Effectiveness of out-patient based acute heart failure care: a pilot randomised controlled trial.

OBJECTIVES: Acute heart failure (AHF) hospitalisation is associated with 10% mortality. Outpatient based management (OPM) of AHF appeared effective in observational studies. We conducted a pilot randomised controlled trial (RCT) comparing OPM with standard inpatient care (IPM). METHODS: We randomised patients with AHF, considered to need IV diuretic treatment for ≥2 days, to IPM or OPM. We recorded all-cause mortality, and the number of days alive and out-of-hospital (DAOH). Quality of life, mental well-being and Hope scores were assessed. Mean NHS cost savings and 95% central range (CR) were calculated from bootstrap analysis. Follow-up: 60 days. RESULTS: Eleven patients were randomised to IPM and 13 to OPM. There was no statistically significant difference in all-cause mortality during the index episode (1/11 vs 0/13) and up to 60 days follow-up (2/11 vs 2/13) [p = .86]. The OPM group accrued more DAOH {47 [36,51] vs 59 [41,60], p = .13}. Two patients randomised to IPM (vs 6 OPM) were readmitted [p = .31]. Hope scores increased more with OPM within 30 days but dropped to lower levels than IPM by 60 days. More out-patients had increased total well-being scores by 60 days (p = .04). OPM was associated with mean cost savings of £2658 (95% CR 460-4857) per patient. CONCLUSIONS: Patients with acute HF randomised to OPM accrued more days alive out of hospital (albeit not statistically significantly in this small pilot study). OPM is favoured by patients and carers and is associated with improved mental well-being and cost savings.

Quality of life improvement in older patients with heart failure initiated on ivabradine: Results from the UK multi-centre LIVE:LIFE prospective cohort study.

AIMS: LIVE:LIFE is a multi-centre, open-label, prospective observational cohort study assessing health-related quality of life (HRQoL) in older patients with chronic heart failure (CHF) following initiation of ivabradine. The primary endpoint is change in Minnesota Living with Heart Failure Questionnaire (MLWHFQ) total score after 6months. METHODS AND RESULTS: Consenting patients aged ≥70years with CHF, in whom ivabradine was initiated within its licensed indication, were enrolled. Demographic, clinical and HRQoL (MLWHFQ, SF-12) data were collected at baseline (V1), 2 (V2) and 6months (V3). Over 14months, 240 patients were recruited from 44 UK centres. Ninety-nine (41%) were female and 28% aged ≥80years. Aetiology was ischaemic in 152 (63%) and 59% had been diagnosed with CHF for ≤2yrs. 52% of patients were New York Heart Association (NYHA) Class III and 57% had left ventricular ejection fraction <35%. 57% received beta-blockers. Patients had multiple comorbidities (144 (60%) hypertension, 105 (44%) asthma/COPD, 80 (33%) diabetes) and were prescribed a mean of 9±3 daily medications. Resting heart rate was 83bpm at baseline and fell 13bpm by V3. In patients completing both visits (n=187), comparing V3 to baseline: MLWHFQ total score improved by 9 points (p<0.0001, 95% CI: 7-12); 30% of patients improved ≥1 NYHA class and global assessment improved from patient (59%) and physician (60%) perspectives. 88% of patients completing V3 were still taking ivabradine. CONCLUSIONS: These contemporary prospective UK data demonstrate improvements in HRQoL and functional status with ivabradine therapy in typical older CHF patients. Despite comorbidities and polypharmacy, ivabradine was well tolerated.

Sudden cardiac death in end stage renal disease: unlocking the mystery.

Sudden cardiac death (SCD) is a major cause of concern in end stage renal disease (ESRD), contributing to 70% of cardiovascular mortality and 27% of all-cause mortality in dialysis patients. Yet its mechanisms and pathogenesis remain largely obscure. This review discusses the potential reasons for an exaggerated risk of SCD in ESRD populations taking into account recent studies and registry data and additionally explores the reasons for the reported recent decline in SCD. The types of arrhythmias typical of the hemodialysis population are yet to be fully characterised and in this paper, we introduce an ongoing implantable loop recorder (ILR) based study in hemodialysis patients--CRASH ILR (Cardio Renal Arrhythmia Study in Haemodialysis patients using Implantable Loop Recorders). The findings of this study will hopefully guide the design and implementation of larger ILR based studies before undertaking larger scale interventional therapeutic trials in this high risk population.

The impact of age and chronic kidney disease on secondary prevention post-primary percutaneous coronary intervention.

