Management Of Chronic Heart Failure Research Articles

Aetiology, diagnosis and management of heart failure in infants and children

Heart failure is due to failure of ventricular filling with failure of ejection of blood from the ventricles. It may present as volume overload with ventricular dysfunction, volume overload with preserved ventricular function, and pressure overload. Causes of heart failure in the paediatric age group include both congenital and acquired heart diseases. Dilated cardiomyopathy remains the most common cause of heart failure in the paediatric population. In this article, epidemiology; pathophysiology; aetiology; clinical presentation; investigations including radiological and laboratory investigations; medical and non-medical management of acute, chronic and end-stage heart failure and prognosis will be reviewed.

Insights into cardiorenal interactions in acute decompensated heart failure.

Acute decompensated heart failure (ADHF) is one of the biggest challenges in the management of chronic heart failure. Despite the advances in medical and device therapy, high readmission and mortality rates continue to be a burden on healthcare systems worldwide. One of the strongest predictors of adverse outcomes in ADHF is renal dysfunction, referred to as cardiorenal syndrome (CRS) type 1. This review discusses some of the recently introduced findings related to the pathophysiology, diagnosis, and management of this disorder. There is a better understanding of the pathophysiology of ADHF and CRS. Systemic and intrarenal hemodynamic data provided a much deeper insight into various mechanisms of interaction between the heart and the kidney. Novel biomarkers have been discovered and developed recently to help diagnose and predict prognosis of CRS. Although there was optimism toward using ultrafiltration in treating ADHF with CRS, recent data did not support that, and management remains primarily driven by reversing ADHF hemodynamic and neurohormonal derangements. ADHF with CRS carries poor prognosis and high mortality. There is a need for individual risk assessment and management. A dedicated experienced multidisciplinary team is needed to diagnose and manage patients with this problem. Different approaches are needed to address the complex elements of this disorder.

A review of the current management of acute and chronic heart failure in the context of ischemic heart disease

AbstractHeart failure secondary to left ventricular systolic dysfunction is a prevalent condition across Europe with ischemic heart disease the most common etiology. Acute heart failure is a medical emergency and management comprises diuretics and vasodilators. Several alternative intravenous treatments have been trialed in recent years but no mortality benefit has been found with these agents. For chronic heart failure there are several well‐characterized disease‐modifying treatments available which include beta blockers, ACE inhibitors, mineralocorticoid antagonists, and device therapy. Sacubitril/valsartan is a novel therapy that has recently been demonstrated to have additional prognostic benefit.Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/5222693/Activity.aspx

Multimorbidity and the Risk of All-Cause 30-Day Readmission in the Setting of Multidisciplinary Management of Chronic Heart Failure: A Retrospective Analysis of 830 Hospitalized Patients in Australia.

Multimorbidity has an adverse effect on health outcomes in hospitalized individuals with chronic heart failure (CHF), but the modulating effect of multidisciplinary management is unknown. The aim of this study was to test the hypothesis that increasing morbidity would independently predict an increasing risk of 30-day readmission despite multidisciplinary management of CHF. We studied patients hospitalized for any reason with heart failure receiving nurse-led, postdischarge multidisciplinary management. We profiled a matrix of expected comorbidities involving the most common coexisting conditions associated with CHF and examined the relationship between multimorbidity and 30-day all-cause readmission. A total of 830 patients (mean age 73 ± 13 years and 65% men) were assessed. Multimorbidity was common, with an average of 6.6 ± 2.4 comorbid conditions with sex-based differences in prevalence of 4 of 10 conditions. Within 30 days of initial hospitalization, 216 of 830 (26%) patients were readmitted for any reason. Greater multimorbidity was associated with increasing readmission (4%-44% for those with 0-1 to 8-9 morbid conditions; adjusted odds ratio, 1.25; 95% confidence interval, 1.13-1.38) for each additional condition. Three distinct classes of patient emerged: class 1-diabetes, metabolic, and mood disorders; class 2-renal impairment; and class 3-low with relatively fewer comorbid conditions. Classes 1 and 2 had higher 30-day readmission than class 3 did (adjusted P < .01 for both comparisons). These data affirm that multimorbidity is common in adult CHF inpatients and in potentially distinct patterns linked to outcome. Overall, greater multimorbidity is associated with a higher risk of 30-day all-cause readmission despite high-quality multidisciplinary management. More innovative approaches to target-specific clusters of multimorbidity are required to improve health outcomes in affected individuals.

