New York Heart Association Stage Research Articles

Health care resource use, diagnostic delay and disease burden in transthyretin amyloid cardiomyopathy in Sweden

Aims To estimate healthcare resource use and direct healthcare costs of Transthyretin Amyloid Cardiomyopathy (ATTR-CM) in Sweden over 12 months across severity stages as defined by the New York Heart Association (NYHA). Secondary to investigate the current diagnostic trajectory for patients with ATTR-CM in Sweden. Methods A stratified inclusion of patients with a confirmed diagnosis of ATTR-CM in different NYHA classes. Data was extracted from medical records in two cardiology clinics in Sweden. Healthcare resource use data were retrospectively collected for 12 months. Results 38 patients were included, of whom 7 were in NYHA class II, 20 in class III and 4 in class IV. The total cost of health care per patient increased from SEK 69,000 (€6800) in NYHA stage II, SEK 219,000 (€21,500) in NYHA stage III, to SEK 638,000 (€62,900) in stage IV, mainly due to an increase in inpatient stays. Mean time (standard deviation, SD) from any cardiac related diagnosis prior to ATTR-CM diagnosis was 3.5 (3.1) years. Conclusions Advanced ATTR-CM stages are associated with significant healthcare costs, as patients more often require resource-intensive inpatient care. The current diagnostic trajectory of ATTR-CM in this study was characterized by a diagnostic delay of several years.

Therapeutic Itinerary of Patients with Chronic Heart Failure at the Bafoussam Regional Hospital, West Region, Cameroon

Background: Cardiovascular diseases have emerged as a growing public health problem worldwide, with heart failure being the end point of a greater majority of poorly diagnosed and managed heart diseases. In Sub-Saharan Africa, traditional medicine still has a remarkable influence on health care systems, and in Cameroon, the referral/counter-referral system thought to be implemented is not efficiently applied. Heart failure patients fall amongst the group of victims affected by this problem. Many studies have been carried on heart failure in Cameroon, but data on this subject remains sparse.
 Objective: To identify the therapeutic itinerary adopted by symptomatic patients with chronic heart failure seen at the Bafoussam Regional Hospital (BRH) and determine the outcome following management by cardiologists, so as to provide results-driven interventions to increase the rate of early management of heart failure by appropriate health services and limit complications due to wrong therapeutic orientations.
 Methods: A hospital-based cross-sectional descriptive study was carried, from February 2019 to May 2019 at the Bafoussam Regional Hospital. A consecutive sampling technique using objective-related structured questionnaire was used to select patients aged above 18 years seen at the study site. Data was analyzed using SPSS (Statistical Package for Social Sciences) version 23. A p-value less than 0.05 was considered statistically significant.
 Results: The BRH Cardiologist consultation was the 1st station sought by 32 (23.7%) of patients. We found 14.8% of cases and 8.9% who had as first therapeutic stations home management and traditional healers respectively. Majority of participants went through a total of 2 stations, 60 (44.4%), and only 5 (3.7%) went through 5 therapeutic stations. Most participants (36.3%), delayed for 1-3 weeks after onset of symptoms before seeking a means of intervention. NYHA (New York Heart Association) stages were generally improved after cardiologists’ follow up (54.1% and 26.7% for stages I and II respectively), compared to that before entry (0.7% stage I, 41.5% stage II, 38.5% stage 3, and 19.3% stage IV), which was statistically significant with P < 0.0005.
 Conclusion: There is a high proportion of HF patients who do no adopt an ideal therapeutic itinerary following the health pyramid from the onset of symptoms, hence the need to educate the population on cardinal signs of heart failure, especially patients with known risk factors, and to encourage the referral of patients in order to limit complications between the onset of symptoms till cardiologist consultation.

Subclinical hypothyroidism and dilated cardiomyopathy (DCM) in children

Introduction: Subclinical hypothyroidism is defined by the combination of an elevated thyroid-stimulating hormone (TSH) level and a normal free thyroxine (T4L) level. Dilated cardiomyopathy is characterized by both dilation of the ventricles and hypokinesia of these ventricles. It predominantly involves the left ventricle, but the right ventricle is frequently involved.We present two cases of idiopathic dilated cardiomyopathy associated with a subclinical picture of hypothyroidism. Case report 1: An 11-year-old female patient was admitted to cardiology for congestive heart failure on CMD; she presented with New York Heart Association (NYHA) stage IV dyspnea and generalized edema. Tran’s thoracic echocardiography showed left ventricular (LV) dilatation with global hypokinesia, LV ejection fraction at 15%. The biological workup showed a subclinical hypothyroidism profile with TSH at 11.2 mIU/l, T4: 21.2 pmol/l, T3: 4.2pmol/l. Case report 2: A 9-year-old patient, without any notable history, was referred to the cardiology department for global cardiac decompensation with NYHA stage IV dyspnea and lower limb edema despite optimal medical treatment. Tran’s thoracic echocardiography showed dilated cardiomyopathy with severe impairment of LV systolic function (10%). The biological workup showed a subclinical hypothyroidism profile with TSH: 7.7 mIU/l, T4: 19.2 pmol/l. Conclusion: Dilated cardiomyopathies (DCM) represent the most common cardiomyopathies in children either of constitutional or acquired origin. Subclinical hypothyroidism is frequently observed in patients with DCM and increases the risk of mortality.

