A health perception score predicts cardiac events in patients with heart failure: results from the IMPRESS trial.

BACKGROUND: New York Heart Association (NYHA) class and treadmill exercise test variables are widely used for estimating prognosis and measuring the outcomes of treatment in patients with heart failure, but they do not take patients' perceptions into account. METHODS AND RESULTS: Five hundred forty-five patients enrolled in a multicenter 24-week comparison of the effects of omapatrilat and lisinopril on functional capacity in patients with heart failure reported a visual analog scale (VAS) score of their overall health perception at week 12 of the study. A total of 27 first events, defined as death or worsening heart failure (hospitalization, emergency room visit, or study discontinuation), occurred in the subsequent 12 weeks. The mean (+/-SD) health perception scores were 0.43 +/- 0.31 and 0.68 +/- 0.20 in patients with and without events, respectively (P =.0006). The risk ratio (RR) for an event associated with a decile change in the health perception score was 0.74 (95% confidence interval [CI], 0.61-0.88; P =.001). The RR was unaltered by adjustment for demographic variables, treadmill time, and NYHA functional class. Although the week 12 NYHA functional class was predictive of events (RR = 2.1; 95% CI, 1.2-4.6; P =.04), treadmill time was not (RR = 0.87; 95% CI, 0.73-1.03; P = 0.11). CONCLUSIONS: A patient-reported measure of perceived health predicts events in patients with heart failure.

Heart failure practice improvement effort in the outpatient setting: a health care financing administration initiative to improve the care of medicare beneficiaries with heart failure.

This column is the fourth in a series describing Health Care Financing Administration initiatives to improve care for Medicare beneficiaries with heart failure. The first three papers addressed the background, design, and baseline results of the Health Care Financing Administration national initiative to improve quality of inpatient care for heart failure through the activities of each state's Health Care Financing Administration contractor Peer Review Organization. This paper describes a smaller-scale but equally important endeavor: the Heart Failure Practice Improvement Effort, a pilot project to test the feasibility of assessing and improving heart failure care in the outpatient setting. (c)2001 by CHF, Inc.

Improving heart failure care in the office setting.

This column is the sixth in a series describing Health Care Financing Administration (HCFA) initiatives to improve care for Medicare beneficiaries with heart failure. The fourth column addressed the Heart Failure Practice Improvement Effort, HCFA's pilot project to test the feasibility of assessing and improving heart failure care in the outpatient setting through the activities of HCFA-contracted peer review organizations in eight states. This column is dedicated to illustrating the progress of the Heart Failure Practice Improvement Effort project at an individual state and practice level, focusing on the quality improvement activities in outpatient heart failure care conducted by the Colorado peer review organization. (c)2001 CHF, Inc.

Profiles of quality improvements in heart failure care.

The Health Care Financing Administration, with its National Heart Failure project, has made heart failure care one of its targets for quality improvement. Previous columns have highlighted the clinical and epidemiologic background for the National Heart Failure project. This column provides "real-world" examples of hospitals improving care for their heart failure patients. (c)2001 by CHF, Inc.

Lessons learned from the national heart failure project: a center for medicare and medicaid services initiative to improve the care of medicare beneficiaries with heart failure.

This column is the seventh in a series reporting on the efforts of the Center for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration, to improve care for Medicare beneficiaries with heart failure. In previous columns we have described the overall structure of Medicare quality improvement efforts, detailed the structure of the national inpatient fee-for-service program known as the National Heart Failure project, and discussed the baseline quality indicator rates for the project, which are focused on rates of ejection fraction documentation and angiotensin-converting enzyme inhibitor prescription. In more recent columns, we reported on quality improvement projects from several participating hospitals, and on a pilot project exploring quality improvement efforts for heart failure based in physicians' offices. This column will focus on ways in which systematic examination of data, such as those from the National Heart Failure project, might shape future quality improvement and research efforts. The National Heart Failure project's quality indicator data are collected primarily to guide and evaluate the efforts of the CMS contractor peer-review organizations to facilitate quality improvement efforts in hospitals throughout the United States. (c)2001 CHF, Inc.

Influencing care in acute myocardial infarction: a randomized trial comparing 2 types of intervention.