Current evidence-based therapy does not restore plasma apelin level in phenotypically diverse chronic heart failure patients

Background: Apelin, endogenous peptide acting through its receptor (APJ), is the most potent inotropic agent known to man. Plasma apelin and cardiac APJ mRNA levels rise in early stages of chronic heart failure (CHF) but fall later in decompensated CHF. The effect of current evidence-based management of CHF on plasma apelin level is not known. We estimated change in plasma apelin level in CHF patients of diverse phenotypes treated with standard pharmacotherapy and compared it with the corresponding change in left ventricular ejection fraction (LVEF), plasma brain natriuretic peptide (BNP) level and quality of life (QoL).Methods: With ethical approval and written informed consent, venous blood samples were collected from 39 CHF [dilated cardiomyopathy (DCM) (n=21), restrictive cardiomyopathy (RCM) (n=9) and chronic constrictive pericarditis (CCP) (n=9)] patients and 10 age-matched healthy controls, at baseline and after 12 weeks. Plasma apelin and BNP were estimated by competitive ELISA (RayBiotech Inc.) and an auto-analyzer (Triage, Allere Inc.), respectively. QoL was assessed using Kansas City Cardiomyopathy Questionnaire (KCCQ). Nonparametric tests were applied and p-value &lt;0.05 was considered significant.Results: Low LVEF, KCCQ score and high BNP levels were observed in all CHF patients compared to controls. Plasma apelin level was depressed in RCM and CCP patients compared to controls but not in DCM patients. These parameters did not change in any group after 3 months of standard pharmacotherapy.Conclusions: Current evidence-based management of CHF does not restore the depressed apelin-APJ axis. New drugs are required for specifically modulating this promising therapeutic target in CHF.

Chronic heart failure part 2: treatment and management.

Chronic heart failure is a common and complex clinical syndrome that results from impaired cardiac relaxation or contraction. There have been considerable advances in the management of chronic heart failure; however, the mortality rate remains high. Patients with chronic heart failure may experience multiple debilitating symptoms, such as fatigue, pain, and peripheral oedema. However, breathlessness may be considered the most debilitating symptom. The management of chronic heart failure aims to improve the patient's quality of life by reducing symptoms and supporting the patient to manage their condition. Treatment of patients with chronic heart failure may involve a combination of pharmacological therapy, device implantation and cardiac rehabilitation. This is the second of two articles on chronic heart failure. Part 1 discussed the pathophysiology of chronic heart failure, its causes, assessment, signs and symptoms. Part 2 outlines the treatment and management of patients with the condition, including pharmacological strategies, device implantation, lifestyle modification, cardiac rehabilitation and palliative care.

Nurse Practitioner Led Cardiac Gym Clinic for Heart Failure Patients; A New Initiative

Objective: The onsite hospital cardiac gym provides patients of the Advanced Heart Failure Service with a safe environment to exercise. Benefits of exercise in heart failure (HF) have been well documented [[1]NHF&CSANZ Guidelines for the prevention, detection and management of chronic heart failure in Australia. 2011; Google Scholar]. The HF nurse practitioner (NP) initiated a NP gym clinic aiming to provide clinical support and prompt solutions to presenting problems combined with medication management. NPs have been proven to improve outcomes for HF patients [[2]Kaan A. Dunne J. Development of a Nurse Practitioner Role in Heart Failure Management: An Australian Experience.Prog Cardiovasc Nurs. 2001; 16: 33-34Crossref PubMed Scopus (3) Google Scholar]. Management of HF includes optimisation of angiotension receptor antagonists and betablockers [[1]NHF&CSANZ Guidelines for the prevention, detection and management of chronic heart failure in Australia. 2011; Google Scholar] Design: The NP is onsite at the cardiac gym 1 day per week. This retrospective study reviews data collected over 12 months. Method: NP reviewed 74 patients, 63 male for 322 episodes. Average age 52 years (SD 12.8) with varying aetiology of heart failure, ejection fraction 27.4% (SD 12.9). Results: NP initiated 62% of cases, 59% for routine follow up and 41% due to a symptom change. Of symptoms reported, 51% were shortness of breath + - fluid overload. Treatment included medication optimisation and blood work. Most cases were independently managed by the NP without consultation with medical staff. Improvement in EF on echocardiogram increased to 38.4% (SD 13.6). Patient satisfaction was positive on survey. Conclusion: The presence of an NP in the cardiac gym proved to be a valuable adjunct to exercise. Patients were uptitrated to maximal doses of HF medications where tolerated. Improvement in EF on echo was statistically significant.

