The 'real' woman with heart failure. Impact of sex on current in-hospital management of heart failure by cardiologists and internists.

AIM: To identify differences between sexes in the clinical profile, use of resources, management and outcome in a large population of 'real world' patients with heart failure (HF). METHODS: A prospective cross-sectional survey was conducted on 2127 consecutive patients (47% women) admitted with HF to 167 cardiology and 250 internal medicine departments between February 14 and 25, 2000. RESULTS: Women were older, had a higher prevalence of atrial fibrillation, and more frequently a hypertensive or valvular aetiology. Females were admitted more frequently in Medical than in Cardiology Departments. The rate of invasive and non-invasive procedures was lower in women than in men, slightly higher if managed by cardiologists. Women were less frequently prescribed ACE-inhibitors, amiodarone, and spironolactone, and more frequently prescribed digoxin. In-hospital mortality was similar, without difference between health-care providers. A 6-month follow-up was performed in 56.4% of the cases in both setting, but less frequently in women. Event rates were similar with nearly half of patients re-hospitalised at least once. CONCLUSION: The 'real' HF woman has generally a more severe disease; she is an old lady who is more frequently hospitalised in a medical unit, receives few diagnostic, and cardiovascular procedures and pharmacological therapy, has a relatively low probability of dying in hospital, but a high likelihood of requiring readmission.

[Risk of sudden death in heart failure patients]. / Rischio aritmico nei pazienti con scompenso cardiaco cronico.

Sudden death is one of the more important cause of mortality in patients with chronic heart failure. The highest risk occurs among patients with less severe functional impairment, whereas patients in NYHA class IV usually die of progression of heart failure. Predictors of sudden death have been evaluated. Nevertheless, current methods of risk stratification for sudden death are still inadequate, especially in patients with advanced heart failure. Low left ventricular ejection fraction is widely used for the risk stratification, but it lacks of sensitivity and specificity in distinguishing patients with an increased arrhythmic mortality from those with an increased mortality due to pump failure. Unsustained ventricular tachycardia and inducibility at electrophysiological study may help identifying high-risk patients, requiring more aggressive therapy, as the ICD implantation. Heart rate variability and baroreflex sensitivity analysis have been utilized to obtain information on autonomic modulation, but with uncertain conclusion on the identification of high-risk patients. Increased QT dispersion, the presence of T-wave alternans and abnormal signal-averaged electrocardiography have also been proposed, but, up-to-now, any of these parameters showed a strong predictor power. In conclusion, our capability to identifying heart failure patients at risk for arrhythmic death is still far from being satisfactory.

Treatment of chronic heart failure with beta adrenergic blockade beyond controlled clinical trials: the BRING-UP experience.

BACKGROUND: Several large controlled trials have shown that beta blockers given to patients with heart failure (New York Heart Association functional class II-IV) reduce morbidity and mortality. Despite these impressive results, implementing the use of beta blockade in clinical practice appears slow and difficult. The BRING-UP study was designed to tackle this problem. OBJECTIVES: To accelerate the adoption of beta blockade in clinical practice; to provide an epidemiological estimate of the proportion of patients with heart failure suitable for this treatment in general cardiology care; and to assess effectiveness of these drugs outside the setting of clinical trials. METHODS: The design of the study and recommendations derived from available evidence on the use of beta blockers were discussed with cardiologists during regional meetings. All consecutive heart failure patients in a one month period, whether treated or not with beta blockers, were eligible for the study. In each patient, the decision to prescribe a beta blocker was a free choice for the participating physicians. All centres were provided with carvedilol, metoprolol, and bisoprolol at appropriate doses; the choice of the drug and dosage was left to the responsible clinician. All patients were followed for one year. RESULTS: 197 cardiological centres enrolled 3091 patients, 24.9% of whom were already on beta blocker treatment at baseline. beta Blockers were newly prescribed in 32.7% of cases, more often in younger and less severely ill patients. The mean daily dose of the drugs used at one year corresponded to about 70% of the maximum dose used in clinical trials. Starting treatment with beta blockers did not affect the prescription or dosage of other recommended drugs. The overall rate of beta blocker treatment increased over the year of the study from 24.9% to 49.7%. During the 12 month period, 351 deaths occurred (11.8%). In multivariate analysis, the use of beta blockers was independently associated with a better prognosis, with a relative risk of 0.60 and a lower incidence of hospital admissions for worsening heart failure. CONCLUSIONS: The implementation of beta blockers in clinical practice is feasible and could be accelerated. These drugs are associated with a lower mortality and reduced hospital admission rates, not only in clinical trials but also in the normal clinical setting.

