Heart Failure Deadly At Earlier Age in Poorer Countries

MedicalResearch.com Interview with:

Hisham Dokainish, M.D., FRCPC, FASE, FACC Associate Professor of Medicine, McMaster University Principal Investigator, Population Health Research Insitute Director of Heart Failure Services, Director of Medical Diagnostic Units & Echocardiography, Hamilton Health Sciences Hamilton, ON, Canada

Dr. Dokainish

Hisham Dokainish, M.D., FRCPC, FASE, FACC
Associate Professor of Medicine, McMaster University
Principal Investigator, Population Health Research Insitute
Director of Heart Failure Services,
Director of Medical Diagnostic Units & Echocardiography, Hamilton Health Sciences
Hamilton, ON, Canada

MedicalResearch.com: What is the background for this study?

Response: Most data on mortality and prognostic factors in patients with heart failure come from North America and Europe, with little information from other regions of the world, particularly from low and middle income countries.

MedicalResearch.com: What are the main findings?

Response: We enrolled 5823 patients within 1 year (with 98% follow-up). Overall mortality was 16·5%: highest in Africa (34%) and India (23%), intermediate in southeast Asia (15%), and lowest in China (7%), South America (9%), and the Middle East (9%). These large regional differences in mortality persisted after multivariable adjustment for demographic, clinical, medication and socioeconomic variables. About half of the mortality risk was explained by multivariable modeling with these variables; however, the remainder was unexplained.

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Advanced Heart Failure Patients Should Have Option of LVAD Device

MedicalResearch.com Interview with:
Amrut V. Ambardekar, MD
Medical Director Cardiac Transplant Program
Division of Cardiology, Section of Advanced Heart Failure-Transplant Cardiology
University of Colorado

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: As left ventricular assist device (LVAD) technology has improved, the appropriate timing for implant of these devices (essential a form of an artificial heart pump) in patients with advanced heart failure is unknown.

The goal of the MedaMACS study was to describe the prognosis of a group of patients with advanced heart failure who currently do not require intravenous therapies, and determine how they compare to a similar group of patients who received a LVAD.

The main finding from this study is that the “sickest” group of patients with advanced heart failure on oral medical therapy (known as INTERMACS profile 4 patients) have very poor outcomes with a strong trend for improvement in survival with LVAD therapy.

The other take home message is that among all of the patients enrolled in the study on medical therapy, only approximately half were alive after an average of 12 months of follow up without needing a heart transplant or LVAD placement.

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Adaptive Servo-Ventilation Therapy Has Variable Effects in Heart Failure Patients

MedicalResearch.com Interview with:

Christopher M. O’Connor, MD FACC  CEO and Executive Director,  Inova Heart & Vascular Institute IHVI Administration Falls Church, Virginia 22042

Dr. Christopher O’Connor

Christopher M. O’Connor, MD FACC 
CEO and Executive Director,
Inova Heart & Vascular Institute
IHVI Administration
Falls Church, Virginia 22042

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Sleep apnea is a very common comorbidity of patients with heart failure (both reduced ejection fraction and preserved ejection fraction). Early evidence from observational and small studies suggested that treating sleep apnea with adaptive servo-ventilation (ASV) therapy may improve patient outcomes. There is minimal clinical evidence about identifying and treating sleep apnea in those who’ve been hospitalized with acute decompensated heart failure. The CAT-HF study was designed to help address this, with the primary endpoint being cardiovascular outcomes measured as a Global Rank Score that included survival free from cardiovascular hospitalization and change in functional capacity as measured by the six-minute walk distance. It was also planned to expand on the SERVE-HF study that was investigating the use of ASV therapy to treat central sleep apnea (CSA) in chronic stable heart failure patients with reduced ejection fraction patients (HFrEF).

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Enrollment in Heart Failure Registry Associated With Improved Survival

MedicalResearch.com Interview with:
Lars H. Lund, MD Phd, Assoc. Prof., FESC
Department of Medicine, Karolinska Institutet, and
Department of Cardiology, Karolinska University Hospital
Sweden

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Registries are accepted for quality reporting but it is actually unknown whether in heart failure they directly improve outcomes.

Here, enrollment in SwedeHF was strongly associated with reduced mortality.

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Biomarker sST2 Predicts All-Cause and Cardiac Death in Heart Failure Patients

MedicalResearch.com Interview with:

Prof. Michele Emdin, MD, PhD, FESC Associate Professor of Cardiovascular Medicine Institute of Life Sciences Scuola Superiore Sant'Anna - Sant'Anna School of Advanced Studies Director, Cardiology & Cardiovascular Medicine Division Fondazione Toscana Gabriele Monasterio per la Ricerca Medica e di Sanità Pubblica

Prof. Michele Emdin

Prof. Michele Emdin, MD, PhD, FESC
Associate Professor of Cardiovascular Medicine
Director, Cardiology & Cardiovascular Medicine Division
Fondazione Toscana Gabriele Monasterio
per la Ricerca Medica e di Sanità Pubblica
CNR-Regione Toscana with the collaboration of
Dr. Alberto Aimo, MD
Institute of Life Sciences
Scuola Superiore Sant’Anna – Sant’Anna School of Advanced Studies
Pisa, Italy

MedicalResearch.com: What is the background for these meta-analyses?

