Validation of the ELAN-HF Score and self-care behaviour on the nurse-led heart failure clinic after admission for heart failure.

AIM: To validate the predictive value of the European coLlaboration on Acute decompeNsated Heart Failure (ELAN-HF) score, and to assess the effect of self-care behaviour on readmission and mortality in patients after admission with acute decompensated heart failure (ADHF). DESIGN: Quantitative, prospective, single centre, cohort study. METHODS: N-Terminal pro-B-type natriuretic peptide (NT-proBNP) levels were measured on admission and discharge, and were used together with clinical and laboratory parameters to calculate the ELAN-HF score. Patients were stratified into four risk groups (low, intermediate, high, very high) according to their ELAN-HF score. The performance of the ELAN-HF score was evaluated and compared to the original study. Self-care behaviour was assessed by the European Heart Failure Self-care Behaviour Scale (EHFScBS-9). Survival analysis was used to estimate the association between both scores and re-admission for HF and/or all-cause mortality within 180 days. RESULTS: 88 patients were included. The median age of the study population was 75 years (IQR 69-83), 43% was female. NYHA III/IV functional class was present at discharge in 68 patients (85%) and 27 patients (34%) had a left ventricular ejection fraction < 40%. Complete data and 180 day follow up was available for 80 patients. 55% reached the endpoint of readmission and/or all-cause mortality. There was a significant association between the ELAN-HF score and re-admission and/or mortality < 180 days (HR = 1.25, 95% CI 1.08-1.45, p = 0.003). The median EHFScBS-9 score was 68.1 (IQR 58.3 - 77.8). There was no significant association between the EHFScBS-9 score and readmission and/or mortality < 180 days (HR = 1.01, 95% CI 0.99-1.03, p = 0.174). CONCLUSION: This study confirms the validity and therefore the potential of the ELAN-HF score to triage patients with ADHF before discharge. Using this score may optimize the follow-up treatment on the nurse-led heart failure clinic in order to decrease readmission and mortality. Self-care behaviour was non-significantly associated with readmission and/or mortality in our study population. TRIAL REGISTRATION: This study has been registered with the ethics committee MEC-U (Nieuwegein, The Netherlands), registration nr: V.160999/W18.208/HG/mk.

The Influence of End-of-Life Care on Organ Donor Potential.

Many patients with acute devastating brain injury die outside intensive care units and could go unrecognized as potential organ donors. We conducted a prospective observational study in seven hospitals in the Netherlands to define the number of unrecognized potential organ donors outside intensive care units, and to identify the effect that end-of-life care has on organ donor potential. Records of all patients who died between January 2013 and March 2014 were reviewed. Patients were included if they died within 72 h after hospital admission outside the intensive care unit due to devastating brain injury, and fulfilled the criteria for organ donation. Physicians of included patients were interviewed using a standardized questionnaire regarding logistics and medical decisions related to end-of-life care. Of the 5170 patients screened, we found 72 additional potential organ donors outside intensive care units. Initiation of end-of-life care in acute settings and lack of knowledge and experience in organ donation practices outside intensive care units can result in under-recognition of potential donors equivalent to 11-34% of the total pool of organ donors. Collaboration with the intensive care unit and adjusting the end-of-life path in these patients is required to increase the likelihood of organ donation.

Prolonged use of extracorporeal membrane oxygenation combined with prone positioning in patients with acute respiratory distress syndrome and invasive Aspergillosis.

Extracorporeal membrane oxygenation (ECMO) is increasingly being used in patients with severe acute respiratory distress syndrome. In two large cohorts of such patients, the median duration of treatment with ECMO was 9 and 10 days. We describe two patients, both with H1N1 pneumonia complicated by invasive Aspergillosis, who required ECMO support significantly longer at 45 and 52 days, but eventually made a full recovery. In both patients, prone positioning was used during ECMO treatment.

Acute myocardial infarction complicating subarachnoid haemorrhage.

An acute myocardial infarction is a rare complication of a subarachnoid haemorrhage. The combination of these two conditions imposes important treatment dilemmas. We describe two patients with this combination of life-threatening conditions. Patient 1 was treated with emergency percutaneous coronary intervention followed by clipping of the anterior communicating artery aneurysm. Six months after discharge the patient's memory and orientation had almost completely recovered. Patient 2 was treated with aspirin until coiling of the aneurysm could be performed. After successful coiling low-molecular-weight heparin was added. One week later the patient died due to a free wall rupture. (Neth Heart J 2009;17:284-7.).