Cost-of-disease of Heart Failure in Turkey: A Delphi Panel-based Analysis of Direct and Indirect Costs.

Background:Heart failure (HF) is considered a significant public health issue with a substantial and growing epidemiologic and economic burden in relation to longer life expectancy and aging global population.Aims:To determine cost-of-disease of heart failure (HF) in Turkey from the payer perspective.Study Design:Cross-sectional cost of disease study.Methods:In this cost-of-disease study, annual direct and indirect costs of management of HF were determined based on epidemiological, clinical and lost productivity inputs provided by a Delphi panel consisted of 11 experts in HF with respect to ejection fraction (EF) status (HF patients with reduced EF (HFrEF), mid-range EF (HFmrEF) and preserved EF (HFpEF)) and New York Heart Association (NYHA) classification. Direct medical costs included cost items on outpatient management, inpatient management, medications, and non-pharmaceutical treatments. Indirect cost was calculated based on the lost productivity due to absenteeism and presenteeism.Results:51.4%, 19.5%, and 29.1% of the patients were estimated to be HFrEF, HFmrEF, and HFpEF patients, respectively. The total annual direct medical cost per patient was $887 and non-pharmaceutical treatments ($373, 42.1%) were the major direct cost driver. Since an estimated nationwide number of HF patients is 1,128,000 in 2021, the total annual national economic burden of HF is estimated to be $1 billion in 2021. The direct medical cost was higher in patients with HFrEF than in those with HFmrEF or HFpEF ($1,147 vs. $555 and $649, respectively). Average indirect cost per patient was calculated to be $3,386 and was similar across HFrEF, HFmrEF and HFpEF groups, but increased with advanced NYHA stage.Conclusion:Our findings confirm the substantial economic burden of HF in terms of both direct and indirect costs and indicate that the non-pharmaceutical cost is the major direct medical cost driver in HF management, regardless of the EF status of HF patients.

Impact of using the modified De Vega Annuloplasty using pericardial patch versus Ring Annuloplasty in Mitral valve replacement with severe functional tricuspid regurgitation

IntroductionTricuspid regurgitation in patients with mitral valve disease is associated with poor outcome and predicts poor survival, heart failure, and reduced functional capacity. The objective was to access if modified De Vega Annuloplasty (mDA) using pericardial patch offered significant surgical, functional and economical benefits over RA done for Mitral valve replacement with severe functional tricuspid regurgitation in a predominant rheumatic population. MethodsThis retrospective study analyzed data from 50 patient who were eligible for this study and underwent mitral valve replacement surgery for severe mitral valve stenosis with functional tricuspid valve disease (30 AR and 20 mDA) between the period of January 2015 and December 2019 at Kem Hospital, Mumbai. Post-operatively all patients has routine TTE (transthoracic echocardiography) before discharge and subsequently at 6 months and 1 year. Severity of TR (Tricuspid Regurgitation), LVEF (Left Ventricular Ejection Fraction), TAPSE (Tricuspid Annular Plane Systolic Excursion) and PASP (Pulmonary Artery Systolic Pressure) were used for determining functional status of the patient. ResultsThere was no statistically significant difference in residual TR. There was significant improvement in NYHA (Newyork Heart Association) stage. Statistically significant difference was seen in the cost, with mDA demonstrating economic benefits for the patient. ConclusionsSimilar functional outcomes were seen with both techniques. Only incremental economic benefit was seen with mDA in the form of lower cost for the patient. However, this is just the early outcome and long term study is ongoing to ascertain outcome.