OBJECTIVE: Historical data suggest elderly patients and those with chronic kidney disease (CKD) receive suboptimal secondary prevention following myocardial infarction (MI). We evaluated the impact of age and CKD on secondary prevention following primary percutaneous coronary intervention (PPCI) in a contemporary unselected cohort. DESIGN: We studied 1169 consecutive patients from five UK centres receiving PPCI for ST elevation MI, with use of evidence-based secondary prevention at discharge assessed by age (<60, 60-75 and >75 years) and estimated glomerular filtration rate (eGFR). Follow-up prescribing practice was assessed in 567 patients. RESULTS: One-fifth of patients receiving PPCI were >75 years. This group received fewer secondary prevention drugs at discharge compared to younger patients (P < 0.01 for ß-blockers, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARB) and statins). By 6 weeks post-PPCI, there was a small drop-off in evidence-based therapy; ß-blocker and statin use in those >75 years fell from 90% to 86% and 96% to 93%, respectively. CKD (eGFR<60 ml/min/1.73 m(2)) was seen in 17.6%. Declining renal function was associated with age, female sex and lower use of ACE inhibitor/ARB. At discharge 83.5% of patients with eGFR<60 ml/min/1.73 m(2) were receiving ACE inhibitors/ARB, dropping to 77.5% at 6 weeks (compared with 95% and 92%, respectively, in patients with eGFR >60 ml/min/1.73 m(2)). CONCLUSION: The uptake of secondary prevention medication is high following PPCI in the UK, even in the elderly and in those with renal dysfunction. A focus on strategies to improve up-titration and continuation of drugs following discharge is required.

Is there a Failure to Optimize theRapy in anGina pEcToris (FORGET) study?

BACKGROUND: In the management of chronic stable angina, percutaneous coronary intervention (PCI) provides symptomatic relief of angina rather than improvement of prognosis. Current guidelines recommend optimization of medical therapy prior to elective PCI. It is not clear if these guidelines are adhered to in clinical practice. AIM: The aim of this multi-centre study was to determine the extent to which these treatment guidelines are being implemented in the UK. DESIGN: This was a multi-centre study involving six hospitals in the UK. METHODS: The medical treatment and extent of risk factor modification was recorded for consecutive patients undergoing elective PCI for chronic stable angina at each site. Data collected included anti-anginal drug therapy, lipid levels and blood pressure (BP). Data on heart rate (HR) control were also collected, since this represents a fundamental part of medical anti-anginal therapy. Target HR is <60 b.p.m. for symptomatic angina. RESULTS: A total of 500 patients [74% male; mean age +/- SD (64.4 +/- 10.1 years)] were included. When considering secondary prevention, 85% were receiving a statin and 76% were on an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. In terms of medical anti-ischaemic therapy, 78% were receiving beta-blockers [mean equivalent dose of bisoprolol 3.1 mg (range 1.25-20 mg)], 11% a rate limiting calcium antagonist, 35% a nitrate or nicorandil and one patient was receiving ivabradine. The mean total cholesterol (95% confidence interval) was 4.3 mmol/l (4.2-4.4), mean systolic BP of 130 +/- 24 mmHg and mean diastolic BP of 69 +/- 13 mmHg. Serum cholesterol was <5 mmol/l in 77% and <4 mmol/l in 42% of the patients, 62% of the patients had systolic BP < 140 mmHg and 92% had diastolic BP < 90 mmHg. Considering European Society of Cardiology targets, 50% had systolic BP < 130 mmHg and 76% had diastolic BP < 80 mmHg. A large proportion of patients did not achieve target resting HR; 27% of patients had a resting HR of >or=70 b.p.m., 40% had a resting HR between 60 and 69 b.p.m. and 26% had a resting HR between 50 and 59 b.p.m. The resting HR was not related to the dose of beta-blocker. CONCLUSION: A significant proportion of the patients with chronic stable angina undergoing elective PCI did not achieve therapeutic targets for lipid, BP and HR control. Over 50% of patients did not receive adequate HR lowering anti-anginal therapy to achieve recommended target resting HR.

Estimation of the requirement for implantable cardioverter defibrillators for the primary prevention of sudden cardiac death post-myocardial infarction based on UK national guidelines (2006).