Response: Soluble suppression of tumorigenicity 2 (sST2) is a novel and promising biomarker of heart failure (HF). It has been extensively studied in both stable chronic (CHF) and acute HF (AHF), demonstrating substantial potential as a predictor of prognosis in both settings (Dieplinger et al., 2015).

An International Consensus Panel (Januzzi et al., 2015) and latest American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines (Yancy et al., 2013) support the use of sST2 assay for risk stratification in both CHF and AHF patients. By contrast, European Society of Cardiology guidelines do not provide specific recommendations on sST2 (Ponikowski et al., 2016). Because of ambiguity due to discordant conclusions and to the absence of a thorough revision of the literature and of rigorous meta-analyses of published studies up-to-date, we felt it worthwhile to carefully examine and meta-analyze evidence supporting measurement of sST2, in order to assess the prognostic role of this biomarker in CHF and AHF. Most of the groups originally publishing on the topic all over the world and representing the Gotha of clinical research on cardiovascular biomarker, accepted to directly contribute allowing the main Authors to achieve novel information by a guided statistical reappraisal, The final results furnish clinically significant support to the use of sST2 as a risk stratification tool either in the acute or in the chronic heart failure setting.

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The Health ABC Study: Simple Exercise Test Predicts Heart Failure

MedicalResearch.com Interview with:

Vasiliki Georgiopoulou MD MPH PhD Assistant Professor of Medicine (Cardiology) Emory University School of Medicine

Dr. Vasiliki Georgiopoulou

Vasiliki Georgiopoulou MD MPH PhD
Assistant Professor of Medicine (Cardiology)
Emory University School of Medicine

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Although existing evidence suggests that more exercise capacity is associated with lower risk of CV disease and death, we don’t know whether more exercise capacity would lead to lower risk for heart failure also. This would be especially important for older adults, who are the group with the highest risk to develop heart failure. We used the data of a cohort study to test this association.

The exercise capacity was evaluated by a walking test that is easy to perform – the long-distance corridor walk test. We observed that older adults who were able to complete the test had the lowest risk to develop heart failure and the lowest mortality rates, when compared with those who were not able to complete the test and those who could not do the test for medical reasons. We also observed that changes in exercise capacity 4 years later did not predict subsequent heart failure or mortality – perhaps because less fit older patients had already developed heart failure or had died.

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Costs of Generic Drugs for Heart Failure Can Vary Widely

MedicalResearch.com Interview with:

Paul J. Hauptman, MD</strong> Professor Internal Medicine, Division of Cardiology Health Management & Policy, School of Public Health

Dr. Paul Hauptman

Paul J. Hauptman, MD
Professor Internal Medicine, Division of Cardiology
Health Management & Policy, School of Public Health

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We decided to evaluate the cost of generic heart failure medications after an uninsured patient of ours reported that he could not fill a prescription for digoxin because of the cost for a one month’s supply: $100. We called the pharmacy in question and confirmed the pricing. At that point we decided to explore this issue more closely.

We called 200 retail pharmacies in the bi-state, St. Louis metropolitan area, 175 of which provided us with drug prices for three generic heart failure medications: digoxin, carvedilol and lisinopril. We found significant variability in the cash price for these medications. Combined prices for the three drugs ranged from $12-$400 for 30 day supply and $30-$1,100 for 90 day supply.

The variability was completely random, not a function of pharmacy type, zip code, median annual income, region or state. In fact, pricing even varied among different retail stores of the same pharmacy chain.

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Who Returns To Work After First Hospitalization for Heart Failure?

MedicalResearch.com Interview with:

Rasmus Rørth MD From Department of Cardiology Rigshospitalet University of Copenhagen, Denmark

Dr. Rasmus Rørth

Rasmus Rørth MD
From Department of Cardiology
Rigshospitalet
University of Copenhagen, Denmark

MedicalResearch.com: What is the background for this study?

Response: Heart failure is considered to be one of the most common, costly, disabling and deadly medical conditions and is thus a major health care problem. The ability to maintain a full-time job addresses a vital indirect consequence and cost of heart failure, beyond the usual clinical parameters such as mortality and hospitalization. Ability to work is more than just another measure of performance status. As well as its financial importance, employment is crucial for self-esteem and quality of life in patients with chronic illness. Obtaining information on labour force inclusion should, therefore, shed light on an unstudied consequence of heart failure and provide a novel perspective on the impact of heart failure on the lives of those who, perhaps, have most to lose from this condition.

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Black Heart Failure Patients Have More Readmissions and Lower Mortality Than Whites

MedicalResearch.com Interview with:
Matthew Durstenfeld MD
Department of Medicine
Saul Blecker, MD, MHS
Department of Population Health and Department of Medicine
New York University School of Medicine
NYU Langone Medical Center
New York, New York

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Racial and ethnic disparities continue to be a problem in cardiovascular disease outcomes. In heart failure, minority patients have more readmissions despite lower mortality after hospitalization for heart failure. Some authors have attributed these racial differences to differences in access to care, although this has never been proven.