Chromogranin A in heart failure; a novel neurohumoral factor and a predictor for mortality.

BACKGROUND: In chronic heart failure, several hormonal systems are activated with diagnostic and prognostic implications. We tested the hypotheses that serum Chromogranin-A (CgA) -- a 49 kDa acid protein present in the secretor granules of neuroendocrine cells -- is increased in chronic heart failure and that CgA levels are a predictive factor for mortality. METHOD AND RESULTS: In 160 patients with chronic heart failure, we measured serum CgA and other neuroendocrine hormones. The results showed that CgA is increased in chronic heart failure and the increase is related to the clinical severity of the syndrome: CgA levels in New York Heart Failure (NYHA) class II (median 146.9 ng x ml(-1), inter-quartiles 108.3-265.5) were significantly higher (P<0.05) than in class I (median 109.7 ng x ml(-1), inter-quartiles 96.7-137.6), and significantly lower (P<0.05) than in class III (median 279.0 ng x ml(-1), inter-quartiles 203.6-516.1). Class IV patients showed the highest serum levels of CgA (median 545.0 ng. ml(-1), inter-quartiles 231.8-1068.3), being statistically significantly different from class III patients (P<0.001). The association between survival and some recognized variables of prognostic significance, including CgA was also studied. The results showed that ejection fraction, noradrenaline, atrial natriuretic peptide, NYHA class and CgA were significant univariate prognosticators; however, in the multivariate analysis by the Cox proportional-hazard model, CgA and NYHA class were the only independent predictive factors for mortality (P<0.005, RR=1.22, 95% CI=1.06-1.41 and P=0.04, RR=1.58, 95% CI=1.02-2.46, respectively). CONCLUSIONS: CgA is a pro-hormone, precursor of several active fragments likely to exert biological effects in chronic heart failure. CgA serum levels are increased in patients with chronic heart failure and are a predictive factor for mortality.

Relationship between cognitive impairment and clinical status in chronic heart failure patients.

BACKGROUND: In spite of its clinical importance, cognitive functioning is not always taken into account in studies on patients with chronic heart failure. The aim of the present study is to analyse the relationship between cognitive impairment and cardiovascular variables in a sample of patients with chronic heart failure for assessment or candidated for heart transplant. METHODS: Sixty-four male patients with chronic heart failure in NYHA class I-III, in a stable clinical condition, underwent cardiological evaluation and neuropsychological assessment by means of a wide battery of tests: Spinnler and Tognoni's tests and WAIS scale. RESULTS: Compared to the normative group, only 9% of patients did not have impairment in any cognitive function. 26% of patients had impairment of one cognitive function, and 30% of four or more cognitive functions. The cognitive functions that were most often impaired were short-term verbal memory, short-term visual spatial memory, differed verbal memory and verbal learning and visual spatial logical ability. On the whole, no statistical significant relationship was found between cognitive scores and the considered cardiovascular variables. CONCLUSIONS: Our data support the need to take into account the risk of cognitive impairment in CHF patients, regardless of age, disease severity or functional status. The high prevalence of short-term verbal memory impairment has important implications in clinical practice, since CHF patients should be actively involved in the medical management of their disease. Memory deficits could compromise patient's adherence to treatment as well as doctor-patient interactions. The practical consequences of these difficulties require some changes in doctors' behaviour and suggest the need for specific medical staff member training.

Functional and psychological recovery during intensive hospital rehabilitation following cardiac surgery in the elderly.