AIMS: To assess the impact of the new UK National Institute for Health and Clinical Excellence (NICE) guidelines on the incidence of implantable cardioverter defibrillator (ICD) indications for the primary prevention of sudden cardiac death following myocardial infarction (MI). METHODS AND RESULTS: We performed a retrospective single centre study in a District General Hospital. The transthoracic echocardiogram reports of all patients with a discharge diagnosis of MI during a 6-month period were studied. We reviewed the notes of all patients with an estimated left ventricular ejection fraction (LVEF) of <35% and used UK national guidance to assess the incidence of potential ICD indications. Five hundred and forty-six patients had a discharge diagnosis of MI. Fifty had estimated LVEF <35% and 8-11 of these met the NICE post-MI primary prevention criteria for ICD implantation. This gives an estimated incidence based upon our local population of 29-39 patients/million/year. Most of these patients (64-88%) were identified purely by ECG criteria (QRS > 120 ms) and LVEF. CONCLUSION: The latest published UK ICD data give a new implantation rate of approximately 40/million/year. Combining our results with published data for NICE secondary prevention indications gives a combined ICD indication incidence of approximately 105-115/million/year. This suggests there is currently significant under-provision of ICD therapy in the UK.

Anaemia is an independent predictor of poor outcome in patients with chronic heart failure.

BACKGROUND: Mild anaemia frequently occurs in patients with chronic heart failure (CHF), particularly in the advanced stages of the disease. The correction of anaemia with erythropoietin is a therapeutic possibility. The aim of this study was to assess prospectively the relationship between the prevalence of anaemia (haemoglobin level18 months in all survivors), and the end-point of the study was all-cause mortality. RESULTS: A total of 176 patients were enrolled (mean age: 63 years, New York Heart Association (NYHA) classification I/II/III/IV: 15/81/51/29; left ventricular ejection fraction (LVEF): 42%, ischaemic aetiology in 62%). In the whole population the mean haemoglobin level was 140+/-15 g/l. Anaemia was found in 18 (10%) patients, and was significantly more common in women than in men (18 vs. 7%, respectively, P=0.02) and in those with most severe CHF symptoms (frequency in NYHA I/II/III/IV: 0/9/10/21%, respectively; NYHA IV vs. I-III, P=0.03), but not related to the other clinical indices. Univariate analysis revealed NYHA class III-IV (hazard ratio 3.8, 95% CI: 1.6-8.9, P=0.003), low LVEF <35% (hazard ratio 2.3, 95% CI: 1.0-4.9, P=0.04) and anaemia (hazard ratio 2.9, 95% CI: 1.2-7.2, P=0.02) as predictors of 18-month mortality. In multivariate analysis, anaemia remained an independent predictor of death when adjusted for NYHA class and LVEF (hazard ratio: 2.6, 95% CI: 1.0-6.5, P=0.04). In anaemic patients, 18-month survival was 67% (95% CI: 45-89%) compared to 87% (81-92%) in patients with a normal haemoglobin level (P=0.016). CONCLUSIONS: Mild anaemia is a significant and independent predictor of poor outcome in unselected patients with CHF. Correction of low haemoglobin level may become an interesting therapeutic option for CHF patients.

DANAMI-2: is primary angioplasty superior to thrombolysis in acute MI when the patient has to be transferred to an invasive centre?

Primary angioplasty is superior to thrombolysis in acute myocardial infarction when performed in a timely manner but the benefits are unknown when inter-hospital transfer is required for angioplasty. On the 20th March 2002 at the American College of Cardiology 51st Annual Scientific Session, the results of the Danish Multicentre Randomized Trial on Thrombolytic Therapy versus Acute Coronary Angioplasty in Acute Myocardial Infarction (DANAMI-2) were presented. 1,572 patients were randomized to front loaded tPA or angioplasty on presentation within 12 h of acute myocardial infarction; 1,129 from hospitals requiring transfer for up to 3 h for angioplasty. The trial was stopped early since there was a 40% relative reduction in the composite primary end-point of death, disabling stroke or reinfarction within 30 days (absolute reduction 13.7 to 8%, p=0.0003) with primary angioplasty. This appeared to be driven by a significant reduction of reinfarction from 6.3 to 1.6%. Ambulance transfer was shown to be safe but time to angioplasty was approximately 60 min longer than time to thrombolysis. No data are as yet available on the relative infarct sizes or left ventricular function in the two groups. The management of acute myocardial infarction is an area of missed opportunities. Patients present late to hospital, up to 30% of eligible patients do not receive reperfusion therapy and door to needle time is longer than is ideal. Whilst we await the full details of the trial and long term follow-up, we should not forget the challenges of conventional management of acute myocardial infarction.

Complex and extensive infective endocarditis: a novel surgical approach.

Endocarditis involving the central fibrous body of the heart requires carefully planned surgical intervention. We present a novel approach in a 65-year-old male with extensive endocarditis involving the aortic root, ventricular septum, central fibrous body together with mitral, aortic and tricuspid valves.