Pathology of the peripheral circulation in chronic heart failure

In the mechanisms of chronic heart failure (CHF) the key role traditionally given to a violation of intracardiac haemocirculation. Thus, in the guidelines for the evaluation and management of chronic heart failure in the adult, experts of the American College of Cardiology and the American Heart Association (2001-2013) define CHF as «a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood». Usually rightly believe that than the expression of inotropic and/or lusitropic failure of the appropriate ventricle in patients with CHF, the generally lower of him quality of life and a worse prognosis. However, the severity of the clinical manifestations of heart failure, on the one hand, and reducing the level of satisfaction with life - on the other, is not always depends only on the state of intracardiac hemodynamics. The authors of the review have analyzed papers published on the problem of the pathology of the peripheral circulation in CHF. Consistently examines the role of peripheral vascular remodeling and increased arterial stiffness, endothelial dysfunction of major and resistance arteries, as well as pathology of microcirculation. It has been shown that the development and progression of heart failure is accompanied by a deterioration in the peripheral circulation due to the remodeling of arteries muscular-elastic type and veins with a reduction in vascular dilatation reserve, increase of regional vascular resistance and venous tone, disturbances of tissue transcapillary exchange of oxygen and activate of procoagulant properties of blood. The significance of the effects of vasoconstrictor neurohormonal systems and inflammation in mechanisms of disorders of peripheral circulation in patients with CHF, particularly associated with the metabolic syndrome, have discussed.

New guidelines, new recommendations! But what is really new? A pragmatic interpretation of the 2016 European guidelines for the management of chronic heart failure

New guidelines, new recommendations! But what is really new? A pragmatic interpretation of the 2016 European guidelines for the management of chronic heart failure

Korean Guidelines for Diagnosis and Management of Chronic Heart Failure.

The prevalence of heart failure (HF) is skyrocketing worldwide, and is closely associated with serious morbidity and mortality. In particular, HF is one of the main causes for the hospitalization and mortality in elderly individuals. Korea also has these epidemiological problems, and HF is responsible for huge socioeconomic burden. However, there has been no clinical guideline for HF management in Korea. The present guideline provides the first set of practical guidelines for the management of HF in Korea and was developed using the guideline adaptation process while including as many data from Korean studies as possible. The scope of the present guideline includes the definition, diagnosis, and treatment of chronic HF with reduced/preserved ejection fraction of various etiologies.

Long-term cost-effectiveness of home versus clinic-based management of chronic heart failure: the WHICH? study

Background: The cost-effectiveness of a heart failure management intervention can be further informed by incorporating the expected benefits and costs of future survival.Methods: This study compared the long-term costs per quality-adjusted life year (QALY) gained from home-based (HBI) vs specialist clinic-based intervention (CBI) among elderly patients (mean age = 71 years) with heart failure discharged home (mean intervention duration = 12 months). Cost-utility analysis was conducted from a government-funded health system perspective. A Markov cohort model was used to simulate disease progression over 15 years based on initial data from a randomized clinical trial (the WHICH? study). Time-dependent hazard functions were modeled using the Weibull function, and this was compared against an alternative model where the hazard was assumed to be constant over time. Deterministic and probabilistic sensitivity analyses were conducted to identify the key drivers of cost-effectiveness and quantify uncertainty in the results.Results: During the trial, mortality was the highest within 30 days of discharge and decreased thereafter in both groups, although the declining rate of mortality was slower in CBI than HBI. At 15 years (extrapolated), HBI was associated with slightly better health outcomes (mean of 0.59 QALYs gained) and mean additional costs of AU$13,876 per patient. The incremental cost-utility ratio and the incremental net monetary benefit (vs CBI) were AU$23,352 per QALY gained and AU$15,835, respectively. The uncertainty was driven by variability in the costs and probabilities of readmissions. Probabilistic sensitivity analysis showed HBI had a 68% probability of being cost-effective at a willingness-to-pay threshold of AU$50,000 per QALY.Conclusion: Compared with CBI (outpatient specialized HF clinic-based intervention), HBI (home-based predominantly, but not exclusively) could potentially be cost-effective over the long-term in elderly patients with heart failure at a willingness-to-pay threshold of AU$50,000/QALY, albeit with large uncertainty.