UNLABELLED: The recovery process in the elderly after cardiac surgery is influenced not only by clinical cardiac conditions, but also by comorbidity, cognitive decline and disability. We evaluated the relationship between clinical objective and self-perceived factors and their influence on functional recovery in 204 consecutive, over-70s pts who were admitted into an intensive hospital rehabilitation program following cardiac surgery. The variables taken into consideration were: comorbidity (Charlson index), length of hospital stay and complications in cardiac surgery and rehabilitation, disability (nursing needs score index), functional status (6-min walking test), left ventricular EF, number of training sessions, self-perceived health status (EuroQol questionnaire), emotional impairment (anxiety/depression, CBA-2.0/interview). RESULTS: Functional capacity: the distance walked was 198 +/- 103 m at admission and 287 +/- 121 m at discharge (p < 0.0001). Only the nursing needs score index resulted as a weak, independent predictor of the distance walked at admission (r2 = 0.14, p < 0.001, beta = 0-.21), which (beta = 0.49), together with complications during rehabilitation (beta = -0.15), self-perceived health status at discharge (beta = 0.15) and number of training sessions (beta = 0.20), was independently correlated with the distance walked at time of discharge (r2 = 050, p < 0.0001). Patients mood: anxiety correlated with depression. Emotional scores did not correlate with functional measures. Patients self-perceived health status: only the nursing needs score index was a weak, independent predictor of well-being at entry (r2 = 0.15, p < 0.0001, beta = -0.29), which, in turn, was the only predictor of perception at discharge (r2 = 0.33, p < 0.0001, beta = 0-.42). CONCLUSIONS: In an intensive hospital rehabilitation program following cardiac surgery in patients over 70 a) there was no correlation between clinical and psychological variables; b) anxiety and depression were associated, but neither influenced the recovery process nor correlated to health status perception; c) functional impairment was strongly influenced by nursing needs which also affected the self-perceived health status; d) both functional and perception recovery were influenced by disability at time of admission and reacted positively after rehabilitation.

[Educating and communicating: non-pharmacologic treatment for patients with chronic heart failure?]. / Educare e comunicare: terapie non farmacologiche per il paziente con scompenso cardiaco cronico?

Chronic heart failure shows an increasing prevalence and extremely high rate of both hospital admission and readmission. Thus, in recent years there has been a growing interest in the development of more effective strategies for disease management. The existing literature shows programs involving multidisciplinary teams, specialized clinics, that employ a systematic approach and provide continuity of care, frequently involving a specialized nurse dedicated to comprehensive management. These experiences reported a favourable effects on clinically relevant outcome, including readmission, quality of care and cost of care. A recent randomized trial conducted by Krumholtz and colleagues emphasises the importance of patient's education and support intervention, without medical management components. This model was effective in reducing readmissions and in-hospital costs. On the basis of these data, patients education and support should be considered a "non-pharmacological therapy" for heart failure patients.

[Communication between physician and patient with chronic heart decompensation may help to reach the therapeutic objectives. How to make it efficient]. / La comunicazione tra medico e paziente con scompenso cardiaco cronico può aiutare ad ottenere gli obiettivi terapeutici. Come renderla efficace?

In the management of chronic heart failure there is increasing evidence that effective communication with the patient is an important tool in health care since it permits the achievement of therapeutic goals and the patient's satisfaction in terms of the quality of health assistance received. In fact, the variations in the communication processes relevantly influence the results in some behaviors and attitudes of the patient, such as adherence to the therapeutic prescriptions, understanding and remembering the information received, satisfaction with the medical examination and less worry. The capacity of the patient of co-administering the illness may result in a reduction in the instability due to avoidable concomitant factors, and thus reduce the heart failure morbidity and rehospitalization rate. Building up an effective doctor-patient relationship becomes an important goal to achieve, and the necessary instruments are not only instinctive or the result of experience, but can also be taught and learnt. The aim of this work was to give a contribution, which, in addition to underlining the theoretic aspects of the communicative process by means of numerous examples taken from everyday practice in patient management, is to induce reflection and to propose ways of intervention for the improvement of the therapeutic relationship between the cardiologist and the patient with heart failure.

Chronic infusion of dobutamine and nitroprusside in patients with end-stage heart failure awaiting heart transplantation: safety and clinical outcome.