Our study examined patients hospitalized within the municipal hospital system in New York City to see whether racial and ethnic disparities in readmissions and mortality were present among a diverse population with similar access to care. We found that black and Asian patients had lower one-year mortality than white patients; concurrently black and Hispanic patients had higher rates of readmission. These disparities persisted even after accounting for demographic and clinical differences among racial and ethnic groups.
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Entresto (valsartan/sacubitril) Extends Life and Reduces Hospitalizations and Costs in Heart Failure Patients

MedicalResearch.com Interview with:

Thomas Andrew Gaziano, MD, MSc Department of Cardiology Assistant Professor Harvard Medical School

Dr. Thomas Gaziano

Thomas Andrew Gaziano, MD, MSc
Department of Cardiology
Assistant Professor
Harvard Medical School

MedicalResearch.com: What is the background for this study?

Response: Heart failure (HF) is the leading cause of admissions to hospitals in the United States and the associated costs run between $24-47 billion annually. Targeting neurohormonal pathways that aggravate the disease has the potential to reduce admissions. Enalapril, an angiotensin converting enzyme-inhibitor (ACEI), is more commonly prescribed to treat HF than Sacubitril/Valsartan, an angiotensin-receptor/neprilysin inhibitor (ARNI). The latter was shown to reduce cardiovascular death and hospitalizations due to heart failure in a multi-country, randomized clinical (PARADIGM-HF), compared to Enalapril. In order to assess the cost-effectiveness of Sacubitril/Valsartan, compared to Enalapril, in the United States, we created a model population with population characteristics equivalent to the population in the PARADIGM-HF trial. Using a 2-state Markov model we simulated HF death and hospitalizations for patients with a left ventricular ejection fraction (LVEF) of 40% or less.

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Cognitive Impairment Linked to Readmissions For Heart Failure

MedicalResearch.com Interview with:

Thomas H. Marwick, MBBS, PhD, MPH Baker IDI Heart and Diabetes Institute Melbourne, Australia

Dr. Thomas Marwick

Thomas H. Marwick, MBBS, PhD, MPH
Baker IDI Heart and Diabetes Institute
Melbourne, Australia

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Marwick: Readmission for heart failure (HF) remains common and the risk of this remains hard to predict. It’s possible that existing risk scores don’t cover all important patient features. We confirmed that cognitive impairment was an unmeasured contributor and incorporated this measurement in a prediction model. The resulting model was the most reliable reported to date and could be used to identify patients who need the closest follow up to avoid readmission.

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Unrecognized Cognitive Impairment in Heart Failure Patients Increases Costs and Readmissions

MedicalResearch.com Interview with:

Mark W Ketterer PhD, ABPP Health Psychology Henry Ford Hospital Detroit Michigan

Dr. Mark Ketterer

Mark W Ketterer PhD, ABPP
Health Psychology
Henry Ford Hospital
Detroit Michigan

MedicalResearch.com: What is the background for this study? What are the main findings? 

Dr. Ketterer:  Reducing wasteful healthcare costs is a high priority For Medicare/Medicaid, Obamacare and all third party payors.  Cognitive impairment (CI) is highly prevalent in patients  with chronic illnesses identified as having high readmission rates by the Center for Medicare and Medicaid Services (1,2,3), such as Congestive Heart Failure (4,5), End Stage Renal Disease (6,7) and Chronic Obstructive Pulmonary Disease (8-14). CI  is also a known prospective predictor of longer term admissions and deaths (15-18). Poor adherence is a frequent consequence of cognitive impairment (19,20), particularly when the family and/or patient have not yet recognized and intervened for the evolving problem, or the patient is not in a setting (e.g., Nursing Homes) that supervises medication administration

MedicalResearch.com: What should clinicians and patients take away from your report? 

Dr. Ketterer:  

  • Aggressive evaluation of heart failure patients for cognitive impairment.
  • Involvement of family in maximizing adherence is better care, and more efficient care.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Dr. Ketterer:  A randomly-assigned, controlled clinical trial of this intervention is warranted, needed and should be a high priority in healthcare research.

MedicalResearch.com: Is there anything else you would like to add? 

Dr. Ketterer:  As currently constructed, our healthcare system neglects common behavioral causes of waste, misdiagnosis and treatment failure.  Nonrecognition of cognitive impairment in heart failure patients is about 90%.  This can be a catastrophic failure for a given patient, resulting in a preventable death.