The purpose of this study was to evaluate performance feedback delivered by on-site presentations compared to mailed feedback on improving acute myocardial infarction (AMI) care. We used a randomized trial including 18 hospitals nested within the Cooperative Cardiovascular Project. Patients comprised AMI Medicare patients admitted before (n = 929, 1994 and 1995) and after intervention (n = 438, 1996). Control hospitals received written feedback by mail. The experimental intervention group received a presentation led by a cardiologist and a quality improvement specialist. We assessed the proportion of patients receiving appropriate AMI care before and after the intervention. Both univariate and multivariate analyses demonstrated no effect of the intervention in increasing the proportion of patients who received reperfusion, aspirin, beta-blockers, or angiotensin-converting enzyme inhibitors. On-site feedback presentations were not associated with a larger improvement in AMI care compared to the mailed feedback. Other interventions, such as opinion leaders and patient-directed interventions, may be necessary in order to improve the care of AMI patients.

Medicare initiatives to improve heart failure care: an introduction.

Purchasers of health care, patients, physicians, and other health care professionals are increasingly seeking to evaluate quality of health care. Scattered reports have suggested that there is currently marked variation in evaluation and treatment of heart failure and substantial gaps between guideline recommendations and care delivered to heart failure patients. Heart failure is the most common discharge diagnosis for Medicare beneficiaries and yet, until recently, relatively little national information was available to describe the quality of care and to identify opportunities to improve practice. To address the need to evaluate care of patients with heart failure and support national, state, and local efforts to improve care and outcomes, the Health Care Financing Administration has initiated three programs that stretch across much of the continuum of care: the National Heart Failure Quality Improvement Project, focusing on inpatient care; the Heart Failure Practice Improvement Effort (HF PIE), a pilot outpatient effort in 11 states; and the 2001 requirement for Medicare+Choice Organizations to initiate quality improvement efforts for their heart failure patients. This paper is the first in a series that will provide information about these programs. We hope that this series will stimulate discussion on how clinicians can join these national efforts to improve the care and outcomes of patients with heart failure. (c)2000 by CHF, Inc.

The National Heart Failure Project: a health care financing administration initiative to improve the care of Medicare beneficiaries with heart failure.

This is the second in a series describing Health Care Financing Administration (HCFA) initiatives to improve care for Medicare beneficiaries with heart failure. The first article outlined the history of HCFA quality-improvement projects and current initiatives to improve care in six priority areas: heart failure, acute myocardial infarction, stroke, pneumonia, diabetes, and breast cancer. This article details the objectives and design of the Medicare National Heart Failure Quality Improvement Project (NHF), which has as its goal the improvement of inpatient heart failure care. (c)2000 by CHF, Inc.

Prevalence of depression in congestive heart failure.

Patients with congestive heart failure had higher scores than control subjects using a case-finding instrument for depression; such patients also were more likely to exceed the diagnostic threshold for depression with this instrument. Identification and treatment of depressed CHF patients may significantly improve level of functioning in these patients.

Patient preferences for heart failure treatment: utilities are valid measures of health-related quality of life in heart failure.

BACKGROUND: Current standards hold that cost-effectiveness analyses should incorporate measures of both quantity and quality of life, and that quality of life in this context is best measured by a utility. We sought to measure utility scores for patients with heart failure and to assess their validity as measures of health-related quality of life (HRQL). METHODS AND RESULTS: We studied 50 patients with heart failure. We measured utilities with the time trade-off technique, exercise capacity with a 6-minute walk test, and HRQL with the Minnesota Living With Heart Failure questionnaire, the Medical Outcomes Study Short Form-36 (SF-36) questionnaire, and a visual analogue score. Validity was assessed by establishing correlation between utilities and these other measures. Mean utility score was 0.77 +/- 0.28. There were significant (P < .05) curvilinear relationships between utility score and visual analogue score, the physical function summary scale of the SF-36, 6-minute walk distance, and the Living With Heart Failure score. Utility scores on retest at 1 week were unchanged in a subset of 12 patients. Utilities did not vary systematically with age, sex, or ethnicity. CONCLUSION: Utilities are valid measures of HRQL in patients with heart failure, and cost-effectiveness analyses of heart failure treatments incorporating utilities in the outcome measure can be meaningful.

Deletion polymorphism of the angiotensin converting enzyme gene is associated with an increase in left ventricular mass in men with type 2 diabetes mellitus.

Previous studies evaluating the angiotensin converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism have revealed that expression of the DD genotype is associated with an increase in myocardial infarction, cardiomyopathy, and left ventricular (LV) mass in nondiabetic patients. In the present study, a cross-sectional analysis was performed to evaluate the potential relationship between the ACE I/D genotypes and the LV mass index in 289 non-insulin-dependent diabetes mellitus (NIDDM) subjects without known coronary artery disease. Two dimensional directed M-mode echocardiograms along with selected patient characteristics were obtained from the study population. The distribution of the I/D polymorphism was as follows: 63 were II (22%), 137 were ID (47%), and 89 were DD (31%). Univariately, the DD genotype was associated with an increase in LV mass in men but not in women. When subjected to a multiple regression model that included age, systolic blood pressure, duration of diabetes, duration of hypertension, presence of the black race, and the presence of the DD genotype, the DD genotype was independently associated with an increase in the LV mass index with a parameter estimate of 10.5 g/m2 (95% CI = 3.9, 17.0; P < .002) in the male subjects. Thus, in this NIDDM study population, male patients with the DD genotype are independently associated with an increased LV mass.

