Comprehensive physical rehabilitation of patients with heart failure: impact on clinical and functional status and analysis of problems related to the enrollment

Aim. To evaluate functional, clinical and psychological status of patients with class II-III heart failure, who underwent comprehensive cardiac rehabilitation program.Material and methods. Patients of both sexes with class II-III heart failure who met the inclusion criteria, did not have the exclusion criteria, and signed informed consent were included. The training process consisted of a 4-week respiratory muscle (RM) training using the THRESHOLD® IMT breathing trainer followed by a 12-week moderate intensity aerobic exercise (AE). AE were conducted under the supervision of an instructor 3 times a week for 40 minutes. RM training was carried out by patients at home on their own 5-7 times a week. Minnesota Living With Heart Failure Questionnaire (MLwHFQ.23) was used to assess quality of life. In addition, we applied Hospital Anxiety and Depression Scale (HADS). The evaluation was performed before the start of the study (visit 1), after 4 weeks of respiratory training (visit 2) and at the end of 16 weeks of AE (visit 3). The baseline characteristics of patients who were screened and not enrolled in the study were compared with those who participated in training.Results. A total of 102 patients were included in the study (passed the first visit). Subsequently, for various reasons, including due to the pandemic, 82 patients refused to participate in the study. Only 20 patients participated in RM training for 4 weeks followed by a 12-week cycle of moderate-intensity AR (median age, 67,0 (58,7-74,3) years; men, 70%; Δ peak oxygen uptake (VO2peak) (1-2) =1,1, p=0,3863; ΔVO2 peak (1-3) =2,3 ml/kg/min, p=0,139. During 16-week training, we revealed an increase in expiratory muscle strength (EMS) (ΔEMS =10 cmH2O (p=0,037), six-minute walk test (6MWT) (Δ6MTX=60 meters, p=0,005), and SHOKS score (p=0,0117), as well as improvement in anxiety and depression symptoms (ΔHADS =-2 points, p=0,0346). Patients who refused to be included in the study were older, had lower blood pressure, and had a worse quality of life. The groups did not differ significantly in other clinical, functional and laboratory parameters.Conclusion. Patients’ motivation to exercise was associated with younger age and better subjective health perception and did not depend on objective status. In patients undergoing a comprehensive rehabilitation program, there was a significant change in RM strength, as well as an increase in 6MWT distance, clinical and psychological status already at the stage of respiratory training. This trend continued at the AE stage as well

Improving outpatient care in chronic heart failure

Despite advances in pharma and high-technology medicine, the rate of burdensome hospital admissions and mortality in patients with chronic heart failure (CHF) remains high. Over half of all admission-entailing decompensations have been repeatedly shown to emerge from non-compliance with outpatient prescriptions. Poor adherence to medication and non-medication treatment can only be broken by improving the patient’s awareness of the disease and his closer monitoring by healthcare professionals. The power of clinical and laboratory illness monitoring in line with the recommended quality criteria of medical aid in heart failure (HF) is strongly limited today by time resources available in outpatient and midwifery clinics. Meanwhile, an international and certain domestic experience has been built up to run CHF outpatient centres with involvement of specially-trained nursing and senior medical staff. Analytic evidence on such centres suggests a reduction in mortality and hospitalisation rate among the visiting patients. To combat existing drawbacks of CHF outpatient care, the National Medical Research Center of Cardiology in alliance with the Specialist Society of Heart Failure have developed the nurses’ guidelines for CHF rooms and are launching a medical staff training programme to manage CHF rooms, registry and data analysis. Furthermore, a procedure has been developed for patient routing to regional CHF outpatient cabinets that is being actively deployed in the Tyumen Region

Steroid pulse -therapy in patients With coronAvirus Pneumonia (COVID-19), sYstemic inFlammation And Risk of vEnous thRombosis and thromboembolism (WAYFARER Study)