Citation:

Cognitive Impairment and Reduced Early Readmissions in Congestive Heart Failure? –

Mark W. Ketterer, PhD; Jennifer Peltzer, PsyD; Usamah Mossallam, MD; Cathy Draus, RN; John Schairer, DO; Bobak Rabbani, MD; Khaled Nour, MD; Gayathri Iyer, MD; Michael Hudson, MD; and James McCord, MD –

American Journal Managed Care Published Online: January 25, 2016

Mark W Ketterer PhD, ABPP (2016). Unrecognized Cognitive Impairment in Heart Failure Patients Increases Costs and Readmissions 

Heart Failure Readmission Risk Related To Patient and Disease Characteristics

Javed Butler MD MPH Chief, Division of Cardiology Stony Brook University Health Sciences Center SUNY at Stony Brook, NY

Dr. Javed Butler

MedicalResearch.com Interview with:
Javed Butler MD MPH

Chief, Division of Cardiology
Stony Brook University
Health Sciences Center
SUNY at Stony Brook, NY

Medical Research: What is the background for this study? What are the main findings?

Dr. Butler: There is a lot of emphasis on reducing the risk of readmission after heart failure hospitalization. The main focus is on early readmissions as the risk for readmission is highest earlier post discharge. In this study, we described the fact that certainly there is some increased risk post discharge, the majority of the risk is actually dependent on the patient and disease characteristics at the time of discharge as opposed to true reduction in risk over time, which is partially related to differential attrition of high risk patients earlier post discharge.

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PA Catheterization Use Increases in CHF Without Shock or Respiratory Failure

Ambarish Pandey M.D. Division of Cardiology University of Texas Southwestern Medical Center Dallas, TX

Dr. Ambarish Pandey

Ambarish 

MedicalResearch.com Interview with:
Ambarish Pandey M.D.

Division of Cardiology
University of Texas Southwestern Medical Center
Dallas, TX

Medical Research: What is the background for this study? What are the main findings?

Dr. Pandey: Pulmonary artery (PA) catheters have been used for invasive bedside hemodynamic monitoring for past four decades. The ESCAPE trial, published in October 2005, demonstrated that use of  Pulmonary Artery catheter was not associated with a significant improvement in clinical outcomes of patients with heart failure. Accordingly, the current ACC/AHA guidelines discourage the routine use of PA catheter for routine management of acute heart failure in absence of cardiogenic shock or respiratory failure (Class III). Despite the significant evolution of available evidence base and guideline recommendations regarding use of  Pulmonary Artery catheters, national patterns of PA catheter utilization in hospitalized heart failure patients remain unknown.

In this study, we observed that use of PA catheter among patients with heart failure decline significantly in the Pre-ESCAPE era (2001 – 2006) followed by a consistent increase in its use in the Post-ESCAPE era (2007-2012). We also observed that the increase in use of  Pulmonary Artery catheters is most significant among heart failure patients without underlying cardiogenic shock or respiratory failure.

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Most Heart Failure Patients on Mineralocorticoid Receptor Antagonist Don’t Receive Recommended Laboratory Tests

Lauren Cooper, MD Fellow in Cardiovascular Diseases Duke University Medical Center Duke Clinical Research Institute

Dr. Cooper

MedicalResearch.com Interview with:
Lauren Cooper, MD

Fellow in Cardiovascular Diseases
Duke University Medical Center
Duke Clinical Research Institute

Medical Research: What is the background for this study? What are the main findings?

Dr. Cooper: Heart failure guidelines recommend routine monitoring of serum potassium and renal function in patients treated with a mineralocorticoid receptor antagonist (MRA). Specific monitoring recommendations include: within 2-3 days of initiation of the drug, again at 7 days, monthly for at least 3 months, then every 3 months thereafter. However, no large studies had evaluated compliance with these safety recommendations in routine clinical practice. Using Medicare claims data from 2011, we evaluated monitoring of serum creatinine and potassium levels among patients with heart failure initiated on an MRA.

After MRA initiation, rates of guideline-recommended laboratory monitoring of creatinine and potassium were low. Of 10,443 Medicare beneficiaries included in this study, 91.6% received pre-initiation testing; however, only 13.3% received appropriate testing in the first 10 days after drug initiation and 29.9% received appropriate testing in the first 3 months. Only 7.2% of patients received guideline-recommended laboratory monitoring both before and after MRA initiation. Chronic kidney disease was associated with a greater likelihood of appropriate testing (relative risk, 1.83; 95% CI, 1.58-2.13), as was concomitant diuretic use (relative risk, 1.78; 95% CI, 1.44-2.21).

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LVADs Improve Survival and Quality of Life In Some Heart Failure Patients

Jerry D. Estep, MD, FACC, FASE Associate Professor of Clinical Cardiology Houston Methodist Institute of Academic Medicine Section Head of Heart Transplant & Mechanical Circulatory Support, Division of Heart Failure Medical Director, Heart Transplant & LVAD Program Methodist DeBakey Heart & Vascular Center Houston MethodistMedicalResearch.com Interview with:
Jerry D. Estep, MD, FACC, FASE
Associate Professor of Clinical Cardiology
Houston Methodist Institute of Academic Medicine
Section Head of Heart Transplant & Mechanical Circulatory Support, Division of Heart Failure
Medical Director, Heart Transplant & LVAD Program
Methodist DeBakey Heart & Vascular Center
Houston Methodist

 

Medical Research: What is the background for this study? What are the main findings?