Cardiotoxicity of perioperative chemotherapy for neublastoma in pediatric visceral surgery

Neuroblastoma is a cancer of the sympathetic nervous system, which accounts for 7% of all childhood cancers and 15% of childhood cancer deaths. During the diagnosis and treatment of these pediatric cancers, children have a high-risk of developing cardiotoxicity due to chemotherapy and perioperative decompensation of this heart disease. The management of side effects mainly involves screening for risk situations based on clinical examination, ECG and echocardiography, mainly preoperatively. The main objective of this study was the cardiac assessment of patients scheduled for neuroblastoma excisional surgery who are on neoadjuvant chemotherapy. Our sample was 20 patients. Average age was 3 years (13 months–6 years) with male predominance, the sex ratio M/F is 1.4. The abdominal seat represented 70% (14 cases) of all locations, the thoracic seat represented 20% (4 cases) of the locations, the pelvic seat represented 10% of the locations. Sixty percent of neuroblastomas were metastatic at the time of diagnosis. Spinal cord infiltration accounted for 60% of all metastatic cases. All of our patients were receiving an anthracycline as part of their chemotherapy regimen, which caused heart damage. The pre-anesthetic clinical examination assessed dyspnea according to the NYHA (New York Heart Association) class. NYHA class I dyspnea was found in 15 patients (75%) of patients. NYHA class II dyspnea was found in 4 patients (20%) of the patients. NYHA class III dyspnea was found in one patient (5%) of patients with pulmonary metastases. NYHA stage IV dyspnea has not been found in any patient. In our study, 40% of cases or 8 patients retained their cardiac function under anthracyclines, 50% or 10 patients developed a moderate to slight decrease in cardiac function. Two patients or 10% of cases developed severe cardiotoxicity with one case of symptomatic cardiac involvement and one case of asymptomatic cardiac involvement. This required a discontinuation of treatment and hospitalization in intensive care in a picture of cardiomyopathy. The two patients with impaired systolic function were put on an Angiotensin-converting enzyme inhibitor. We observed regression of dyspnea and signs of heart disease with improvement in left ventricular ejection fraction. There have been no deaths from heart failure. We changed the chemotherapy protocol with stopping the anthracyclines. We advocated careful ultrasound monitoring for patients with mild to moderate cardiotoxicity. The diagnosis of cardiovascular complications associated with chemotherapy must be early. Cardiopulmonary complications are the third leading cause of death after primary cancer recurrence and the onset of a second cancer.

Strong and Direct Correlation in Heart Failure Between B-Lines and NT-ProBNP Levels

The aim of the study was to evaluate the compliance of the number of B-lines on focused lung ultrasound with the clinical heart failure classification of the New York Heart Association (NYHA) and NT-proBNP levels in the emergency department. This prospective study was conducted in a tertiary university hospital emergency department. Patients over 18 years of age complaining of shortness of breath or heart failure diagnosis between January 2016 and July 2016. The number of B-lines according to the BLUE point regions was measured. Correlations between the clinical heart failure stage, NT-proBNP level and number of B-lines on ultrasonography were analyzed. Of the 143 patients, 92 (64.3%) were male and 51 (35.7%) were female. The median age was 73.00 (66.00-79.00). There was a very strong correlation between the number of B-lines and NYHA stages for each region (r > 0.85 for all variables; p <0.001 for all). There was also a strong and direct correlation between the number of B-lines and the NT-proBNP levels for each region (r > 0.70; p <0.001). Regarding the shortness of breath numerical score (r > 0.45; p <0.001), there was an inverse relationship with ejection fraction (EF). The relationship between the EF and BLUE points was moderate, but negative and significant (p <0.001). NT-proBNP levels, the NHYA classification, and lung ultrasound can be used as a tool in the emergency department for a faster diagnosis and decision-making in lung congestion.

The walking estimated limitation stated by history (WELSH): a visual tool to self-reported walking impairment in a predominantly illiterate population.

The prevalence of cardiovascular diseases is increasing in low-income countries. Various questionnaires to estimate walking capacity in patients are available in multiple languages but they are not suitable for illiterate patients. The walking estimated limitation stated by history (WELSH) tool aims at rating individual walking disability using only drawings and four items. A six-month prospective study was performed on new patients referred to the Department of Cardiology at the Centre Hospitalier Universitaire Sourô Sanou in Bobo-Dioulasso, Burkina Faso. We administered the WELSH tool after a short oral presentation in the patient's language or dialect. Thereafter, patients performed a six-minute walking test in the hospital corridor under the supervision of a nurse who was blinded to the results of the WELSH score. We performed a step-by-step multilinear regression analysis to determine the factors predicting maximal walking distance (MWD). There were 40 female and 10 male patients in this study. Their ages ranged from 54.8 ± 10.7 years. Only 32% of the patients had attended primary school. Most patients were classified as stage I to III of the New York Heart Association (NYHA) classification. The objective measurement of MWD during a six-minute walking test showed no association with the subjects' educational level, body mass index, NYHA stage or gender, but a significant correlation with the WELSH scores. The Spearman r-value for the WELSH score-to-MWD relationship was 0.605 (p < 0.001). The WELSH tool is feasible and correlated with measured MWD in a population of predominantly illiterate patients.

