[Therapeutic education of heart failure patients in France]. / Education thérapeutique des patients insuffisants cardiaques en France.

Heart failure is a frequent and severe disease. The rate of avoidable hospitalizations due to lack of treatment adherence is estimated at 30% and, makes this disease a prime target for patient education. Implementation of such education initially began as a function of the local possibilities and willingness, which has led to great variety in the programs (only some of which meet the criteria set forth in the National Authority for Health guidelines) and the tools used. More recently, regional and even national programs, such as ICARE, sponsored by the two principal learned societies (The French Society and French Federation of Cardiology) have helped more than 200 private and public hospitals to set up field patient education programs based upon common concepts and tools.

Characterisation of peripartum cardiomyopathy by cardiac magnetic resonance imaging.

Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure. Only half of the patients recover normal cardiac function. We assessed the usefulness of magnetic resonance imaging (MRI) and late enhancement imaging to detect myocardial fibrosis in order to predict cardiac function recovery in patients with peripartum cardiomyopathy. Among a consecutive series of 1,037 patients referred for heart failure treatment or prognostic evaluation between 1999 and 2006, eight women had confirmed PPCM. They all underwent echocardiography and cardiac MRI for assessment of left ventricular anatomy, systolic function and detection of myocardial fibrosis through late enhancement imaging. Mean (+/- SD) baseline left ventricular ejection fraction (LVEF) was 28 +/- 4%. After a follow-up of 50 +/- 9 months, half the patients recovered normal cardiac function (LVEF = 58 +/- 4%) and four did not (LVEF = 35 +/- 6%). None of the eight patients exhibited abnormal myocardial late enhancement. No difference in MRI characteristics was observed between the two groups. Patients with PPCM do not exhibit a specific cardiac MRI pattern and particularly no myocardial late enhancement. It suggests that myocardial fibrosis does not play a major role in the limitation of cardiac function recovery after PPCM.

The effects of beta-blockers in patients with stable chronic heart failure. Predictors of left ventricular ejection fraction improvement and impact on prognosis.

BACKGROUND: Previous studies, with limited number of patients, have tried to determine the predictors of left ventricular ejection fraction (LVEF) improvement after beta-blockade. No study has demonstrated that LVEF improvement was an independent predictor of cardiac survival. METHODS: The aims of the study were to determine in a large group of patients with stable chronic heart failure associated with reduced LVEF the predictors of LVEF improvement (difference in LVEF [deltaLVEF], ie, the value after beta-blockade minus the value before beta-blockade) after beta-blockade and to analyze prognostic impact of deltaLVEF. Three hundred fourteen consecutive patients underwent an echocardiogram, a radionuclide angiogram, and a maximum cardiopulmonary exercise test before and 3 months after maximal tolerated doses of beta-blockers have been reached. RESULTS: After beta-blockade, LVEF improved from 30% +/- 11% to 40% +/- 13%. In the whole population, independent predictors of deltaLVEF were nonischemic etiology, baseline LVEF (negative correlation), and baseline heart rate (positive correlation). In ischemic patients, independent predictors of deltaLVEF were absence of history of myocardial infarction, baseline heart rate, and baseline LVEF; whereas in nonischemic patients, independent predictors were baseline LVEF and baseline QRS width (negative correlation). After 1082 days of follow-up, there were 53 cardiovascular deaths and 2 urgent transplantations. Left ventricular ejection fraction improvement (defined as an absolute increase in LVEF > 5%) was an independent predictor of cardiac survival. Patients who had an LVEF < or = 45% after beta-blockade with a deltaLVEF < or = 5% represented a high-risk subgroup. CONCLUSIONS: In patients with chronic heart failure, predictors of LVEF improvement after beta-blockade were different according to etiology. Left ventricular ejection fraction improvement was an independent predictor of cardiac survival.

High-sensitivity C-reactive protein: potential adjunct for risk stratification in patients with stable congestive heart failure.

AIMS: To determine the potential adjunct of high-sensitivity (hs) C-reactive protein for risk stratification in patients with stable congestive heart failure (CHF). METHODS AND RESULTS: We studied 546 consecutive patients clinically stable with an ejection fraction <45% who were referred to our centre for evaluation of left ventricular dysfunction. hs C-reactive protein levels were determined on blood samples obtained on entry into the study. Clinical follow-up (median 972 days) was obtained for 545 patients. Cardiovascular mortality was significantly increased (P=0.001) in patients with hs C-reactive protein >3 mg/L. By multivariable analysis, including clinical, biological, and echocardiographic variables, hs C-reactive protein >3 mg/L was an independent predictor of cardiovascular mortality [HR=1.78 (1.17-2.72); P=0.008]; the strongest predictive parameter in this model was B-type natriuretic peptide (BNP) (P=0.005). When peak VO(2) was included into the model, hs C-reactive protein >3 mg/L remained an independent predictor of cardiovascular mortality [HR=1.55 (1.02-2.38); P=0.04]; the strongest predictive parameter in this model was peak VO(2) (P<0.0001). In patients with ischaemic CHF, cardiovascular mortality was significantly increased in patients with hs C-reactive protein >3 mg/L (P=0.001), whereas in patients with non-ischaemic CHF, hs C-reactive protein >3 mg/L was not associated with cardiovascular mortality (P=0.098). By multivariable analysis, hs C-reactive protein >3 mg/L was an independent predictor of cardiovascular mortality in ischaemic patients [HR=2.16 (1.23-3.78)] but not in non-ischaemic patients [HR=1.05 (0.52-2.11)]. CONCLUSION: Cardiovascular mortality is increased in CHF patients with hs C-reactive protein >3 mg/L. The impact of hs C-reactive protein is independent of usual prognostic parameters, in particular BNP and peak VO(2). The interest of hs C-reactive protein determination appears to be especially marked in patients with ischaemic cardiomyopathy.