Dr. Estep: Data for left ventricular assist devices (LVADs) in non-inotrope-dependent advanced heart failure (HF) patients are limited. The risk-benefit tradeoff of LVADs versus optimal medical management (OMM) in this patient cohort is not well understood.  ROADMAP is the first prospective, nonrandomized, observational study comparing LVAD support to OMM in advanced, ambulatory HF patients who are not dependent on intravenous inotropic support, and meet the FDA-approved indications for LVAD destination therapy.  The main  5 findings from the ROADMAP Study include the following:

1) LVAD patients were more severely ill, with more INTERMACS profile 4 compared to OMM patients (65% LVAD vs. 34% OMM, p < 0.001);

2) more LVAD patients met the primary endpoint of survival on original therapy with improvement in 6 minute walk distance of at least 75 meters at 12 months (39% LVAD vs. 21% OMM; [OR: 2.4 [95% CI: 1.2 to 4.8]; p = 0.012) with differences in the primary endpoint primarily due to the use of delayed LVADs in the OMM group;

3) on the basis of as-treated (event free) analysis, 12-month survival (freedom from death, urgent transplant, or delayed LVAD) was greater for LVAD versus OMM (80 ± 4% vs. 63 ± 5%, p = 0.022);

4) adverse events (AEs) were higher in LVAD patients, at 1.89 events/patient-year (eppy), primarily driven by bleeding (1.22 eppy), than with OMM, at 0.83 eppy, primarily driven by worsening HF (0.68 eppy);  and

5) health-related quality of life and depression improved from baseline more significantly with LVADs than with OMM (Δvisual analog score [VAS]: 29 ± 25 vs. 10 ± 22, p < 0.001 and ΔPHQ9: -5 ± 7 vs. -1 ± 5, p < 0.001).

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High Blood Pressure In Young Adulthood Increases Risk Of Later Heart Failure

Satoru Kishi, MD Division of Cardiology Johns Hopkins University Baltimore, MarylandMedicalResearch.com Interview with:
Satoru Kishi, MD
Division of Cardiology
Johns Hopkins University
Baltimore, Maryland

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Kishi: Blood pressure (BP) at the higher end of the population distribution may represent a chronic exposure that produces chronic injury to the cardiovascular system. Cumulative BP exposure from young adulthood to middle age may adversely influence myocardial function and predispose individuals to heart failure (HF) and other cardiovascular disease (CVD) later in life. The 2005 guidelines for the diagnosis and treatment of HF from the American College of Cardiology and American Heart Association highlight the importance of early recognition of subclinical cardiac disease and the importance of non-invasive tests in the clinical evaluation of heart failure.

Our main objective was to investigate how cumulative exposure to high blood pressure from young to middle adulthood influence LV function. In the Coronary Artery Risk Development in Young Adults (CARDIA) study, multiple repeated measures of BP and other cardiovascular risk factors was recorded over a 25 year time span, starting during early adulthood (ages 18-30). Continue reading

Emergency Room Coding Of Heart Failure Diagnosis Validated

Justin A. Ezekowitz, MBBCh MScAssociate Professor, University of Alberta Co-Director, Canadian VIGOUR Centre Director, Heart Function Clinic Cardiologist, Mazankowski Alberta Heart InstiMedicalResearch.com Interview with:
Justin A. Ezekowitz, MBBCh MSc
Associate Professor, University of Alberta
Co-Director, Canadian VIGOUR Centre
Director, Heart Function Clinic
Cardiologist, Mazankowski Alberta Heart Institute

Medical Research: What is the background for this study?

Dr. Ezekowitz: Heart Failure is a prevalent health issue that carries high morbidity and mortality. Most epidemiologic research derives information from hospital discharge abstracts, but emergency department visits are another source of information. Many have assumed this code is accurate in the emergency department but uncertainty remains.

In our study, we assessed patients at their presentation to Emergency Department, which is usually the first medical contact for acutely ill patients with heart failure.

The objective of our study was to compare administrative codes for acute heart failure (I50.x) in the emergency department against a gold standard of clinician adjudication.

Medical Research: What are the main findings?

Dr. Ezekowitz: Emergency department administrative data is highly correlated with a clinician adjudicated diagnosis. The positive predictive value of acute heart failure as the main diagnosis was 93.3% when compared to clinician adjudication, supported by standardized scoring systems and elevated BNP. Continue reading

Depression Linked To Worse Heart Failure Outcomes in Blacks

 Dr. Robert J. Mentz MD Assistant Professor of Medicine Director, Duke University Cooperative Cardiovascular Society Advanced Heart Failure and Cardiac Transplantation Duke University Medical Center Duke Clinical Research InstituteMedicalResearch.com Interview with:
Dr. Robert J. Mentz MD
Assistant Professor of Medicine
Director, Duke University Cooperative Cardiovascular Society
Advanced Heart Failure and Cardiac Transplantation
Duke University Medical Center
Duke Clinical Research Institute

Medical Research: What is the background for this study? What are the main findings?

