart failure differences in blacks, who, when receiving their diagnosis of heart failure, are younger; have greater risk factor burden; are more overweight; and are more likely to have diabetes, renal disease, less coronary disease, and higher heart failure-related hospitalization and death rates than whites.3,4 Unique in this report is that the cohort is entirely high-risk patients with hypertension. The small numbers of black participants (497) compared with white participants (8199), and thus, small numbers of new heart failure cases in blacks, is an important recognized limitation. The definition of heart failure relied on predefined hospital-based criteria and confirmatory evidence of heart failure as a cause of death. Blacks more often have impaired medical access, and thus …

Exercise training for systolic heart failure: Cochrane systematic review and meta-analysis.

To determine the effect of exercise training on clinical events and health-related quality of life (HRQoL) of patients with systolic heart failure. We searched electronic databases including Medline, EMBASE, and Cochrane Library up to January 2008 to identify randomized controlled trials (RCTs) comparing exercise training and usual care with a minimum follow-up of 6 months. Nineteen RCTs were included with a total of 3647 patients, the majority of whom were male, low-to-medium risk, and New York Heart Association class II-III with a left ventricular ejection fraction of <40%. There was no significant difference between exercise and control in short-term (<or=12 months) or longer-term all-cause mortality or overall hospital admissions. Heart failure-related hospitalizations were lower [relative risk: 0.72, 95% confidence interval (CI): 0.52-0.99] and HRQoL improved (standardized mean difference: -0.63, 95% CI: -0.80 to -0.37) with exercise therapy. Any effect of cardiac exercise training on total mortality and HRQoL was independent of degree of left ventricular dysfunction, type of cardiac rehabilitation, dose of exercise intervention, length of follow-up, trial quality, and trial publication date. Compared with usual care, in selected heart failure patients, exercise training reduces heart failure-related hospitalizations and results in clinically important improvements in HRQoL. High-quality RCT and cost-effectiveness evidence is needed for the effect of exercise training in community-based settings and in more severe heart failure patients, elderly people, and women.

Beta-blockers modify the prognostic value of adiponectin in chronic heart failure

Background Recent evidence suggests that high adiponectin levels serve as an independent predictor of mortality in chronic heart failure (CHF) patients. We aimed to assess the prognostic importance of adiponectin in CHF towards heart failure-related hospital admissions and mortality, in relation to other clinical, laboratory and exercise data. Methods Seventy-three CHF patients were recruited from the Heart Failure Clinic of the Antwerp University Hospital and followed for a median of 7 (range 1.5–9.1) years. Study endpoint was the combined occurrence of heart failure-related hospitalizations and all-cause death. At baseline patients underwent clinical assessment, echocardiography and cardiopulmonary exercise testing. Circulating concentrations of adiponectin, NT-proBNP and lipoproteins were measured. After follow-up the hazard ratio (HR) of adiponectin for outcome was estimated using multivariable Cox proportional hazard regression analysis. Results During follow-up, 14 (19%) patients died and 46 (63%) were admitted for CHF deterioration. The unadjusted hazard for poor outcome was higher in patients with adiponectin values above the 75th percentile (15.2 mg/L) ( P = 0.031). Adiponectin remained independently predictive [HR (95% CI) 2.47 (1.21–5.03), P = 0.013], when controlling for well-established predictors of mortality/morbidity in CHF. Additional correction for BMI, NT-proBNP, VO 2 peak, HDL and triglycerides did not affect the HR estimate. After adjusting for beta-blocker intake the association between adiponectin and poor outcome was no longer significant. Conclusions High adiponectin levels predict poor outcome in CHF patients independently of well-established and novel prognostic factors, but this prognostic value is significantly affected by beta-blocker treatment.

Overcoming the resistance to impedance monitoring in heart failure patients

This editorial refers to ‘Device-based impedance measurement is a useful and accurate tool for direct assessment of intrathoracic fluid accumulation in heart failure’ by J. Becher et al ., doi:10.1093/europace/eup413 and ‘Intrathoracic impedance and pulmonary wedge pressure for the detection of heart failure deterioration' by M. Maines et al ., doi:10.1093/europace/eup419 Patients with moderate to severe heart failure who meet the criteria for implantation of a cardiac resynchronization therapy (CRT) device and/or an implantable defibrillator (ICD) carry a startling risk of suffering from adverse clinical events, in particular heart failure-related hospitalizations and death. Though CRT and ICDs improve survival and CRT also decreases morbidity, the event risk in device carriers remains high: while ICD treatment per se does not impact heart failure severity—from the perspective of the devil's advocate, it may contribute to prolonged suffering from recurring heart failure exacerbation—even many CRT recipients continue to suffer from frequent heart failure-related events, especially in the unfortunate group of non-responders. Therefore, increasing attention has recently been paid to the use of heart failure devices not only for therapeutic but also for diagnostic purposes. Device-based sensors and algorithms for continuous surveillance of various physiological parameters such as the heart rate, heart rate variability, physical activity, or arrhythmia incidence, may add valuable information to patient assessment and, thus, help to improve patient management in heart failure. In particular, diagnostic features of monitoring of cardiac filling pressures and pulmonary fluid retention have raised interest due to their potential to reveal changes in heart failure status timely and early enough to initiate appropriate therapeutic interventions and prevent further progression to overt cardiac decompensation. Both methods showed promising results in pilot studies,1,2 encouraging the design of large-scale clinical trials3, … *Corresponding author. Tel: +46 8 517 71629; fax: +46 8 31 1044, Email: frieder.braunschweig{at}karolinska.se