Abstract 11868: Intracardiac Pressures Measured Using an Implantable Hemodynamic Monitor: Relationship to Mortality in Patients With Chronic Heart Failure

Introduction: The use of implantable hemodynamic monitor (IHM)-derived pressure to facilitate management of chronic heart failure (CHF) has been shown to decrease ventricular filling pressures and reduce heart failure hospitalizations. However, whether IHM-derived pressures predict mortality rate is unknown. Hypothesis: Determine whether IHM-derived baseline estimated pulmonary artery diastolic pressure (ePAD) and change from baseline ePAD were independent predictors of all-cause mortality in patients with CHF. Methods: A retrospective analysis used data from three studies in CHF patients with an IHM (n=790). Baseline ePAD, mean of daily median ePAD from 0-14 days after IHM implantation, was related to mortality using a multivariable model including baseline and demographic data. Change in ePAD defined from baseline to 6 month and from baseline to 14 days prior to death or exit from study were related to mortality. Area under the pressure vs time curve (AUC) during 180 days prior to death or exit from study was related to mortality. Results: Baseline ePAD, independent of other covariates, was a significant predictor of mortality (Chi-square=36.7, HR=1.067, 95% CI=1.047, 1.089, p&lt;0.0001) (Fig. A). Change in ePAD was a predictor of mortality. There was a significant relationship between change in ePAD from baseline to 6 months and mortality (HR=1.074, 95% CI=1.048, 1.100, p=0008). Change in ePAD = 3, 4, or 5 mmHg from baseline to 6 months was associated with a change in mortality risk of 23.8%, 32.9%, or 42.8% respectively (Fig. B). Change in ePAD from baseline to 14 days prior to death or exit from study was higher in patients that died 3.0±8 vs 1.7±10 mmHg, p=0.003). AUC in the 180 days prior to death or exit from study was higher in the patients that died (185±668 vs 17±482 mmHg.days, p=0.006). Conclusions: Implantable hemodynamic monitor -derived baseline ePAD and change from baseline ePAD were independent predictors of mortality in CHF patients.

Coagulation Abnormalities in Heart Failure: Pathophysiology and Therapeutic Implications.

Heart failure (HF) represents a heterogeneous condition characterized by vulnerabilities in the blood, vasculature, and impaired flow dynamics that predispose to both arterial and venous thrombosis. Despite evidence-based advances in the medical and device management of chronic HF, it remains a leading cause of morbidity and mortality in the USA due to repeat hospitalizations and comorbid conditions such as atrial fibrillation (AF) and stroke. The presence of platelet activation and hypercoagulability in HF has been well documented. Anticoagulation is effective in HF when comorbidities such as AF and prior venous thromboembolism exist. However, data is less clear for HF in sinus rhythm. Moreover, there is a paucity of data regarding antiplatelet therapy in HF. No consensus guidelines exist regarding the precise role of antiplatelet or antithrombotic therapy in HF. This review addresses the pathophysiology of coagulation abnormalities in HF, examines the available evidence regarding the use of anticoagulants and antiplatelet agents in HF, and discusses its therapeutic implications.

Evolving therapies for the management of chronic and acute decompensated heart failure.

The pharmacology, clinical efficacy, and safety profiles of evolving therapies for the management of chronic heart failure (HF) and acute decompensated heart failure (ADHF) are described. HF confers a significant financial burden despite the widespread use of traditional guideline-directed medical therapies such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, and aldosterone receptor antagonists, and the rates of HF-related mortality and hospitalization have remained unacceptably high. In response to a demand for novel pharmacologic agents, several therapeutic compounds have recently gained approval or are currently under review by the Food and Drug Administration. Sacubitril-valsartan has demonstrated benefit in reducing cardiovascular mortality and HF-related hospitalizations in clinical trials, while ivabradine and ferric carboxymaltose have proven efficacious in reducing HF-related hospitalizations. Lastly, the role of serelaxin in ADHF is currently under investigation in an ongoing Phase III study. While large, outcome-driven clinical trials are fundamental in informing the clinical application of these therapeutic agents, careful patient selection is imperative to ensuring similar outcomes postmarketing. In addition, optimization of current guideline-directed medical therapy remains essential as new therapies emerge and are incorporated into guideline recommendations. Additional therapeutic agents currently undergoing investigation include bucindolol hydrochloride, cimaglermin alfa, nitroxyl, omecamtiv mecarbil, TRV027, and ularitide. Clinical practitioners should remain abreast of emerging literature so that new therapeutic entities are optimally applied and positive patient outcomes are achieved. Recently introduced agents for the treatment of patients with HF include sacubitril-valsartan, ivabradine, and ferric carboxymaltose. Additional agents worthy of attention include serelaxin and other therapies currently under investigation.

