Multispecialty multidisciplinary input into comorbidities along with treatment optimisation in heart failure reduces hospitalisation and clinic attendance.

AIMS: Heart failure (HF) is associated with comorbidities which independently influence treatment response and outcomes. This retrospective observational study (January 2020-June 2021) analysed the impact of monthly HF multispecialty multidisciplinary team (MDT) meetings to address management of HF comorbidities and thereby on provision, cost of care and HF outcomes. METHODS: Patients acted as their own controls, with outcomes compared for equal periods (for each patient) pre (HF MDT) versus post-MDT (multispecialty) meeting. The multispecialty MDT comprised HF cardiologists (primary, secondary, tertiary care), HF nurses, nephrologist, endocrinologist, palliative care, chest physician, pharmacist, clinical pharmacologist and geriatrician. Outcome measures were (1) all-cause hospitalisations, (2) outpatient clinic attendances and (3) cost. RESULTS: 334 patients (mean age 72.5±11 years) were discussed virtually through MDT meetings and follow-up duration was 13.9±4 months. Mean age-adjusted Charlson Comorbidity Index was 7.6±2.1 and Rockwood Frailty Score 5.5±1.6. Multispecialty interventions included optimising diabetes therapy (haemoglobin A1c-HbA1c pre-MDT 68±11 mmol/mol vs post-MDT 61±9 mmol/mol; p<0.001), deprescribing to reduce anticholinergic burden (pre-MDT 1.85±0.4 vs 1.5±0.3 post-MDT; p<0.001), initiation of renin-angiotensin aldosterone system inhibitors in HF with reduced ejection fraction (HFrEF) with advanced chronic kidney disease (9% pre vs 71% post-MDT; p<0.001). Other interventions included potassium binders, treatment of anaemia, falls assessment, management of chest conditions, day-case ascitic, pleural drains and palliative support. Total cost of funding monthly multispecialty meetings was £32 400 and resultant 64 clinic appointments cost £9600. The post-MDT study period was associated with reduction in 481 clinic appointments (cost saving £72150) and reduced all-cause hospitalisations (pre-MDT 1.1±0.4 vs 0.6±0.1 post-MDT; p<0.001), reduction of 1586 hospital bed-days and cost savings of £634 400. Total cost saving to the healthcare system was £664 550. CONCLUSION: HF multispecialty virtual MDT model provides integrated, holistic care across all healthcare tiers for management of HF and associated comorbidities. This approach is associated with reduced clinic attendances and all-cause hospitalisations, leading to significant cost savings.

Cardio-nephrology MDT meetings play an important role in the management of cardiorenal syndrome.

Cardiorenal syndrome is a complex condition associated with significant morbidity in the form of symptoms secondary to fluid overload, leading to hospitalisations, and portends increased mortality. Both the diagnosis and management of the conditions are complicated by the fact that there is dysfunction of the heart as well as the kidney, usually with uncertainty with regards to the timing of the first insult. Management in primary care, or in the emergency setting, tends to be predominantly focused on short-term improvement in function of one organ, leading to deleterious effects on the other. A consensus multi-disciplinary approach involving both cardiologists and nephrologists has been advocated in order to devise a unified management plan. Our report presents findings of monthly cardio-nephrology multi-disciplinary team meetings and illustrates that this can be an efficacious approach both in terms of avoiding unnecessary outpatient clinic visits, as well as consensus decision-making.

Hyperhomocysteinemia and Lupus Nephritis.

Background  In SLE, both disease-specific and traditional risk factors are important. Increased serum homocysteine levels are seen in approximately 15% of patients with systemic lupus erythematosus and are associated with an increased risk of atherothrombotic events in this population. The serum level of homocysteine in patients with lupus nephritis has not been well described. Methods We performed a retrospective review of patients who had both biopsy-proven lupus nephritis (class II-VI) and measured homocysteine levels during routine evaluation. Clinical and laboratory data were obtained from reviews of medical records. Results Of the 15 patients with lupus nephritis, 10 had elevated homocysteine levels. The ages ranged from 21-68 years and were predominately African-American females. There were three patients with class III, one with class III-V, two with class IV, and two with class V lupus nephritis. Two patients had more than one biopsy each, one with class III, IV-V, and one with III and IV. At the time, when the serum homocysteine level was measured, of the 10 patients with elevated homocysteine levels, five patients had positive anti-dsDNA, and four had hypocomplementemia predominately low C3 (three patients). All patients were on hydroxychloroquine. Conclusions  This study demonstrates that patients with lupus nephritis are at a higher risk (66.6%) for developing elevated homocysteine levels.

Pericarditis in Lupus.

Pericarditis is a common cardiac manifestation in systemic lupus erythematosus (SLE). Serositis is recognized in the ACR, SLICC, and EULAR/ACR classification criteria. We reviewed the prior research regarding the epidemiology, risk factors, presentation, and treatment of pericarditis in SLE.

Ambulatory management of acute decompensation in heart failure.