Dr. Mentz: Previous studies have shown that depression is associated with worse outcomes in heart failure patients; however, most of these prior studies were conducted in primarily white patient populations. The impact of depressive symptoms on outcomes specifically in blacks with heart failure has not been well studied. We used data from the HF-ACTION trial of exercise training in heart failure patients, which collected data on depressive symptoms via the Beck Depression Inventory (BDI-II), to assess the association between depressive symptoms and outcomes in black patients as compared with white patients. We found that in blacks with heart failure, baseline symptoms of depression and worsening of symptoms over time were both associated with increased all-cause mortality/hospitalization.

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Frequent Fried Food Consumption Linked To Increased Heart Failure

Luc Djousse, MD, ScD, FAHA Associate Professor of Medicine, Harvard Medical School Editor-in-Chief, Current Nutrition Reports Director of Research, Division of Aging Brigham and Women's Hospital Boston, MA 02120MedicalResearch.com Interview with:
Luc Djousse, MD, ScD, FAHA

Associate Professor of Medicine, Harvard Medical School
Editor-in-Chief, Current Nutrition Reports
Director of Research, Division of Aging
Brigham and Women’s Hospital Boston, MA 02120

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Djousse: While some studies have reported a higher risk of coronary heart disease, diabetes, or high blood pressure with frequent consumption of fried foods, other investigators did not confirm those results. To date, only few studies have evaluated whether frequent consumption of fried foods can raise the risk of developing heart failure. Frying foods not only increases the energy density of foods, but also increase the amount of trans fats. Trans fats can lead to development of heart disease and diabetes and consumption of energy-dense foods in large quantity can lead to weight gain and resulting cardiovascular consequences.

We followed about 15000 US male physicians who were free of heart failure for an average of 10 years and found that frequent consumption of fried foods was related to a higher risk of developing heart failure. For example, people that consumed fried foods daily or more were twice more likely to develop heart failure than individuals who consumed fried foods less than once per week.
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Many Patients With Heart Failure Report Impairment of Daily Activities

dr-shannon-dunlayMedicalResearch.com Interview with:
Shannon M. Dunlay, M.D. M.S.
Advanced Heart Failure and Cardiac Transplantation
Assistant Professor of Medicine and Health Care Policy and Research
Mayo Clinic Rochester
MedicalResearch: What is the background for this study?

Dr. Dunlay: Loss of mobility and independence can complicate the care of patients with chronic conditions such as heart failure, and can degrade their quality of life.  However, we have a very poor understanding of the burden of disability in patients with heart failure and how it impacts outcomes.  What are the main findings?  In this study, patients with heart failure were asked whether they had difficulty performing activities of daily living (ADLs)—these include normal activities that most people do in daily life such as eating, bathing, dressing, and walking.  Most patients with heart failure reported having difficulty with at least one ADL at the beginning of the study, and over 1/3 had moderate or severe difficulty with activities of daily living.  Patients who were older, female and had other chronic conditions such as diabetes, dementia and obesity had more difficulty with activities of daily living.  Patients that reported more difficulty with ADLs (worse mobility) were more likely to die and be hospitalized over time.  Some patients had a decline in function over time, and this was also predictive of worse outcomes.

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Research Aims To Understand Heart Failure In Women

Dawn Pedrotty, MD, PhD Cardiovascular Medicine Fellowship University of PennsylvaniaMedicalResearch.com Interview with:
Dawn Pedrotty, MD, PhD

Cardiovascular Medicine Fellowship
University of Pennsylvania

MedicalResearch: What is the background for this review? What are the main findings?

Dr. Pedrotty: Heart failure (HF) is the most common cause for hospitalization among patients 65 years and older, affecting approximately 6 million Americans; at 40 years of age, American males and females have a one in five lifetime risk of developing heart failure. There are two distinct heart failure phenotypes: a syndrome with normal or near-normal left ventricular ejection fraction (LVEF) referred to as HF with preserved ejection fraction (HFpEF), and the phenotype associated with poor cardiac contractility or heart failure with reduced ejection fraction (HFrEF). Risk factors associated with HFpEF include female gender, especially women with diabetes, higher body mass index, smoking, hypertension, concentric left ventricular hypertrophy (LVH), and atrial fibrillation (AF). There has been a growing interest in the development of criteria for specific subsets of HFpEF, a syndromal disease where multiple cardiac and vascular abnormalities exist. One approach is to implement phenomapping, identifying phenotypically distinct HFpEF categories and developing a classification system to group together pathophysiologically similar individuals who may respond in a more homogeneous, predictable way to intervention. Another option would be to focus on a known physiologic differences which might shed light on pathologic mechanisms e.g. gender and the influences of obesity and atrial fibrillation.
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Women With Heart Failure Less Likely To Be Referred For Specialty Care

Jennifer L. Cook, MD FAHA Assistant Professor of Medicine | Heart Failure and Transplantation Medical Director Left Ventricular Assist Device Program Medical University of South Carolina Charleston, SC 29425MedicalResearch.com Interview with:
Jennifer L. Cook, MD FAHA
Assistant Professor of Medicine | Heart Failure and Transplantation
Medical Director Left Ventricular Assist Device Program
Medical University of South Carolina
Charleston, SC 29425

Medical Research: What is the background for this study? What are the main findings?