How robust are clinical trials in heart failure?

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

Correction to: 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America.

In the article by Yancy et al, “2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America,” which published online May 20, 2016, and appeared in the September 27, 2016, issue of the journal ( Circulation. 2016;134:e282–e293. DOI: 10.1161/CIR.0000000000000435), several corrections were needed. 1. On page e282, …

CardioMEMSTM in LVAD Patients: A Case Series

Patients with a left ventricular assist device (LVAD) commonly encounter issues with volume status post-implant. Volume overload can result from incomplete compensation of left ventricular failure or from right ventricular failure. The CardioMEMS™ intracardiac hemodynamic monitoring device is an area of growing interest regarding the management of chronic congestive heart failure, however, its utility has not been serially investigated in patients with an LVAD. We present a case series of patients with ventricular assist devices care for at our institution in which the CardioMEMS™ device aided in the management of volume status and pump performance.

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

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

PP.20.06] THE INFLUENCE OF SLOW BREATHING TRAINING ON PHYSICAL EXERCISE CAPACITY AND SLEEP DISTURBANCES IN PATIENTS WITH CHRONIC HEART FAILURE

Objective: Slow breathing has favorable acute effects in chronic heart failure (CHF) patients. Aim of this study was to test the feasibility and efficacy of a new nonpharmacological approach to CHF management based on slow breathing training (SBT). Design and method: The study was a cross-over open trial where patients, in random order, underwent a 10–12 week period of SBT with RESPeRATE device (InterCure Ltd., Lod, Israel) and a 10–12 week follow-up under usual care. Patients during SBT were asked to perform each day two separate 15-min sessions of device-guided SBT at a breathing frequency of 6 breaths per minute. In all patients, clinical data collection, echocardiography, polysomnography, 6 minute walking test (6MWT) and laboratory tests were performed at baseline and after each study phase. Results: 74 patients completed the study, with the following baseline characteristics: age 62.9 ± 11.9 years, 59 M/15F, 52 with ischemic CHF, NYHA Class I:7 Class II:51, Class III:16, left ventricular ejection fraction 30.4 ± 8.1 %, hypertension: 47, history of stroke: 5, diabetes: 28. Compared with values before SBT, after completion of the SBT phase we observed an increase in 6MWT distance (from 482.3 ± 118.9 to 499.2 ± 116.9 m; p = 0.008) and in left ventricular ejection fraction [from 30.0 (25.0–37.0) to 32.0 (27.0–37.0) %; p = 0.047], and a decrease in apnea-hypopnea index (from 9.9 ± 10.3 to 7.9 ± 8.4; p = 0.015). A trend towards reduction of pulmonary artery pressure [35 (27–45) vs 32 (25–40) mmHg; p = 0.063] was also seen. Conclusions: Our data indicate that SBT is feasible in CHF patients and that it is associated with an improvement in functional capacity, haemodynamic variables and sleep disordered breathing severity. These results support SBT as a novel and useful component of cardiorespiratory rehabilitation programs in CHF.

Chronic Heart Failure.

The objectives of this review are to discuss the paradigms used to stage heart failure in children, the classification and physiologic profile of cardiomyopathies, and the acute and chronic pharmacologic management of heart failure. MEDLINE, PubMed. The etiology of chronic heart failure in pediatrics is vast. The paradigm of extrapolating adult clinical trials and technological advancements to treat heart failure in children has become a nonsustainable model. The field of pediatric heart failure continues to advance with more robust guideline-directed care and the imminent creation of a dynamic, contemporary international database. As the field involves a markedly heterogeneous patient population, it is imperative to use pediatric specific descriptors of disease impact. The fields of pediatric heart failure and critical care medicine will continue to evolve together as childhood specific registries, quality improvement guidelines, and research will lead to practice models eliciting optimal therapy for patients with heart failure in the intensive care setting.