Assessment of the functional state of left heart in patients with chronic heart failure with preserved ejection fraction

Aim. To research the myocardial function in patients with chronic heart failure with preserved left ventricular ejection fraction (CHF-PEF) by speckle tracking echocardiography and function of the left atrium. Material and methods . Eighty patients aged from 50 to 68 years with verified CHF-PEF with NYHA (New York Heart Association) class I-IIa and stage A-C of the ABCD classification of the American College of Cardiology, and 30 healthy persons were examined. CHF-PEF was initiated by arterial hypertension and coronary artery disease. In our study we use 6-minute walk test to evaluate the functional class of CHF-PEF, echocardiography and speckle-tracking echocardiography to examine left ventricle systolic, diastolic function and speckle tracking echocardiography to determine the parameters of the myocardial deformation. Results. Patients were divided as followed: 27% had stage A of CHF, 47,9% — stage B, 25,1% — stage C. The average left ventricular ejection fraction (by Simpson’s method) was 63,3±4,43%. Indexed end systolic volume of the left atrium (LP) in CHF-SFV patients 45,2±8,1 ml/m 2 . All patients had the diastolic dysfunction: 60 patients had abnormal relaxation pattern, and 20 patients had pseudonormal pattern. Patients with CHF-PEF had reduced global longitudinal strain (GLS) -16,56±2,61% and GLS rate (GLSR) -0,75±0,11s -1 of the left ventricle and reduced segmental strain and strain rate in basal anteroseptal (-14,72±2,54% and -0,76±0,05s -1 ) and basal anterolateral (-14,27±3,29% and -0,79±0,12s -1 ) segments. Also patients with CHF-PEF has lower reduction of the circular strain and strain rate (-16,63±3,5% and -1,43±0,21s -1 ), (p<0,05) in comparison with the GLS. Changes of the radial strain and strain rate were not revealed. Positive correlation between GLS and left atrium volume (r=0,601, р<0,01) was found. Conclusion . In patients with CHF-PEF we revealed abnormal relaxation pattern and pseudonormal pattern of the diastolic dysfunction. Reduced global and segmental strain and strain rate of the left ventricle were shown, circular strain was slightly reduced, radial strain was unchanged.

Low- and High-renin Heart Failure Phenotypes with Clinical Implications.

Blockade of the renin-angiotensin system (RAS) represents a main strategy in the therapy of heart failure with reduced ejection fraction (HFrEF), but the role of active renin concentration (ARC) for guiding therapy in the presence of an RAS blockade remains to be established. This study assessed angiotensin profiles of HFrEF patients with distinct RAS activations as reflected by ARC. Two cohorts of stable chronic HFrEF patients on optimal medical treatment (OMT) were enrolled. We assessed ARC and all known circulating angiotensin metabolites, including AngI and AngII, by mass spectrometry to investigate the effect of different therapy modalities. Low- and high-renin HFrEF patients were identified by ARC screening and subsequently characterized by their angiotensin profiles. Although different modes of RAS blockade resulted in typical AngII/AngI ratios, concentrations of (AngI+AngII) strongly correlated with ARC [r = 0.95, P < 0.001] independent of therapy mode. Despite RAS blocker treatment with angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin II type 1 receptor blockers (ARB), which anticipated ARC upregulation, about 30% of patients showed lower/normal range ARC values. ARC did not correlate with N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations and New York Heart Association (NYHA) stages. Angiotensin concentrations were profoundly diminished for the low-ARC group compared with the high-ARC group: AngI [6.4 ng/L (IQR: 2.1-12.5) vs 537.9 ng/L (IQR: 423.1-728.4), P < 0.001 for ACE-I; and 4.5 ng/L (IQR: 1.4-11.2) vs 203.0 ng/L (IQR: 130.2-247.9), P = 0.003 for ARB] and AngII [<1.4 ng/L (IQR: <1.4-1.5) vs 6.1 ng/L (IQR: 2.0-11.1), P = 0.002 for ACE-I and 4.7 ng/L (IQR: <1.4-12.3) vs 206.4 ng/L (IQR: 142.2-234.4), P < 0.001 for ARB]. In addition to NT-proBNP and NYHA stages, ARC enables classification of HFrEF patients receiving OMT into more distinguished neurohumoral HFrEF phenotypes, offering a rationale for adaptive therapeutic interventions.

Evaluation of malnutrition with blood ghrelin and fecal elastase levels in acute decompensated heart failure patients.

