Heart failure with preserved ejection fraction management: a systematic review of clinical practice guidelines and recommendations.

Multiple guidelines exist for the diagnosis and management of heart failure with preserved ejection fraction (HFpEF). We systematically reviewed current guidelines and recommendations, developed by national and international medical organizations, on the management of HFpEF in adults to aid clinical decision-making. We searched MEDLINE and EMBASE on 28 February 2024 for publications over the last 10 years as well as websites of organizations relevant to guideline development. Of the ten guidelines and recommendations retrieved, seven showed considerable rigour of development and were subsequently retained for analysis. There was consensus on the definition of HFpEF and the diagnostic role of serum natriuretic peptides and resting transthoracic echocardiography. Discrepancies were identified in the thresholds of serum natriuretic peptides and transthoracic echocardiography parameters used to diagnose HFpEF. There was agreement on the general pharmacological and supportive management of acute and chronic HFpEF. However, differences exist in strategies to identify and address specific phenotypes. Contemporary guidelines for HFpEF management agree on measures to avoid its development and the consideration of cardiac transplantation in advanced disease. There were discrepancies in recommended frequency of surveillance for patients with HFpEF and sparse recommendations on screening for HFpEF in the general population, use of diagnostic scoring systems, and the role of newly emerging therapies.

Remote consultations: review of guiding themes for equitable and effective delivery.

The global coronavirus disease (COVID) -19 pandemic has led to a rapid transformation in the ways in which outpatient care is delivered. The need to minimise the risk of viral infection and transmission through social distancing resulted in the widespread adoption of remote consultations, traditional face-to-face appointments ceasing almost overnight in many specialties. The transition to remote consultations had taken place far faster than anticipated and under crisis conditions. As we work towards the "new normal", remote consultations have become an integral part of outpatient provision in secondary care. Adapting to this change in clinical practice requires a judicious approach to ongoing service development to ensure safe, effective, and equitable care for all patients. Medical societies have provided some initial guidance around effective delivery. In this article we discuss the potential benefits, limitations, types of remote consultations, and factors that require consideration when deciding on patient suitability for remote consultation in a hospital setting. We use cardiology as a specialty exemplar, although many of the principles will be equally applicable to other medical specialties.

Effects of yoga on anxiety and depression for high risk mothers on hospital bedrest.

BACKGROUND: and purpose: In recent years, yoga practitioners have joined forces with medical programs to approach patients' well-being holistically. This study is a randomized controlled trial to assess the effects of a specialized adapted yoga program on anxiety and depression for high-risk expectant mothers on bedrest in a hospital setting. MATERIALS AND METHODS: Seventy-nine pregnant subjects on physician ordered hospitalized bedrest were randomized into two groups: receiving biweekly yoga sessions (intervention group) or receiving no yoga (control group). Data collection tool was the Hospital Anxiety and Depression Scale (HADS) to assess outcomes after delivery. RESULTS: Yoga, even as little as three sessions, showed significant impact in reducing anxiety and depression high-risk pregnant women on hospitalized bedrest. Perceived anxiety and depression overall scores were lower in the intervention group than in the control group (p < 0.001). CONCLUSION: Results demonstrated that yoga is an effective intervention to decrease anxiety and depression in high-risk antepartum women on hospitalized bedrest.

Assessing health-related quality of life in heart failure patients attending an outpatient clinic: a pragmatic approach.