Prognostic significance of circulating levels of angiogenic cytokines in patients with congestive heart failure.

BACKGROUND: Recent experimental studies have suggested that the angiogenic cytokines hepatocyte growth factor (HGF) and vascular endothelial growth factor (VEGF) may play a role in the pathogenesis of congestive heart failure (CHF). The aim of the present study was to test the hypothesis that HGF and VEGF concentrations may vary according to the different markers of CHF severity and to analyze the impact of HGF and VEGF concentrations on the cardiovascular mortality of patients with CHF. METHODS: We studied 529 consecutive patients who were referred to our center for an evaluation of left ventricular dysfunction. Hepatocyte growth factor and vascular endothelial growth factor levels were determined on blood samples obtained on entry into the study. Clinical follow-up (median 988 days) was obtained for 528 patients. RESULTS: Hepatocyte growth factor concentrations were strongly associated with age, diabetes mellitus, and all markers of CHF severity; by contrast, baseline characteristics did not differ among VEGF tertiles. Cardiovascular survival rates at 1, 2, and 3 years were 91%, 87%, and 80%, respectively. The survival curves indicated a worse outcome for patients with high HGF concentrations at baseline (P < .0001); by contrast, cardiovascular survival was similar across the tertiles of VEGF (P = .37). Hepatocyte growth factor concentrations were higher in the 109 patients with a cardiovascular event (1001 [741-1327] pg/mL) than in the 419 patients without (773 [610-1045] pg/mL, P < .0001). By multivariate analysis, a baseline HGF concentration >802 pg/mL was associated with an increased cardiovascular mortality (hazard ratio = 1.85, 95% CI 1.09-3.13, P = .02); other variables retained into the final model were B-type natriuretic peptide (P < .0001), peak oxygen consumption (P = .0002), and ischemic etiology (P = .0005). CONCLUSIONS: Hepatocyte growth factor levels correlate with CHF severity and are associated with an increased cardiovascular mortality during follow-up.

B-type natriuretic peptide and peak exercise oxygen consumption provide independent information for risk stratification in patients with stable congestive heart failure.

OBJECTIVES: The aim of this study was to compare the prognostic value of peak oxygen consumption (VO(2)) and B-type natriuretic peptide (BNP) in patients with stable congestive heart failure (CHF). BACKGROUND: Previous studies have demonstrated that both peak VO(2) and BNP are useful for risk stratification in patients with CHF. No study has compared the respective prognostic value of these two parameters in a large series of patients receiving a combination of angiotensin-converting enzyme inhibitors and of beta-blockers. METHODS: Patients with stable CHF underwent radionuclide angiography, echocardiography, 24-h Holter monitoring, and a cardiopulmonary exercise test. Blood samples were drawn for standard measurements and for hormonal determinations. RESULTS: After a median follow-up period of 787 days, there were 75 cardiac-related deaths and three urgent transplantations. Independent predictors of cardiac survival were percent of maximal predicted VO(2) (%VO(2), relative risk [RR] = 2.84 [95% confidence interval, CI = 1.73 to 4.65], p < 0.00001), BNP (RR = 3.17 [95% CI 1.68 to 5.96], p = 0.0004), left atrial diameter (LAD) (RR = 2.04 [95% CI 1.25 to 3.34], p = 0.004), age (RR = 1.93 [95% CI 1.22 to 3.05], p = 0.005), and aldosterone (RR = 1.84 [95% CI 1.12 to 3.00], p = 0.015). In patients with infra-median levels of BNP (<109 pg/ml), age was the only independent predictor of cardiac survival. However, in patients with supra-median levels of BNP, independent predictors of cardiac survival were %VO(2) (RR = 3.76 [95% CI 2.19 to 6.45], p < 0.00001) and LAD (RR = 1.90 [95% CI 1.10 to 3.28], p = 0.02). CONCLUSIONS: B-type natriuretic peptide, in combination with %VO(2), improves risk stratification of patients with stable CHF.