Exocrine pancreatic dysfunction may contribute to malnutrition and lack of appetite in the advanced stages of heart failure. Nutritional assessment was carried out on patients diagnosed with mild or moderate/severe heart failure. Fecal elastase levels are an indicator of pancreatic exocrine function and ghrelin is an appetite hormone which is also investigated for its contribution to malnutrition. This is an observational study. 52 patients (32 males, 20 females) aged over eighteen years and hospitalized for acute decompensated heart failure (ADHF) were included in the study. They were compared with 31 people (16 male, 15 female) of the same age as Control Group (C). Patients in New York Heart Association (NYHA) stages 1 and 2 were grouped as mild (miADHF), while those in NYHA stages 3 and 4 were grouped as moderate/severe ADHF (seADHF). Fecal and blood samples were taken at admission. In ADHF patients, exocrine pancreatic functions and their relationship with malnutrition were evaluated. Statistical analyses were performed using Tukey's test, the independent-sample t-test, the Kruskal-Wallis test, the Mann-Whitney U-test, the chi-square test and Pearson's bivariate correlation analysis. Significantly decreased fecal elastase levels were found when moderate/severe ADHF patients and the control group were compared. (C 278.9±144.8, miADHF 336.6±181.7, seADHF 168.7±153.6, p=0.002). 10 seADHF patients (50%) had severe, 4 (20%) moderate, and 6 (30%) mild pancreatic insufficiency. Ghrelin levels were higher in seADHF patients compared to C and miADHF patients (C 69.7±34.6, miCHF 82.5±48.2, SeADHF 105.0±78.1 p=0.361). Fecal elastase and ghrelin hormone levels can contribute to the determination of malnutrition in ADHF patients.

Patient education in chronic heart failure in primary care (ETIC) and its impact on patient quality of life: design of a cluster randomised trial.

BackgroundChronic heart failure, is increasing due to the aging population and improvements in heart disease detection and management. The prevalence is estimated at ~10% of the French general practice patient population over 59 years old. The primary objective of this study is to improve the quality of life for heart failure patients though a complex intervention involving patient and general practitioner (GP) education in primary care.MethodsA randomised, cluster controlled trial, stratified over 4 areas of the Auvergne region in France comparing intervention and control groups. The inclusion criteria are: patients older than 50 years with New York Heart Association (NYHA) stage I, II, or III heart failure, with reduced ejection fraction or with preserved ejection fraction. Heart failure should be confirmed by the patient’s cardiologist according to the European Society of Cardiology guidelines criteria. The exclusion criteria include: severe cognitive disorders, living in an institution, participating in another clinical trial, having NYHA stage IV heart failure, or a lack of French language skills. The complex intervention consists of training at the GP practice with an interactive 2-day workshop to provide a patient’s education programme. GPs are trained to perform case management, lifestyle counselling and motivational interviewing, to educate patients on the main topics including clinical alarm signs, physical activity, diet and cardiovascular risk factors. The patients’ education sessions are scheduled at 1, 4, 7, 10, 13 and 19 months following the start of the trial. The primary outcome to be assessed is the impact on the quality of life as determined using two questionnaires: the Minnesota Living with Heart Failure Questionnaire and SF-36. To detect a difference in the mean quality of life at 19 months, we anticipate studying a minimum of 400 patients from 80 GPs.DiscussionThis trial will provide insight into the effectiveness of a complex intervention to educate patients with heart failure including a 2-day GP workshop and patients’ education programme in the setting of a GP consultation to improve the quality of life in patients with chronic heart failure. This complex intervention tool could be used during initial and further medical training.Trial registrationETIC is a cluster-randomised, controlled trial registered on ClinicalTrials.gov [NCT01065142, 2010, Feb 8] and the French drug agency [Agence Nationale de Sécurité du Médicament et des produits de santé; registration number: 2009-A01142-55, on March 5th, 2010].Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-014-0208-3) contains supplementary material, which is available to authorized users.

Derivation of baseline lung impedance in chronic heart failure patients: use for monitoring pulmonary congestion and predicting admissions for decompensation.

The instantaneous lung impedance (ILI) is one of the methods to assess pulmonary congestion or edema (PCE) in chronic heart failure (CHF) patients. Due to usually existing PCE in CHF patients when evaluated, baseline lung impedance (BLI) is unknown. Therefore, the relation of ILI to BLI is unknown. Our aim was to evaluate methods to calculate and appraise BLI or its derivative as reflecting the clinical status of CHF patients. ILI and New York Heart Association (NYHA) class were assessed in 222 patients (67 ± 11 years, LVEF <35 %) during 32 months of frequent outpatient clinic visits. ILI, measured in 120 asymptomatic patients at NYHA class I, with no congestion on the chest X-ray and a low-normal 6-min walk, was defined as BLI. Using measured BLI and ILI values in these patients, formulas for BLI calculation were derived based on logistic regression analysis or on the disparity between BLI and ILI values at different NYHA stages. Both models were equally reliable with <3 % difference between measured and calculated BLI (p = NS). ΔLIR = (ILI/BLI - 1) × 100 % reflected the degree of PCE, or deviation from baseline, correlated with NYHA class (r = -0.9, p < 0.001) and could serve for monitoring. Of study patients, 123 were re-hospitalized for PCE during follow up. Their ΔLIR decreased gradually from -21.7 ± 8.2 % 4 weeks pre-admission to -37.8 ± 9.3 % on admission (p < 0.001). Patients improved during hospital stay (NYHA 3.7 ± 0.5 to 2.9 ± 0.8, p < 0.0001) with ΔLIR increasing to -29.1 ± 12.0 % (p < 0.001). ΔLIR based on calculated BLI correlated with the clinical status of CHF patients and allowed the prediction of hospitalizations for PCE.