Arrhythmogenic right ventricular cardiomyopathy: asymptomatic to life threatening as illustrated by the cases of two sisters.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a heart muscle disorder of unknown cause that is characterised by fibrofatty replacement, primarily of the right ventricular myocardium, which can lead to life-threatening arrhythmias. It is a disease with a very diverse phenotype. In the present article we describe two sisters, each with a different manifestation of this disorder. The first patient died suddenly at the age of 18 during exercise. Her 17-year-old sister did not have any abnormalities at first cardiac consultation, but a few years later she met several diagnostic criteria for ARVC and an internal cardioverter defibrillator was implanted. Genetic analysis identified a mutation in the plakophilin- 2 (PKP2) gene. Cardiac evaluation of a third sister did not reveal any abnormalities and no mutation in the PKP2 gene was found. Thus, ARVC can vary in its clinical presentation, not only between siblings but also in time. This raises difficulties for the physician for diagnosis, treatment and followup. It is important for the physician involved to consider this disease in patients with palpitations and syncope, especially when there is a family history of ARVC or unexplained sudden death. (Neth Heart J 2007;15:348-53.).

Unmasking accessory pathway conduction due to AV block following tricuspid valve replacement.

Atrioventricular block during radiofrequency (RF) ablation of an accessory pathway may be due to inadvertent RF damage or catheter pressure to the conduction system, or a pre-existent conduction defect. Conversely, block in the normal conduction system may unmask pre-excitation. We describe a case where total infra-Hisian block complicated tricuspid valve surgery, unmasking a hitherto undiagnosed left lateral accessory pathway.

Clinical efficacy of the use of information technology in cardiology: initial results of angiographic teleconsultation in the Netherlands.

BACKGROUND: With the increasing use of cineless diagnostic angiography laboratories, modern telecommunication networks provide an excellent opportunity to transfer dynamic cardiac catheterisation images from a referring centre to a cardiac intervention centre. This electronic data transfer may lead to improved patient care and reduced waiting times. METHODS: Two departments of cardiology started a pilot project using a digital ISDN-30 point-to-point data-line connection between Alkmaar and Amsterdam over which MPEG compressed angiograms are sent. The network consists of a PC based client/server structure and two ISDN modular routers. RESULTS: From June 1998 to January 2001, 127 patients were referred for urgent PTCA or CABG using this network. All patients were admitted to the CCU for unstable angina and had a suitable anatomy for coronary angioplasty or coronary artery bypass surgery. In all cases the MPEG compressed images were successfully stored on the server and could be accessed in Amsterdam. During the pilot phase all X-ray runs (11 + 3) were sent. Following transmission, all patients were accepted for intervention. Review of the DICOM images from the CD-Medical immediately before the PTCA or CABG did not change the planned strategy. The patients were successfully treated 1 to 2 days after data transmission. During this phase, the average variable costs of this network was € 5.90 per patient as opposed to € 69.00 when using a courier service. CONCLUSION: This study shows that personal computer-based telecommunication network systems are feasible for clinical use in daily practise. Access to a remotely located cardiac intervention centre can be achieved promptly at low costs and improves patient care by reducing waiting times.

Inefficient ventilation and reduced respiratory muscle capacity in congestive heart failure.

The extent and time-course of changes in lung volumes, ventilatory efficiency at rest and during exercise, and respiratory muscle function and their influence on exercise limitation in congestive heart failure (CHF) are unclear. It is unknown whether respiratory muscle function may predict changes in exercise limitation or may be impaired in patients with poor outcome. 145 male patients (54 +/- 1 years) suffering from CHF (NYHA class I-III, mean 2.3 +/- 0.1), with a LVEF of 23 +/- 1%, and a mean peak O2 uptake (VO2peak) 15.0 +/- 0.5 mL X min(-1) X kg(-1), were studied. They were grouped in Weber functional classes A to D according to their VO2peak. Significant increases in ventilatory equivalents for O2 and CO2 (VE/VCO2peak) and in dead space ventilation at rest and during exercise were found with increasing exercise limitation. Moreover, there was a correlation of static and dynamic lung volumes (inspiratory vital capacity, IVC, r = 0.43, P < 0.01), as well as of maximal inspiratory pressure (MIP; r = 0.46, P < 0.01) with VO2peak. Patients who died (n = 26) or were heart transplanted (n = 20) during a follow-up (mean 800 +/- 10 days) had a reduced MIP (6.4 +/- 0.4 kPa) as compared with survivors (n = 82; 9.3 +/- 0.7 kPa, P < 0.01). In a subgroup of 33 patients re-evaluated after six months, individual changes in IVC and VE/CO2peak, but not in MIP, correlated to changes in VO2peak (r = 0.69 and r = 0.72 respectively; P < 0.01). In CHF, exercise limitation is associated with reversible lung restriction and inefficient ventilation at rest and during exercise. Patients with severe CHF have a significant reduction in MIP, a finding that is associated with poor outcome.