AIMS: Improving quality of life (QoL) in heart failure patients is a key management objective. Validated health-related QoL (HR-QoL) measurement tools have been incorporated into clinical trials but not routinely into daily practice. The aims of this study were to investigate the acceptability and feasibility of implementing validated HR-QoL instruments into heart failure clinics and to examine the impact of patient characteristics on HR-QoL. METHODS AND RESULTS: One hundred and sixty-three patients attending heart failure clinics at a UK tertiary centre were invited to complete three HR-QoL assessments: the Minnesota Living with Heart Failure Questionnaire (MLHFQ); the EuroQoL 5D-3L (EQ-5D-3L); and the Kansas City Cardiomyopathy Questionnaire (KCCQ) in that order. Data on patient demographics, co-morbidities, New York Heart Association (NYHA) class, plasma B-type natriuretic peptide (BNP), renal function, and left ventricular ejection fraction were recorded. 94% of patients attending clinic were willing to participate. The EQ-5D-3L had all questions answered by 92% of patients, compared with 86% and 51% for the MLHFQ and KCCQ, respectively. HR-QoL significantly correlated with NYHA class using each tool (MLHFQ, r = 0.59; KCCQ, r = -0.61; EQ-5D-3L, r = -0.44, all P < 0.01). However, within each NYHA class, there was a widespread of HR-QoL scores. There was no association between patient demographics, left ventricular ejection fraction, plasma B-type natriuretic peptide, or renal function with HR-QoL using any tool. CONCLUSIONS: Health-related QoL assessment by validated questionnaire was acceptable to patients and feasible to perform in routine practice. Although NYHA class correlated significantly with HR-QoL scores, there was high variability in HR-QoL within each NYHA class, highlighting its limitation as the sole assessment of HR-QoL. Clinicians should encourage the assessment of HR-QoL to facilitate patient-centred care and make more specific use of HR-QoL measurement tools.

Sleep Disordered Breathing and Heart Failure: What Does the Future Hold?

Most patients with heart failure (HF) have sleep-disordered breathing (SDB), with central (rather than obstructive) sleep apnea becoming the predominant form in patients with more severe disease. Cyclical apnea and hypopneas are associated with sleep disturbance, hypoxemia, hemodynamic changes, and sympathetic activation. These patients have a worse prognosis than those without SDB. Mask-based therapies of positive airway pressure targeted at SDB can improve measures of sleep quality and can partially normalize the sleep and respiratory physiology. However, recent randomized trials of cardiovascular outcomes in central sleep apnea in chronic HF with reduced ejection fraction have had neutral findings or suggested the possibility of harm, likely from an increased rate of sudden death. Further randomized outcome studies are required to determine whether mask-based treatment is appropriate for patients with chronic HF with reduced ejection fraction and obstructive sleep apnea, for patients with heart failure with preserved ejection fraction, and for patients with decompensated heart failure. New therapies for sleep apnea (e.g., implantable phrenic nerve stimulators) also require robust assessment. No longer can the surrogate endpoints of improvement in respiratory and sleep metrics be taken as adequate therapeutic outcome measures in patients with HF and sleep apnea.

Crisis averted: How consumers experienced a police and clinical early response (PACER) unit responding to a mental health crisis.

When mental health crisis situations in the community are poorly handled, it can result in physical and emotional injuries. The purpose of this study was to ascertain the experiences and opinions of consumers about the way police and mental health services worked together, specifically via the Alfred Police and Clinical Early Response (A-PACER) model, to assist people experiencing a mental health crisis. Semi-structured in-depth interviews were conducted with 12 mental health consumers who had direct contact with the A-PACER team between June 2013 and March 2015. The study highlighted that people who encountered the A-PACER team generally valued and saw the benefit of a joint police-mental health clinician team response to a mental health crisis situation in the community. In understanding what worked well in how the A-PACER team operated, consumers perspectives can be summarized into five themes: communication and de-escalation, persistence of the A-PACER team, providing a quick response and working well under pressure, handover of information, and A-PACER helped consumers achieve a preferred outcome. All consumers acknowledged the complementary roles of the police officer and mental health clinician, and described the A-PACER team's supportive approach as critical in gaining their trust, engagement and in de-escalating the crises. Further education and training for police officers on how to respond to people with a mental illness, increased provision of follow-up support to promote rehabilitation and prevent future crises, and measures to reduce public scrutiny for the consumer when police responded, were proposed opportunities for improvement.

The role of adjuvant radiation therapy for resected stage III thymoma: a population-based study.