BACKGROUND: in patients with severe heart failure additional therapeutic support with intravenous inotropic or vasodilator drugs is frequently employed in an attempt to obtain hemodynamic and clinical control. No data comparing the use and efficacy of chronic intravenous inotropic and vasodilator therapy in patients with advanced heart failure are available. AIMS: we evaluated, in a group of patients with advanced heart failure undergoing chronic infusion with dobutamine or nitroprusside, in addition to optimized oral therapy, (1) the safety of chronic infusion, (2) the efficacy of both drugs in managing unloading therapy and (3) clinical outcome of the two therapeutic strategies. METHODS: one hundred and thirteen patients receiving optimized oral therapy, in functional class III/IV with symptoms and signs of refractory heart failure and requiring additional pharmacological support with either intravenous dobutamine or nitroprusside were evaluated. Clinical and therapeutic management and clinical outcome of the two groups were considered. RESULTS: dobutamine was administered for 12 h/day for 20+/-23 days at a dosage of 7+/-3 microg/kg/min to 43 patients. The mean dose of nitroprusside was 0.76+/-0.99 microg/kg/min. The mean duration of use of this drug, administered as a 12-h/day infusion was 22+/-38 days. Nitroprusside infusion allowed greater doses of short-term ACE-inhibitors to be used compared to pre-infusion (ACE-inhibitor dose: 55+/-30 mg/day vs. 127+/-30 mg/day P<0.0001) and during dobutamine infusion (ACE-inhibitor dose: 85+/-47 mg/day vs. 127+/-30 mg/day P<0.002). Nitroprusside unlike dobutamine significantly improved the NYHA functional class. Of the 113 patients, 109 (97%) had a cardiac event during a mean follow-up of 337+/-264 days. Forty-four patients required hospitalization for worsening congestive heart failure, 45/113 (39%) patients died during the follow-up and 27/113 (24%) patients had a heart transplant in status one. Hospitalization, because of worsening heart failure was less frequent in the nitroprusside than in the dobutamine subgroup [29/51 (57%) vs. 19/22 (86%) P<0.02]. The overall mortality was 28% (20/70) in the nitroprusside group and 58% (25/43) in the dobutamine group (odds ratio 0.33 CI 0.16 to 0.73 P<0.006). In the group treated with nitroprusside, heart transplantation in status one was performed in 16/33 patients (48%), while in the dobutamine group this was done in 11/14 patients (78%) (odds ratio 0.25 CI 0.06-1.02 P<0.06). There was a significant reduction in the combined end-point of mortality/heart transplantation in status one in patients treated with nitroprusside compared to those treated with dobutamine (36/70 (51%) vs. 36/43 (84%) - (odds ratio 0.34 CI 0.14-0.80 P<0.01). The incidence of adverse events in the patients treated with nitroprusside was similar to that in those treated with dobutamine (20% vs. 17% P=ns). CONCLUSIONS: for patients awaiting heart transplantation chronic intermittent nitroprusside infusions are more effective and safer than dobutamine in relieving symptoms, facilitating unloading therapy management and improving survival. Whether chronic intermittent infusion of nitroprusside could represent a feasible medical strategy in out-patients with severe heart failure remains to be investigated.

Precipitating factors and decision-making processes of short-term worsening heart failure despite "optimal" treatment (from the IN-CHF Registry).

This study sought to prospectively assess which factors were related to short-term worsening heart failure (HF) leading to or not to hospital admission, in long-term outpatients followed by cardiologists. The subsequent decision-making process was also analyzed. The study population consisted of 2,701 outpatients enrolled in the registry of the Italian Network on Congestive Heart Failure (IN-CHF) and followed by 133 cardiology centers (19% of all existing Italian cardiology centers). Clinical and follow-up data were collected by local trained clinicians; 215 patients (8%) had short-term decompensation (on average 2 months after the index outpatient visit). Multivariate analysis showed that previous hospitalization, long duration of symptoms, ischemic etiology, atrial fibrillation, higher functional class (New York Heart Association classification III to IV), higher heart rate, and low systolic blood pressure were independently associated with HF destabilization. Poor compliance (21%) and infection (12%) were the most frequent precipitating factors, but a precipitating factor was not identified in 40% of the patients. Poor compliance was more common in women, but no other clinical characteristics emerged as being related with a specific precipitating factor. Fifty-seven percent of the patients with a short-term recurrence of worsening HF required hospital admission; infusion treatment with inotropes and/or vasodilators was necessary in 19% of them. Long-term therapy was changed in 48% of the patients. Thus, in ambulatory HF patients, short-term worsening HF can be predicted according to the clinical characteristics on an outpatient basis. Nearly 1/3 of precipitating factors can be prevented. Patient education and avoidance of inappropriate treatment may reduce the number of relapses.