Dr. Cook: Although the incidence of heart failure is similar in men and women, women are more likely to die from it.  Despite this fact a common misperception persists that men are at greater risk.  Although advanced therapies such as mechanical support are as effective in women as in men, women are less likely to receive mechanical support.  In clinical trials investigating mechanical support as a bridge to transplant less than 30% of patients were women.  In trials investigating mechanical support for patients ineligible for heart transplant even fewer were women, less than 20%.  .

Medical Research: What should clinicians and patients take away from your report?

Dr. Cook: It has been shown that women with heart failure are more likely to remain under the care of a primary physician instead of being referred for specialized cardiovascular care.  The explanation for this pattern is not understood.  It is important to raise awareness and emphasize the high risk of heart failure mortality among women.

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New Approach Assesses Barrier To Self Care In Heart Failure Patients

Richard J. Holden, PhD Assistant Professor Department of BioHealth Informatics Indiana University School of Informatics and Computing – Indianapolis Indianapolis, IN  46202MedicalResearch.com Interview with:
Richard J. Holden, PhD Assistant Professor
Department of BioHealth Informatics
Indiana University
School of Informatics and Computing – Indianapolis
Indianapolis, IN  46202

Medical Research: What was your motivation for this study?

Dr. Holden: Many patients arrive in the emergency room with acute heart failure (AHF), a worsening of their chronic heart failure condition. These visits and subsequent hospital admissions and readmissions for acute heart failure represent a sizeable cost in the US healthcare system. Evidence suggests that some of these cases could be prevented if patients were better able to perform self-care activities such as monitoring their symptoms, taking medications, getting exercise, and maintaining a sodium-restricted diet. However, in community-based studies that we and others have done, patients with heart failure face a variety of barriers to optimally performing self-care. We therefore created an instrument to assess barriers to self-care, which we designed to be implemented in the emergency room. We tested the instrument with 31 patients with acute heart failure at Vanderbilt University’s adult Emergency Department.

Medical Research: What are the main findings?

Dr. Holden: Almost everyone who participated reported experiencing barriers to self-care. A median of 15 barriers per patient were reported. Of the 47 barriers that we tested, 34 were reported by at least one quarter of participants. The top ten most prevalent barriers included individual-level factors such as physical disability, disease knowledge, and memory deficits as well as factors related to the organization of home life, including major disruptions such as holidays. Other barriers were related to inadequate health information, low literacy, and lack of resources. Many barriers interacted with one another, for example, lack of transportation yet not wanting to rely on others. We found that the instrument could be feasibly administered within a short period following the patient’s emergency room arrival.
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Quality of Discharge Summaries Linked to Hospital Readmission Rate

Leora Horwitz, MD, MHS Director, Center for Healthcare Innovation and Delivery Science New York University Langone Medical Center Director, Division of Healthcare Delivery Science Department of Population Health, NYU School of Medicine New York, NY 10016MedicalResearch.com Interview with:
Leora Horwitz, MD, MHS

Director, Center for Healthcare Innovation and Delivery Science
New York University Langone Medical Center
Director, Division of Healthcare Delivery Science
Department of Population Health, NYU School of Medicine
New York, NY 10016

Medical Research: What is the background for this study? What are the main findings?

Dr. Horwitz: We reviewed over 1500 discharge summaries from 46 hospitals around the nation that had been collected as part of a large randomized controlled trial (Telemonitoring to Improve Heart Failure Outcomes). All summaries were of patients who were admitted with heart failure and survived to discharge. We found that not one of them met all three criteria of being timely, transmitted to the right physician and fully comprehensive in content. We also found that hospitals varied very widely in their average quality. For instance, in some hospitals, 98% of summaries were completed on the day of discharge; in others, none were. In the accompanying Data Report, we show that summaries transmitted to outside clinicians and including more key content elements are associated with lower risk of rehospitalization within 30 days of discharge. This is the first study to demonstrate an association of discharge summary quality with readmission.

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Stroke Risk Lower For Women With Heart Failure

MedicalResearch.com Interview with:
Torben Bjerregaard Larsen
Associate professor, MD, PhD, FESC
Aalborg University Hospital Department of Cardiology
Aalborg Thrombosis Research Unit Denmark

Medical Research: What is the background for this study? What are the main findings?

Dr. Larsen: Heart failure is a major public health issue with an increasing prevalence. Heart failure is associated with an increased risk of stroke, also in patients without concomitant atrial fibrillation. However, recent prospective randomized controlled trials investigating the effect of antithrombotic therapy in heart failure patients in sinus rhythm revealed that the benefit of warfarin in reducing stroke was counterbalanced by an increased risk of bleeding. Whether subgroups within the heart failure population would benefit from antithrombotic therapy is currently unknown. Therefore, possible subgroups with a higher risk of stroke within the heart failure population must be identified. We investigated whether female sex was associated with a higher risk of stroke, since female sex has been associated with an increased stroke risk among patients with atrial fibrillation.