Primary prevention of CHD: nine ways to reduce risk.

Lowering cholesterol can reduce the incidence of coronary heart disease. Treating hypertension reduces overall mortality and is most effective in reducing the risk of coronary heart disease in older patients. Smoking cessation reduces the level of risk to that of nonsmokers within about three years of cessation. Aspirin is likely to be an effective means of primary prevention, but a group in whom treatment is appropriate has yet to be defined. Evidence that supplementation with vitamin A or C reduces the risk of coronary heart disease is inadequate; the data for use of vitamin E are inconclusive. Epidemiologic evidence is sufficient to recommend that most persons increase their levels of physical activity. Lowering homocysteine levels through increased folate intake is a promising but unproven primary prevention strategy. Hormone replacement therapy was associated with reduced incidence of coronary heart disease in epidemiologic studies but was not effective in a secondary prevention trial.

Dose-related beneficial long-term hemodynamic and clinical efficacy of irbesartan in heart failure.

OBJECTIVES: The primary purpose of this study was to determine the acute and long-term hemodynamic and clinical effects of irbesartan in patients with heart failure. BACKGROUND: Inhibition of angiotensin II production by angiotensin-converting enzyme (ACE) inhibitors reduces morbidity and mortality in patients with heart failure. Irbesartan is an orally active antagonist of the angiotensin II AT1 receptor subtype with potential efficacy in heart failure. METHODS: Two hundred eighteen patients with symptomatic heart failure (New York Heart Association [NYHA] class II-IV) and left ventricular ejection fraction < or = 40% participated in the study. Serial hemodynamic measurements were made over 24 h following randomization to irbesartan 12.5 mg, 37.5 mg, 75 mg, 150 mg or placebo. After the first dose of study medication, patients receiving placebo were reallocated to one of the four irbesartan doses, treatment was continued for 12 weeks and hemodynamic measurements were repeated. RESULTS: Irbesartan induced significant dose-related decreases in pulmonary capillary wedge pressure (average change -5.9+/-0.9 mm Hg and -5.3+/-0.9 mm Hg for irbesartan 75 mg and 150 mg, respectively) after 12 weeks of therapy without causing reflex tachycardia and without increasing plasma norepinephrine. The neurohormonal effects of irbesartan were highly variable and none of the changes was statistically significant. There was a significant dose-related decrease in the percentage of patients discontinuing study medication because of worsening heart failure. Irbesartan was well tolerated without evidence of dose-related cough or azotemia. CONCLUSIONS: Irbesartan, at once-daily doses of 75 mg and 150 mg, induced sustained hemodynamic improvement and prevented worsening heart failure.

Determinants of mortality in elderly patients with heart failure: the role of angiotensin-converting enzyme inhibitors.

BACKGROUND: Despite randomized controlled trials demonstrating mortality reduction, many studies have documented persistent low rates of prescription of angiotensin-converting enzyme inhibitors (ACE-I) in patients with heart failures; the reasons for this pattern remain poorly defined. In addition, some authors have argued that the results of carefully controlled clinical trials do not translate well into the uncontrolled world of clinical practice, and the mortality benefits of ACE-I may not extend into special populations such as the elderly. OBJECTIVES: To understand the reasons for failure to prescribe ACE-I to Medicare patients with heart failure and to assess the impact of this failure on mortality. METHODS: We obtained data by reviewing charts of Medicare patients discharged from 7 Colorado hospitals with a diagnosis of heart failure during 1994. RESULTS: We identified a diagnosis of heart failure in 1016 patients without a contraindication to ACE-I. Three hundred seventy-eight of these patients were receiving ACE-I at the time of admission. Of the 638 remaining, 257 had their left ventricular systolic function assessed and 92 had diminished function. Of these 92, 50 (54.3%) were discharged on a regimen of ACE-I. The only significant difference in baseline comorbidity or demographic variables between those given and those not given ACE-I was that patients not prescribed ACE-I were older. Using multivariate analysis, younger age and cardiology consultation predicted ACE-I prescription (P = .02). By life-table analysis, mortality at 1 year following discharge from the index hospitalization was lower in those treated with ACE-I than in those not so treated (P = .03). The Deyo index of comorbidity, prescription of an ACE-I, site of treatment, and presence or absence of cardiology consultation were significantly associated with 1-year mortality by multivariate analysis (P<.001). CONCLUSIONS: Underinvestigation and undertreatment of chronic heart failure persists. Failure to treat elderly patients with ACE-I is associated with a mortality that appears to be greater than that seen in the placebo arms of large clinical trials of ACE-I therapy. Within the population studied, older patients are less likely to be treated. Failure of age to significantly add to prediction of mortality implies that the apparent bias against treating older patients with chronic heart failure with ACE-I is not justified. Because mortality is dependent on provider and site of treatment, further reductions in mortality from chronic heart failure may require intensive and selective local efforts, or development of regional heart failure centers.