Natriuretic Peptides and Troponin I Do Not Predict Chemotherapy-Induced Cardiac Toxicity

Background/Aims: Cytostatics and human antibodies are successfully being used to treat oncological diseases. Despite the beneficial effects of these potent drugs, cardiotoxicity represents one of the most relevant side effects and limits their usage. It is very important to detect cardiotoxicity at an early stage particular in patients under curative chemotherapy to avoid long-term side effects and impairment of quality of life. The aim of this prospective study was to investigate the value of natriuretic peptides and troponin for early detection of cardiotoxicity. Patients and Methods: In this single-center study, 99 cancer patients under treatment with anthracyclines, taxanes, and/or trastuzumab were prospectively included. Clinical examination, echocardiography, and blood sampling (brain natriuretic peptide (BNP), N-terminal-proBNP, and troponin I) were performed at baseline and at 3 and 12 months, respectively. Cardiotoxicity was defined as clinical or echocardiographic signs of heart failure as defined by an increment in New York Heart Association (NYHA) class by more than one and a decline in left ventricular ejection fraction (LVEF) depending on baseline situation. Results: During the 12-month follow-up, 27 patients presented with at least one predefined endpoint. Neither BNP, nor NT-proBNP, nor troponin I was related to the incidence of cardiotoxicity as defined by the combined endpoint. In post-hoc analysis a significant association between an increasing NYHA stage and a decrease in LVEF was found (negative predictive value of 91%). Conclusion: The occurrence of cardiotoxicity could not be detected either by natriuretic peptides or troponin. However, we hypothesize that an increase of more than one NYHA stage as a marker for dyspnea may be an indicator of cardiotoxicity.

Coenzyme Q10 and cardiovascular disease

More than 5 million Americans have heart failure (HF), according to the American Heart Association. Although survival has improved with the use of drugs such as ACE inhibitors, half of patients die within 5 years of a HF diagnosis. In addition, the disease remains a frequent cause of hospitalization among Medicare beneficiaries. Coenzyme Q10 is one of the supplements most commonly used for cardiovascular diseases. Many consumers taking statins have tried this supplement to prevent or lessen muscle aches, despite conflicting findings from studies. Early studies in the 1990s also evaluated the role of coenzyme Q10 in heart failure, and initial findings were promising. ■Few data exist on the cardiovascular benefits of coenzyme Q10.■Patients with heart failure should be appropriately managed with standard therapy. ■Few data exist on the cardiovascular benefits of coenzyme Q10.■Patients with heart failure should be appropriately managed with standard therapy. In a recent meta-analysis published in January’s American Journal of Clinical Nutrition, Domnica Fotino, MD, MPH, and colleagues evaluated the effect of coenzyme Q10 on major outcomes associated with HF in randomized controlled trials. The primary outcomes were changes in left ventricular ejection fraction (EF) and New York Heart Association (NYHA) classification. Hospitalization for HF was also initially included, but this outcome was dropped because none of the reviewed studies had sufficient data on this measure. The authors identified 120 articles, with 13 eventually included in the analysis. Only randomized, placebo-controlled studies of coenzyme Q10 alone were considered. EF data were presented in 11 studies and 3 had NYHA class data. Included were 7 crossover and 6 parallel group trials; 12 were doubleblinded. The studies were completed between 1985 and 2005. Study durations ranged from 4 weeks to 28 weeks, and dosages of coenzyme Q10 varied between 60 mg to 300 mg daily. Men comprised 80% of the study populations, and the mean age varied from 50 years to 68 years. Patients’ EF ranged from 22% to 46%. Based on the meta-analysis, the researchers reported that coenzyme Q10 demonstrated a 3.67% increase in EF compared with placebo and a 0.3-point improvement in NYHA functional class; the latter finding did not achieve statistical significance. The benefit of coenzyme Q10 on EF was greater in crossover than in parallel group studies. Trials conducted before 1994, those with a duration of less than 12 weeks, those including patients with a baseline EF of 30% or greater, or those evaluating a coenzyme Q10 dosage of no more than 100 mg daily demonstrated benefit. Given the few studies in this meta- analysis, interpretation of these subgroups should be done with caution. Also, many advances in the management of heart failure have occurred since the publication of the oldest studies used in the meta-analysis. Little information is available on the drug regimens and concomitant diseases of participants. Urban Alehagan, MD, PhD, and colleagues conducted a 5-year randomized, placebo-controlled trial of 443 participants to evaluate the effect of combined selenium and coenzyme Q10 on the severity of chronic heart, all-cause mortality, and cardiovascular mortality; their findings were published online in the International Journal of Cardiology in May 2012. The daily dosages of selenium and coenzyme Q10 were 200 pg and 200 mg, respectively. The formulations had been previously documented to have good oral bioavailability. Participants were between 70 years and 88 years of age and were from a rural part of Sweden with potentially low levels of selenium. The use of standard drugs for heart failure was significantly lower than what might have been expected, and at baseline, about 50% of patients had NYHA stage 1 HF. At the end of this study, cardiovascular mortality was 5.9% for patients who received the combination treatment, compared with 12.6% among patients who received placebo. Levels of prohormone brain natriuretic peptide were significantly lower in the selenium and coenzyme Q10 group. Because withdrawal rates were high among patients with lower EF in the placebo group, the placebo and intervention groups were significantly different at the end of the study. The authors considered the study to be hypothesis-generating only, as a larger trial is needed. Coenzyme Q10 is widely promoted for its potential cardiovascular benefits, including benefits on HF. Little information exists on its benefits in patients with HF who are appropriately managed with standard therapy, including ACE inhibitors and beta-blockers.