Six-minute walking performance in patients with moderate-to-severe heart failure; is it a useful indicator in clinical practice?

AIMS: The 6-min walk test has been incorporated into studies on the efficacy of new therapies and into prognostic stratification for chronic heart failure patients. Firm conclusions on the usefulness of the test in clinical practice are still lacking. The aim of this study was to investigate (1) the correlation between walk test performance and standard indices of cardiac function and exercise capacity, and (2) the prognostic value of the walk test with respect to peak VO2 and NYHA class. METHODS AND RESULTS: Three hundred and fifteen chronic heart failure patients (age: 53+/-9 years, NYHA class: II (182), III (133)) underwent a functional evaluation and a 6-min walk test. Of these, 270 were followed-up for a minimum of 6 months (mean 387+/-177 days). Walked distance was 396+/-92 m. There was no significant correlation between distance walked and central haemodynamic data. Functional capacity, as measured by ergometry, correlated moderately with distance walked (duration: r=0.48, peak VO2: r=0.59, anaerobic threshold: r=0.54; all P<0.001). During follow-up, 46 patients died from cardiovascular causes and 12 were urgently transplanted. Either of these events were considered end points of the study. Survival analysis was performed from a continuous walk test and peak VO2 measurements or after categorization of (a) quartile segmentation, (b) cut-off points from the literature and (c) thresholds from receiver operating characteristic curves. At univariate survival analysis (Cox regression), the association of the walk test with survival was of significance (P=0.03, continuous variable), or borderline significance (0.05< or =P< or =0.1, after categorization). Peak VO2 was always significant, independent of the scale used (0.005< or =P< or =0.03). The strongest association was found for NYHA class (P<0.001), which showed the highest sensitivity and specificity for the prediction of the event (0.64 and 0.65, respectively). When walk test performance, continuous or categorized, was entered into a multivariate model with NYHA class or peak VO2, it lost any significant association with survival (P>0.76 in all models with NYHA class and P>0.27 in all models with peak VO2). CONCLUSION: In moderate-to-severe chronic heart failure patients, the 6-min walk test is not related to cardiac function and only moderately related to exercise capacity. Walking performance does not provide prognostic information which can complement or substitute for that provided by peak VO2 or NYHA class. Hence the test is of limited usefulness as a decisional indicator in clinical practice.

[Arrhythmia risk stratification in patients with heart failure. Foreword]. / La stratificazione del rischio aritmico nei pazienti con scompenso cardiaco. Premessa.

The challenge of preventing arrhythmic sudden death is one of the major issues of today's treatment of heart failure. To pursue this aim, an accurate selection of candidates for sudden death has to be routinely carried out, while a maximized and individualized drug treatment has to be extensively administered in all high-risk selected patients. However, in clinical practice there is no agreement on the selection criteria of sudden death risk, particularly in patients with advanced heart failure. Furthermore, the real impact of each category of drugs in reducing the risk of sudden death in heart failure patients is still under debate. As far as non-pharmacological options are concerned, implantable cardioverter-defibrillators (ICD) have been demonstrated to be the most effective therapy in patients with prior cardiac arrest due to ventricular fibrillation or poorly tolerated ventricular tachycardia. Low left ventricular ejection fraction, unsustained ventricular tachycardia and inducibility at electrophysiological study also may identify high-risk patients requiring ICD implantation. However, such a stratification seems to be effective in ischemic more than in non-ischemic patients, while generally the primary prevention of sudden death is still restricted to a minority of patients. Biventricular pacing has been proven to be effective in optimizing left ventricular function in more than 50% of left bundle branch block and advanced heart failure patients, while further studies are needed to evaluate the real impact of cardiac resynchronization therapy on hard endpoints, such as survival and long-term clinical outcome. Therefore, the selection criteria of "responders" to this novel non-pharmacological therapy still have to be defined. There is convincing evidence in the literature that tailored drug therapy can be highly effective in preventing heart failure progression as well as in reducing total and sudden mortality. Nevertheless, prevention of sudden death is still a debated point in heart failure treatment. For this reason, we aimed to provide heart failure specialists with updated reviews on this topic, such as those published in this issue of the Italian Heart Journal Supplement. Therefore, we are proud to present all the authors who contributed with the high quality of their articles to this editorial effort. Obviously, we have to thank the authors, but we also have to address the readers, thanking them in advance for their interest in such an initiative.