Introduction: Coronavirus pneumonia not only severely affects the lung tissue but is also associated with systemic autoimmune inflammation, rapid overactivation of cytokines and chemokines known as “cytokine storm”, and a high risk of thrombosis and thromboembolism. Since there is no specific therapy for this new coronavirus infection (COVID-19), searching for an effective and safe anti-inflammatory therapy is critical.Materials and Methods: This study evaluated efficacy and safety of pulse therapy with high doses of glucocorticosteroids (GCS), methylprednisolone 1,000 mg for 3 days plus dexamethasone 8 mg for another 3-5 days, in 17 patients with severe coronavirus pneumonia as a part of retrospective comparative analysis (17 patients in control group). The study primary endpoint was the aggregate dynamics of patients’ condition as evaluated by an original CCS-COVID scale, which included, in addition to the clinical status, assessments of changes in the inflammation marker, C-reactive protein (CRP); the thrombus formation marker, D-dimer; and the extent of lung injury evaluated by computed tomography (CT). Patients had signs of lung injury (53.2 % and 25.6 %), increases in CRP 27 and 19 times, and a more than doubled level of D-dimer (to 1.41 µg/ml and 1.15 µg/ml) in the active therapy and the control groups, respectively. The GCS treatment group had a more severe condition at baseline.Results: The GCS pulse therapy proved effective and significantly decreased the CCS-COVID scores. Median score difference was 5.00 compared to the control group (р=0.011). Shortness of breath considerably decreased; oxygen saturation increased, and the NEWS-2 clinical status scale scores decreased. In the GCS group, concentration of CRP significantly decreased from 134 mg/dl to 41.8 mg/dl (р=0.009) but at the same time, D-dimer level significantly increased from 1.41 µg/ml to 1.98 µg/ml (р=0.044). In the control group, the changes were nonsignificant. The dynamics of lung injury by CT was better in the treatment group but the difference did not reach a statistical significance (р=0.062). Following the GCS treatment, neutrophilia increased (р=0.0001) with persisting lymphopenia, and the neutrophil/lymphocyte (N/L) ratio, a marker of chronic inflammation, increased 2.5 times (р=0.006). The changes in the N/L ratio and D-dimer were found to correlate in the GCS pulse therapy group (r =0.49, p=0.04), which underlined the relationship of chronic autoimmune inflammation with thrombus formation in COVID-19. No significant changes were observed in the control group. In result, four patients developed venous thromboembolic complications (two of them had pulmonary artery thromboembolism) after the GCS pulse therapy despite the concomitant antiplatelet treatment at therapeutic doses. Recovery was slower in the hormone treatment group (median stay in the hospital was 26 days vs 18 days in the control group, р=0.001).Conclusion: Pulse therapy with high doses of GCS exerted a rapid anti-inflammatory effect but at the same time, increased the N/L ratio and the D-dimer level, which increased the risk of thromboembolism

INFLUENCE OF PSYCHOEMOTIONAL DISORDERS ON THE EFFECTIVENESS OF EDUCATION AND ACTIVE OUTPATIENT CONTROL IN HEART FAILURE PATIENTS

Aim. The influence of depression on the performance of education program and active outpatient control (the “influence”) in patients with heart failure of III-IV functional class.Material and methods. The post-hoc analysis of the SHANS study (School and Ambulatory Observation of Heart Failure Patients), organized by the society of specialists in heart failure (SSHF), was done for the odds estimation for primary endpoints (mortality from any cause, cardiovascular hospitalization, combination endpoint — mortality and hospitalization) in patients from treatment group depending on the presence of depression sympthoms (HADS(d) >11 pts. As the subgroups of depressed and non-depressed differed by functional class and age, the correction was appliaed by the method of Mantel-Hensel for thse two parameters. Values of mean survival rate was calculated, from the moment of baseline assessment to the moment of death with further build-up of Kaplan-Meier curves.Results. The influence showed effectiveness for the all endpoints in depression subgroups, as in non-depressed. Depressed patients reacted a little worse on the program, but there were no any statistical significance for the risk of primary endpoints. Corrected combination endpoint: non-depressed [OD =0,3806 (95% CI 0,2107-0,6876)], depressed [OR =0,4699 (95% ДИ 0,3128-0,7058)], p=0,5651. In analysis by Kaplan-Meier endowment curves it was shown that patients randomized to influence group had lower risk of death. Decrease of relative risk was higher in non-depressed [(RRR =25% (95% CI 0,61; 0,94), p<0,001)], than in depressed [(RRR =17% (95% CI 0,68; 0,99), p=0,036)]. However the effectiveness of the influence was same in both subgroups.Conclusion. The educational and active ambulatory control program, by the secondary analysis data, showed effectiveness in patients with sympthoms of depression. For better reproducibility of such studies more precise diagnostic parameters for depression diagnostics are required

RELIABILITY AND DISCRIMINANT VALIDITY OF THE RUSSIAN VERSION OF EUROPEAN SELF-CARE BEHAVIOUR SCALE IN CHRONIC HEART FAILURE

Aim. To assess reliability and discriminant validity of the Russian version of European Scale of Self-care in patients with heart failure (HF).Material and methods. European Scale of self-help assessment in CHF was translated in Russian according to Brislin model by three not related translators. After discussion by the workgroup members, professional translator retranslated back it to English, and the result was agreed with the author of the score. Then, 95 patients were included with chronic HF (CHF) of various etiology, who responded the questions at admittance and discharge from cardiological departments. Cronbach alpha was used for analysis of intrinsic consistency of the score. Also discriminant validity was evaluated.Results. Edication of CHF patients led to decrease of the whole points summ from 27,7±6,6 at admittance to 15,8±4,5 by discharge event. Coefficient of intrinsic consistency Cronbach alpha of the Russian version of European Scale was 0,826. Absence of significant relation of total points summ from Kansas questionnaire for cardiomyopathy patients and Minnessota questionnaire of life quality in HF proved discriminant validity of the Russian version.Conclusion. Russian version of European Scale of Self-help for patients with HF is easy to use and convenient instrument, which might be helpful for clinical trials as for clinical practice