Costs and Benefits of Personalized Healthcare for Patients with Chronic Heart Failure in the Care and Education Program “Telemedicine for the Heart”

A health economic analysis was conducted to evaluate the program "Telemedicine for the Heart," which the German Foundation for the Chronically Ill organizes for the Techniker Krankenkasse, one of the biggest German statutory health insurance funds. The program consists of nurse-calls to motivate patients to perform regular self-measurements (blood pressure, pulse, weight) with either their own or telemedical measuring devices provided by the program. In the case of measured values outside of set limits, calls to treating physicians were placed to allow for the initiation of therapy adjustments where applicable. To evaluate the program, a retrospective matched-pairs analysis was performed. Program participants (n=281) and regularly insured patients (n=843) were matched for demographics and morbidity status and compared according to their use of resources. Significant cost differences in favor of the study group of up to 25% in relation to total costs could be detected, particularly in the group of New York Heart Association (NYHA) classification II patients (persons with mild symptoms and slight limitation according to the NYHA classification for the extent of heart failure). In the more severe NYHA stages III and IV the cost relation differed and showed a slight cost disadvantage for the program group. Mortality was 35.1% lower in the program group than in the control group. Quality of life measures were almost constant over the observation time, compatible with a positive impact of the program on the highly impaired patient group. The findings suggest that, besides a reduction of costs, by participating in "Telemedicine for the Heart" patients with chronic heart failure experienced a reduced number of hospital stays, optimized medical therapy, better quality of life, and reduced mortality.

Pregnancy outcomes in women with heart disease

To evaluate the maternal and fetal outcome of pregnancies complicated by cardiac disease in a developing country. A retrospective analysis was carried out of 144 pregnancies in women with cardiac disease who delivered in our unit between 1997 and 2006. Perinatal and maternal outcomes were interpreted according to the type of the heart disease and status of the patient according to the New York Heart Association (NYHA) classification. The rates of rheumatic and congenital heart disease were 87.5 and 12.5%, respectively. The distribution of the patients according to the NYHA functional classification were 55.6, 36.1 and 8.3% for NYHA classes I, II and III-IV, respectively. There was no maternal mortality. Maternal morbidity was observed in 16 (11.1%) cases. Six perinatal mortalities (4.2%) occurred in this series. There were no significant difference in birth weight, gestational age at delivery and perinatal morbidity between the NYHA stage I-II and stage III-IV groups (P>0.05), whereas maternal morbidity and cesarean delivery rates were significantly higher in the NYHA stage III-IV group (P<0.001). Rheumatic heart disease with pregnancy is still predominant in Turkey. Most of the patients were in a good functional group. Maternal morbidity strongly correlates with maternal cardiac classification.

Improved guideline adherence to pharmacotherapy of chronic systolic heart failure in general practice – results from a cluster‐randomized controlled trial of implementation of a clinical practice guideline