Reproducibility of the six-minute walking test in chronic heart failure patients.

The six-minute walking test (WT) is used in trials and clinical practice as an easy tool to evaluate the functional capacity of chronic heart failure (CHF) patients. As WT measurements are highly variable both between and within individuals, this study aims at assessing the contribution of the different sources of variation and estimating the reproducibility of the test. A statistical model describing WT measurements as a function of fixed and random effects is proposed and its parameters estimated. We considered 202 stable CHF patients who performed two baseline WTs separated by a 30 minute rest; 49 of them repeated the two tests 3 months later (follow-up control). They had no changes in therapy or major clinical events. Another 31 subjects performed two baseline tests separated by 24 hours. Collected data were analysed using a mixed model methodology. There was no significant difference between measurements taken 30 minutes and 24 hours apart (p = 0.99). A trend effect of 17 (1.4) m (mean (SE)) was consistently found between duplicate tests (p < 0.001). REML estimates of variance components were: 5189 (674) for subject differences in the error-free value; 1280 (304) for subject differences in spontaneous clinical evolution between baseline and follow-up control, and 266 (23) for the within-subject error. Hence, the standard error of measurement was 16.3 m, namely 4 per cent of the average WT performance (403 m) in this sample. The intraclass correlation coefficient was 0.96. We conclude that WT measurements are characterized by good intrasubject reproducibility and excellent reliability. When follow-up studies > or = 3 months are performed, unpredictable changes in individual walking performance due to spontaneous clinical evolution are to be expected. Their clinical significance, however, is not known.

Your cardiac patient wants to become a mother. Risk considerations and advice Part I--your cardiac patient asks advice on a possible pregnancy.

In this part, the risks and complications of pregnancy in women with active or corrected, congenital or acquired heart disease are reviewed, in order to allow individual counseling on a possible pregnancy or treatment recommendations on contraception.

Your cardiac patient wants to become a mother. Risk considerations and advice. Part II--Your cardiac patient is pregnant.

In this part the most updated indications for evidence-based counseling of cardiac patients during pregnancy, labor and the postpartum period are reviewed. Moreover, indications and contraindications for the use of some cardiac drugs during pregnancy and lactation are provided.

Does in-patient ECG monitoring have an impact on medical care in chronic heart failure patients?

BACKGROUND: Heart failure patients' management in non-intensive care units might be improved by telemetry monitoring. However, telemetry adds the cost and evidence of this effectiveness is not available. AIM: To evaluate the utility of the ECG monitoring in chronic heart failure patients admitted to a non-intensive care unit. METHODS: A prospective analysis of the utility of telemetry in 711 patients admitted to a Heart Failure Unit from March 1996 to September 1997. RESULTS: One hundred and ninety-nine patients underwent telemetry; 108 telemetry findings were recorded, in 35% of NYHA class II, in 46% in NYHA class III-IV and 43% in unstable patients. Reasons for telemetry were: known arrhythmia (n=82), electrolytes disturbances (n=20), atrial fibrillation (n=12), symptoms (n=48), i.v. dobutamine (n=13), drugs control (n=16), devices control (n=8). Crossing reasons for telemetry and detected events we had, respectively, 63, 11, 2, 17, 5, 6, and 0 telemetry findings. Treatment was guided by telemetry results in only 33 cases (respectively in 18, 0, 4, 5, 5, 1, and 0 cases). Physicians perceived telemetry as unhelpful in 30% of cases; as helpful in 70%. The percentage of inutility, usefulness with and without related medical intervention were similar between stable and unstable patients (30, 18, 51% and 31, 15, 54%, respectively). CONCLUSION: In a heart failure unit ECG monitoring is mostly used in severe and unstable patients. However, medical decisions are rarely guided by the telemetry findings. The usefulness of telemetry might be underestimated because one of the uncounted results might be the avoidance of inappropriate intervention.

Comparison of one-year outcome in women versus men with chronic congestive heart failure.

Using information from the Italian Network on Congestive Heart Failure, we examined whether clinical epidemiologic characteristics, drug prescription patterns, and outcome of patients with congestive heart failure differed according to sex and whether gender was an independent risk factor for mortality and hospital admissions.