Heart failure is an increasingly prevalent chronic condition which causes substantial morbidity and mortality, placing an increasing economic burden on health care. Hospitalizations as a result of heart failure are projected to increase considerably over the next two decades. A robust restructuring of existing heart failure treatment models in the UK is needed to enable an integrated seamless transition of care across the community, primary care and hospital networks. This has to be achieved with the patient as a partner in health care as a part of a multidisciplinary approach. This uses innovative strategies such as ambulatory treatment (including intravenous diuretics, remote and telemonitoring) as well as shifting heart failure treatment to the community and to patients' homes. This article analyses the existing evidence for ambulatory management of acute decompensated heart failure and looks at future strategies for restructuring care.

Ranolazine-induced Elevation of Creatinine Kinase in the Absence of Statin Usage.

Ranolazine received Food and Drug Administration (FDA) approval in 2006 for the treatment of chronic angina. Ranolazine has previously been linked to the development of statin-induced myopathy, because it also inhibits CYP3A4, which increases serum statin levels. In the absence of concomitant statin therapy, elevated creatinine kinase (CK) and myalgias on ranolazine monotherapy has never been reported.

Campylobacter jejuni myocarditis: A journey from the gut to the heart.

OBJECTIVES: Campylobacter jejuni is an unusual cause of myocarditis and could easily be missed. METHODS: We describe a case of a 25 year old man, who presented with 3 day history of vomiting and diarrhoea, followed by chest pain and significant high sensitive troponin rise. RESULTS: The patient's profuse diarrhoea was accompanied by raised inflammatory markers, electrocardiogram changes and evidence of cardiomyopathy on transthoracic echocardiogram. Various aetiological viral serologies which were tested for came back negative. However, stool culture was positive for the bacteria, Campylobacter jejuni. He was successfully treated with antibiotics and made an uneventful recovery. CONCLUSIONS: Campylobacter jejuni gastroenteritis has a worldwide prevalence. Therefore, prompt diagnosis and treatment is crucial when this organism is implicated in myocarditis.

The effect of carvedilol on B-type natriuretic peptide and cardiac function in patients with heart failure and persistent atrial fibrillation.

OBJECTIVES: We sought to determine the relationship between changes in natriuretic peptides and symptoms as a consequence of introducing beta-blocker therapy, in patients with chronic heart failure (CHF) and persistent atrial fibrillation (AF). METHODS: In a randomised, double-blind, placebo-controlled study involving 47 patients with CHF and persistent AF (mean age 68 years and 62% men), we analysed the individual change (Δ) in B-type natriuretic peptide (BNP) level to the introduction of carvedilol (titrated to a target dose of 25 mg twice daily, group A) or placebo (group B) in addition to background treatment with digoxin. Symptoms score, 6-min walk distance, New York Heart Association (NYHA) class, left ventricular ejection fraction (LVEF), heart rate (24-hour ECG) and BNP were measured at baseline and at 4 months. RESULTS: LVEF (Δ median +5 vs. +0.4, p = 0.048), symptoms score (Δ median -4 vs. 0, p = 0.04), NYHA class (Δ median -33% vs. +3% in NYHA class 3-4, p = 0.046) and heart rate [Δ median 24-hour ventricular rate (VR) -19 vs. -2, p < 0.0001] improved with combination therapy of digoxin and carvedilol compared to digoxin alone, but BNP (Δ median +28 vs. -6 , p = 0.11) trended in the opposite direction. There was no relationship between the degree of symptomatic improvement or VR control and BNP response. CONCLUSION: After the introduction of carvedilol, clinical outcome appears unrelated to BNP changes in patients with CHF and AF. Changes in BNP cannot be used as a marker of clinical response in terms of symptoms or cardiac function in this setting.

The intersection of atrial fibrillation and heart failure in a hospitalised population.

OBJECTIVES: This work set out to comprehensively characterize patients admitted to hospital with both atrial fibrillation (AF) and heart failure (HF) and to compare this cohort of patients to the global hospital population of patients with only one of these diagnoses. METHODS AND RESULTS: This was a retrospective analysis of all in-patients with HF and AF admitted to a large urban hospital over a 3-month period. Patients with AF were identified by both discharge codes and electrocardiograms. HF patients were identified by means of discharge codes for HF and by screening all patients with AF, a common comorbidity of HF. Evidence for left ventricular (LV) dysfunction was sought. Of patients with AF (n = 453), 43% had symptoms of HF and LV dysfunction. Of patients with a discharge code and confirmed HF (n = 286), 34% had AF, 60% of whom were in chronic AF. Compared to HF patients in sinus rhythm those in AF were older (70 +/- 10 y vs 67 +/- 12 y, P < 0.02), had a higher prevalence of valvular heart disease (25% vs 7%, P < 0.0001) and a lower prevalence of ischaemic heart disease (17% vs 40%, P < 0.0001). HF patients identified by discharge codes in AF were more likely to have QRS > or = 120 msec (18% vs 12% in sinus rhythm; P= ns). Patients with AF and deemed to suffer concomitant HF, as opposed to AF alone, were significantly more likely to have QRS prolongation (QRS > or = 120 msec 27% vs 8%, P < 0.05). 8% of patients with AF and HF had a QRS > 150 msec. CONCLUSIONS: AF and HF are frequent, concomitant pathologies in a hospitalised population. AF complicates HF assessment and treatment. Greater dyssynchrony, as denoted by ECG, in the AF and HF population suggests opportunities for treatment of HF by cardiac resynchronization therapy and ablative therapies.