BACKGROUND: Because of the rarity of the disease and long survival of most patients, the role of adjuvant radiation therapy in patients with surgically resected stage III thymoma is unclear, and few prospective studies are available. The objective was to evaluate the impact of postoperative radiation therapy after resection of stage III thymoma. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was queried for all patients with stage III thymoma who underwent surgical therapy and survived more than 30 days after diagnosis. Survival was estimated with the Kaplan-Meier method. The hazard ratio for death was determined using a Cox proportional hazard model. RESULTS: There were 476 patients with stage III thymoma identified who underwent surgical therapy, did not receive preoperative radiotherapy, and had complete SEER records with regard to radiation treatment. Postoperative radiation therapy was given to 322 patients (67.6%). Patients who received postoperative radiation therapy were younger and had a higher rate of debulking surgery than patients who did not. Patients receiving postoperative radiation had a median overall survival of 127 months (95% confidence interval, 100.9 to 153.1) compared with 105 months (95% confidence interval, 76.9 to 133.1) in patients treated with surgery alone (p=0.038). However, in multivariate analysis, postoperative radiation was not a significant factor affecting overall survival. Disease-specific survival was significantly improved in the adjuvant radiation group, and in multivariate analysis, improved outcomes were associated with postoperative radiation (p=0.049). CONCLUSIONS: In this large population-based study, most patients with stage III thymoma were treated with adjuvant radiation. Postoperative radiation was associated with improved disease-specific survival, but not improved overall survival.

Thymomas and extrathymic cancers.

BACKGROUND: Patients with thymoma may have a predisposition toward extrathymic neoplasia. To understand the lifetime risk and incidence of extrathymic neoplasia in patients with thymoma, we evaluated extrathymic neoplasms diagnosed either before or after the diagnosis of thymoma. METHODS: We queried the Surveillance, Epidemiology, and End Results (SEER) cancer database and identified patients with thymoma and extrathymic neoplasms. We collected demographic and treatment data, calculated the incidence of each extrathymic neoplasm (adjusting for age), and compared the incidence of extrathymic neoplasm in patients with thymoma with the age-adjusted incidence in the SEER database general population. RESULTS: Of 2,171 patients with thymoma in the SEER database, 306 (14.1%) had extrathymic primary cancers. Extrathymic neoplasms were diagnosed before the diagnosis of thymoma in 88 patients and after the diagnosis of thymoma in 206 patients. In 12 patients, separate extrathymic neoplasms were diagnosed both before and after thymoma diagnosis. The incidence of extrathymic cancers in patients with thymoma (8,224 per 100,000 persons) was significantly higher than in the SEER general population (459 per 100,000 persons; p<0.001). The standardized incidence ratio for extrathymic cancer was also significantly increased, in particular for lymphomas, leukemias, esophageal cancer, and lung cancer. Increased age at diagnosis (p<0.001), longer survival after diagnosis (p<0.001), and male sex (p=0.041)-but not radiation therapy or surgery-were significant risk factors for the development of extrathymic cancers in patients with thymoma. CONCLUSIONS: The incidence of extrathymic neoplasia is significantly higher in patients with thymoma than in the general population and occurs both before and after the diagnosis of thymoma.

Stomatal index responses of Agrostis canina to CO2 and sulphur dioxide: implications for palaeo-[CO2] using the stomatal proxy.

• Stomatal index values of fossil plants are widely used in reconstructing palaeo-[CO(2)]. This depends upon the assumption that the stomatal index is determined by the atmospheric concentration of CO(2) ([CO(2)]). This study investigates whether fumigation with, and resistance to, sulphur dioxide (SO(2)) induces a reduction in the stomatal index that may affect stomatal reconstructions of palaeo-[CO(2)] coinciding with episodes of global-scale volcanism. • Agrostis canina from Mefite di Ansanto, Italy, grow in atmospheres of elevated-[CO(2)], SO(2) and hydrogen sulphide (H(2)S). Mefite A. canina were compared with a control population in a 'common-garden' experiment and a controlled-environment study under elevated-[CO(2)] and SO(2) fumigation. • In A. canina, resistance to toxic volcanic gases is not associated with reduced stomatal index, and fumigation with SO(2) does not cause a decrease in stomatal initiation. The two populations of A. canina analyzed in this study exhibit different stomatal index-[CO(2)] 'responses', with control plants showing a reduction in stomatal index and Mefite plants showing no response. • Stomatal reconstructions of palaeo-[CO(2)] during past episodes of global-scale volcanism probably reflect atmospheric [CO(2)] and not [SO(2)]. The lack of a reduction in the stomatal index in response to elevated [CO(2)] in the Mefite plants, suggests that resistance to toxic gases and/or long-term growth at high [CO(2)] reduces, or negates, sensitivity of the stomatal index-[CO(2)] relationship, or that stomatal index-[CO(2)] in the Mefite plants is attuned to [CO(2)] fluctuations at much higher concentrations.