In our study, we found an association between female sex and decreased stroke risk in heart failure patients in sinus rhythm which persisted after adjustment for concomitant cardiovascular risk factors. This association was attenuated with increasing age which could possibly be due to competing risks of death, since competing risk of death was substantial among males in the older age groups.

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Fitness An Important Predictor of Heart Failure

Carl "Chip" Lavie MD, FACC Medical  Director, Cardiac  Rehabilitation and Prevention Director, Exercise Laboratories John Ochsner Heart and Vascular Institute Professor of Medicine Ochsner Clinical  School-UQ School of Medicine Editor-in-Chief, Progress in Cardiovascular DiseasesMedicalResearch.com Interview with:
Carl “Chip” Lavie MD, FACC
Medical  Director, Cardiac  Rehabilitation and Prevention
Director, Exercise Laboratories
John Ochsner Heart and Vascular Institute
Professor of Medicine
Ochsner Clinical  School-UQ School of Medicine
Editor-in-Chief, Progress in Cardiovascular Diseases

Medical Research: What are the key points of your editorial?

Dr. Lavie:

1) The importance of higher fitness to predict a lower rate of developing Heart Failure;

2) improvements in fitness over  time  predict a lower rate of developing  Heart Failure, and

3) Once Heart Failure develops, higher fitness predicts a more favorable prognosis.

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Reduced Sodium Intake May Improve Heart Failure Prognosis

MedicalResearch.com Interview with:
Dr. Eloisa Colin-Ramirez, BSc, PhD
and
Justin A. Ezekowitz, MBBCh MSc
Associate Professor, University of Alberta
Co-Director, Canadian VIGOUR Centre
Director, Heart Function Clinic
Cardiologist, Mazankowski Alberta Heart Institute

Medical Research: What is the background for this study? What are the main findings?

Response: The SODIUM-HF study is a randomized control trial on sodium restriction in patients with chronic heart failure (HF). Sodium restriction has been broadly recommended as part of the self-care strategies in heart failure yet is based on little high-quality evidence. This study reports the results of the pilot SODIUM-HF trial in 38 patients with chronic HF. Nineteen patients were prescribed a low sodium containing diet (1500 mg/day) and 19 a moderate sodium containing diet (2300 mg/day). Both interventions were based on a structured and individualized meal plan to achieve the targeted sodium intake, and all patients were followed for 6 months with monthly phone call to reinforce adherence to the diet.

We found a meaningful reduction in sodium intake to less than 1500 mg/day at 6 months in both groups. Additionally, we observed that patients that achieved a sodium intake less than 1500 mg/day at 6 months of follow-up had reduced BNP levels, a biomarker of volume overload and surrogate prognostic marker in heart failure, and increased overall and clinical scores of the Kansas City Cardiomyopathy Questionnaire, compared to those with a sodium intake greater than 1500 mg/day.

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Beta Blockers May Reduce Mortality In Heart Failure with Preserved Ejection Fraction

Dr. Lars H. Lund Department of Medicine, Karolinska Institutet Department of Cardiology, Karolinska University Hospital Stockholm, SwedenMedicalResearch.com Interview with:
Dr. Lars H. Lund

Department of Medicine, Karolinska Institutet
Department of Cardiology, Karolinska University Hospital
Stockholm, Sweden

Medical Research: What is the background for this study?

Dr. Lund: Heart Failure and Preserved Ejection Fraction is common and associated with poor prognosis and there is no therapy.

Beta-blockers reduce mortality in Heart Failure and Preserved Ejection Fraction and we hypothesized that they may be associated with reduced mortality also in Heart Failure and Preserved Ejection Fraction.

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Heart Failure Costs To Increase Due To Aging Population and Improved Medical Therapies

Boback Ziaeian MD Cardiology Fellow, UCLA Division of Cardiology PhD Candidate, UCLA Fielding School of Public HealthMedicalResearch.com Interview with:
Boback Ziaeian MD

Cardiology Fellow, UCLA Division of Cardiology
PhD Candidate, UCLA Fielding School of Public Health

Medical Research: What is the background for this study? What are the main findings?

Dr. Ziaeian: Heart failure is projected to increase dramatically over the coming decade due to an aging population improved medical therapies that prolong heart failure survival. Spending for heart failure is projected to increase from $20.9 billion in 2012 to $53.1 billion in 2030.  Despite the magnitude of the impact of heart failure on the US population and economy, our understanding of the factors associated with the highest cost heart failure hospitalizations is limited.

Our study provides a descriptive analysis of how certain patient and hospital factors are associated with increased medical costs nationally. The top 20% of heart failure hospitalizations average $28,500 per hospitalization compared to $3,000 for the lowest 20%. Overall, patients with more medical conditions (such as obesity, lung disease, and peripheral vascular disease) have much higher costs associated with hospital care. As expected, sicker patients receiving more invasive procedures such mechanical ventilation or blood transfusions incurred higher costs. Certain hospital characteristics were also associated with higher costs. Hospitals in urban centers were higher cost compared to more rural hospitals. Hospitals in the Northeast and West Coast of the US were higher in cost compared to the Midwest and South. The reasons for this disparity in medical costs requires further research to better understand.

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