Endothelium-dependent vasorelaxation is impaired in cocaine arteriopathy.

OBJECTIVES: This study sought to assess endothelium-dependent vasorelaxation in long-term users of cocaine. BACKGROUND: Cocaine use has been associated with myocardial infarction, stroke and intestinal infarction. Previously demonstrated effects of the drug, including increased heart rate and blood pressure and increased vascular tone, do not explain the sporadic nature of these vascular events or the occurrence of ischemia remote from acute administration. Abnormal endothelial function could contribute to focal vasospasm and thrombosis and predispose to premature atherosclerosis, all of which have been demonstrated in cocaine users with myocardial infarction. METHODS: Using plethysmography, we studied the change in forearm blood flow in response to intraarterial acetylcholine and nitroprusside in 10 long-term cocaine users and 13 control subjects of similar age who had not used cocaine; sample size was based on a 70% power to detect a 20% reduction in flow with acetylcholine between subjects and control subjects. Using graded doses of intracoronary acetylcholine (from 10(-9) to 10(-6) mol/liter), we studied a second group of 10 cocaine users with angiographically normal or near-normal arteries. RESULTS: Mean forearm blood flow during acetylcholine infusion was significantly lower in cocaine users than in control subjects (p = 0.02). During nitroprusside infusion, there was no difference (p = 0.2) between cocaine users and control subjects. Cigarette smoking did not explain the differences between cocaine users and control subjects. Acetylcholine elicited coronary vasoconstriction in 8 of 10 subjects. CONCLUSIONS: We conclude that endothelium-dependent vasorelaxation is impaired in long-term users of cocaine.

Effect of risk factors on exercise capacity in NIDDM.

Exercise capacity has been used as a noninvasive parameter for predicting cardiovascular events. It is known that diabetic patients have an impaired exercise capacity when compared with nondiabetic age-matched control subjects, but the risk factors associated with this impairment have not been thoroughly analyzed. A total of 453 male and female NIDDM patients who underwent graded exercise testing with expired gas analysis were studied to determine the possible influences of demographic and cardiac risk factors on exercise capacity. Univariate and multiple linear regression analyses were performed on baseline patient characteristics with respect to peak oxygen consumption (VO2). In the regression analyses, African-American race was strongly associated with a decrease in peak VO2; the difference in means between African-Americans and other subjects for men was -2.50 ml.kg-1.min-1 (-4.28, -0.07, 95% CI) (P < 0.006) and for women was -2.96 ml.kg-1.min-1 (-4.45, -1.47) (P < 0.0002). Univariate analyses revealed that African-American subjects had increased prevalence, longer duration, and higher systolic and diastolic hypertension than the non-Hispanic and Hispanic whites. Other independent predictors of peak VO2 (reported as change in peak VO2 in milliliters per kilogram per minute) were BMI (men: -0.39 kg/m2 [-0.52, -0.29], P < 0.0001; women: -0.39 kg/m2 [-0.48, -0.31], P < 0.0001), age (men: -0.16/year [-0.23, -0.09], P < 0.0001; women: -0.17/year [-0.24, -0.11], P < 0.0001), baseline resting systolic blood pressure (men: -0.03/mmHg [-0.06, -0.01], P < 0.05; women: -0.03/mmHg (-0.06, -0.01)f1p4< 0.05), and pack-years smoking (men: -0.04/pack-years [-0.04, -0.01], P < 0.01; women: -0.04/pack-years [-0.07, -0.01], P < 0.0001). Thus, in this large NIDDM study, weight loss, smoking cessation, and aggressive blood pressure control, particularly in African-Americans with NIDDM, would appear to be important in improving exercise capacity and potentially improving the increased cardiovascular mortality associated with an impaired exercise capacity.