Clinical practice guidelines (CPG) reflect the evidence of effective pharmacotherapy of chronic (systolic) heart failure (CHF) which needs to be implemented. This study aimed to evaluate the effect of a new, multifaceted intervention (educational train-the-trainer course plus pharmacotherapy feedback = TTT) compared with standard education on guideline adherence (GA) in general practice. Thirty-seven participating general practitioners (GPs) were randomized (18 vs. 19) and included 168 patients with ascertained symptomatic CHF [New York Heart Association (NYHA) II-IV]. Groups received CPG, the TTT intervention consisted of four interactive educational meetings and a pharmacotherapy feedback, while the control group received a usual lecture (Standard). Outcome measure was GA assessed by prescription rates and target dosing of angiotensin converting enzyme (ACE) inhibitors (ACE-I) or angiotensin receptor blockers (ARB), beta-blockers (BB) and aldosterone antagonists (AA) at baseline and 7-month follow-up. Group comparisons at follow-up were adjusted to GA, sex, age and NYHA stage at baseline. Prescription rates at baseline (n = 168) were high (ACE-I/ARB 90, BB 79 and AA 29%) in both groups. At follow up (n = 146), TTT improved compared with Standard regarding AA (43% vs. 23%, P = 0.04) and the rates of reached target doses of ACE-I/ARB (28% vs. 15%, P = 0.04). TTT group achieved significantly higher mean percentages of daily target dose (52% vs. 42%, mean difference 10.3%, 95% CI 0.84-19.8, P = 0.03). Despite of pre-existing high GA in both groups and an active control group, the multifaceted intervention was effective in quality of care measured by GA. Further research is needed on the choice of interventions in different provider populations.

Repair of aortic arch and the impact of cross-clamping time, New York Heart Association stage, circulatory arrest time, and age on operative outcome

Aortic arch replacement is associated with high morbidity and mortality. We evaluated the postoperative complications and risk factors in 32 consecutive patients after aortic arch replacement. The mean age was 61+/-15 years and male to female ratio was 24/8. Diameter of ascending aorta was 6.0+/-0.8 cm and diameter of aortic arch was 5.2+/-1.2 cm. The average New York heart association (NYHA) class was 2+/-1. The 30-day mortality was 6.2% (2 of 32 patients), one patient died intraoperatively (3%); all surviving 30 patients had f/u for at least six months, a total of 3 of 32 patients had died within six months, actuarial survival was 90% at six months. The overall incidence of neurologic adverse events was 9%; however, only one patient had a cerebrovascular accident (CVA) with a focal deficit (3%). The other two patients had global neurologic dysfunction. Other significant postoperative complications included atrial fibrillation in 15 patients (46%), ventricular fibrillation requiring cardiopulmonary resuscitation (CPR) in one patient (3%), and pericardial effusion requiring pericardicentesis in eight patients (25%). The need for blood transfusion correlated with the cross-clamping length (Pearson r 0.62; 95% confidence interval (CI), 0.35-0.79; P-value 0.0001; R(2)=0.38). Cross-clamp time (139+/-58 min) did not have an impact on length of intensive care unit (ICU) stay (Pearson r -0.09; 95% CI -0.39-0.23; P=0.58; R(2)=0.008) nor did the length of circulatory arrest (95% CI -0.44-0.21, P=0.44). The length of stay in the ICU (142+/-128 h) correlated with the NYHA stage of the patient (95% CI 0.001-0.62, P=0.04). The length of stay (LOS) (12+/-6 days) correlated with age of the patients (95% CI 0.03-0.57, P=0.03). Elderly patients and patients with high NYHA class need close postoperative monitoring in the ICU. A short circulatory arrest and aortic clamp time do not extend the LOS in ICU or in the hospital.

Thromboendarterectomy in chronic thromboembolic pulmonary hypertension. Hemodynamics and right-heart function over the long term

To find out whether pulmonary thromboendarterectomy (PTE) can achieve lasting reduction of pulmonary vascular resistance in patients with pulmonary arterial hypertension due to chronic thromboembolism. 45 patients (25 women, 20 men; mean age 45 +/- 24 [19-67] years) were re-investigated a mean of 21 (13-32) months after successful PTE. Two patients had then been in New York Heart Association (NYHA) stage II, 26 in stage III, and 17 in stage IV. In addition to clinical examination and chest radiogram 36 patients had right heart catheterization, 28 pulmonary angiography and 44 echocardiography. Definite improvement of symptoms had occurred in all. 34 were now in NYHA stage I, nine in stage II, and two in stage III. The pulmonary vascular resistance was significantly lower than before and immediately after PTE (pre-PTE: 1052 +/- 472 dyn.s.cm-5; post-PTE: 293 +/- 175 dyn.s.cm-5; at follow-up: 187 +/- 92 dyn.s.cm-5; P < 0.001 for follow-up vs pre-PTE; P < 0.05 for follow-up vs post-PTE). Correspondingly, cardiac index had significantly increased (3.0 +/- 0.5 vs 2.0 +/- 0.7 l/min.m2; P < 0.001). Radiological and echocardiographic examinations showed a definite decrease in right ventricular dimensions and improvement in right ventricular function. In patients with pulmonary arterial hypertension due to chronic pulmonary thromboembolism PTE can achieve a reduction in pulmonary vascular resistance with lasting improvement in right heart function and clinical symptoms.