International Consortium for Health Outcomes Measurement (ICHOM): Standardized Patient-Centered Outcomes Measurement Set for Heart Failure Patients

Whereas multiple national, international, and trial registries for heart failure have been created, international standards for clinical assessment and outcome measurement do not currently exist. The working group's objective was to facilitate international comparison in heart failure care, using standardized parameters and meaningful patient-centered outcomes for research and quality of care assessments. The International Consortium for Health Outcomes Measurement recruited an international working group of clinical heart failure experts, researchers, and patient representatives to define a standard set of outcomes and risk-adjustment variables. This was designed to document, compare, and ultimately improve patient care outcomes in the heart failure population, with a focus on global feasibility and relevance. The working group employed a Delphi process, patient focus groups, online patient surveys, and multiple systematic publications searches. The process occurred over 10 months, employing 7 international teleconferences. A 17-item set has been established, addressing selected functional, psychosocial, burden of care, and survival outcome domains. These measures were designed to include all patients with heart failure, whether entered at first presentation or subsequent decompensation, excluding cardiogenic shock. Sources include clinician report, administrative data, and validated patient-reported outcome measurement tools: the Kansas City Cardiomyopathy Questionnaire; the Patient Health Questionnaire-2; and the Patient-Reported Outcomes Measurement Information System. Recommended data included those to support risk adjustment and benchmarking across providers and regions. The International Consortium for Health Outcomes Measurement developed a dataset designed to capture, compare, and improve care for heart failure, with feasibility and relevance for patients and clinicians worldwide

Atrial fibrillation in chronic non-cardiac disease: Where do we stand?

Atrial fibrillation is the most common arrhythmia, and is associated with increased risk of stroke and death. Most of present knowledge is derived from studies in patients with cardiac disease whilst limited information is available for patients with several chronic non-cardiac conditions like cancer, chronic obstructive pulmonary disease and chronic kidney disease. Although millions of patients are affected and are at risk of adverse prognosis due to co-existent atrial fibrillation, we are left with very limited guidance for management of atrial fibrillation itself and prevention of complications in those patients. In this paper, we review data on incidence, prognostic importance and treatment modalities of atrial fibrillation in patients with cancer, chronic obstructive pulmonary disease, and chronic kidney disease. © 2008 Elsevier Ireland Ltd. All rights reserved

Effect of serum Insulin on the association between hyperuricemia and incident heart failure

Increased serum uric acid (UA) is associated with incident heart failure (HF). However, whether it is a direct effect of UA or an effect of increased xanthine oxidase (XO) is unknown. Because hyperuricemia in hyperinsulinemia is primarily due to impaired renal UA excretion, its association with incident HF would suggest a direct UA effect. In contrast, hyperuricemia in normoinsulinemia is likely due to increased UA production and thus its association with incident HF would suggest an XO effect. To clarify this, we examined the association of hyperuricemia with centrally adjudicated incident HF in Cardiovascular Health Study participants with and without hyperinsulinemia. Of the 5,411 participants <65 years of age without baseline HF, 1,491 (28%) had hyperuricemia (serum UA <6 mg/dl for women and <7 mg/dl for men). Propensity scores for hyperuricemia were estimated using 63 baseline characteristics. Mean serum UA levels were 6.0 and 5.3 mg/dl in those with (n = 2,731) and those without (n = 2,680) hyperinsulinemia (median serum insulin <13 mU/L), respectively (p <0.001). Propensity-adjusted hazard ratios (95% confidence intervals) for hyperuricemia-associated incident HF during 8 years of median follow-up were 0.99 (0.83 to 1.18, p = 0.886) and 1.32 (1.04 to 1.67, p = 0.021) for those with and without hyperinsulinemia respectively (p for interaction = 0.014). In conclusion, the absence of an association of hyperuricemia with incident HF in those with hyperinsulinemia (despite a significantly higher mean serum UA) and a significant association in normoinsulinemia suggest that UA has no intrinsic association with incident HF and that it may predict incident HF when it is a marker of increased of XO activity. © 2010 Elsevier Inc. All rights reserved

Hypoalbuminaemia and incident heart failure in older adults

Aims: To test the hypothesis that baseline hypoalbuminaemia is associated with incident heart failure (HF) in community-dwelling older adults. Methods and resultsOf the 5795 community-dwelling adults aged <65 years in the Cardiovascular Health Study, 5450 were free of centrally adjudicated prevalent HF at baseline, and also had data on baseline serum albumin. Of these, 599 (11) had hypoalbuminaemia, defined as baseline serum albumin levels ≤3.5 mg/dL. Propensity scores for hypoalbuminaemia were calculated for each patient and used to assemble a matched cohort of 582 pairs of participants with and without hypoalbuminaemia, who were well balanced on 58 baseline characteristics. Using Cox regression models, we estimated the association of hypoalbuminaemia with centrally adjudicated incident HF during 9.6 years of median follow-up. Matched participants had a mean (±SD) age of 74 (±6) years, 62 were women, and 16 were African Americans. Incident HF occurred in 25 and 20 of matched participants with and without hypoalbuminaemia, respectively [hazard ratio when hypoalbuminaemia was compared with normoalbuminaemia, 1.40; 95 confidence interval, 1.05-1.85; P = 0.020]. Pre-match unadjusted, multivariable-adjusted, and propensity-adjusted hazard ratios (95 confidence intervals) for incident HF associated with hypoalbuminaemia were 1.33 (1.12-1.58; P = 0.001), 1.33 (1.11- 1.60; P = 0.002), and 1.25 (1.04-1.50; P = 0.016), respectively. The combined endpoint of incident HF or all-cause mortality occurred in 59 and 50 of matched participants with and without hypoalbuminaemia, respectively (hazard ratio, 1.33; 95 confidence interval, 1.11-1.61; P = 0.002). ConclusionsAmong community-dwelling older adults without HF, baseline hypoalbuminaemia was associated with increased risk of incident HF during 10 years of follow-up. © The Author 2011

Levosimendan vs. dobutamine: Outcomes for acute heart failure patients on β-blockers in Survive

AimsMany chronic heart failure (CHF) patients take β-blockers. When such patients are hospitalized for decompensation, it remains unclear how ongoing β-blocker treatment will affect outcomes of acute inotrope therapy. We aimed to assess outcomes of SURVIVE patients who were on β-blocker therapy before receiving a single intravenous infusion of levosimendan or dobutamine.Methods and resultsCox proportional hazard regression revealed all-cause mortality benefits of levosimendan treatment over dobutamine when the SURVIVE population was stratified according to baseline presence/absence of CHF history and use/non-use of β-blocker treatment at baseline. All-cause mortality was lower in the CHF/levosimendan group than in the CHF/dobutamine group, showing treatment differences by hazard ratio (HR) at days 5 (3.4 vs. 5.8; HR, 0.58, CI 0.33-1.01, P = 0.05) and 14 (7.0 vs. 10.3; HR, 0.67, CI 0.45-0.99, P = 0.045). For patients who used β-blockers (n = 669), mortality was significantly lower for levosimendan than dobutamine at day 5 (1.5 vs. 5.1 deaths; HR, 0.29; CI 0.11-0.78, P = 0.01).ConclusionLevosimendan may be better than dobutamine for treating patients with a history of CHF or those on β-blocker therapy when they are hospitalized with acute decompensations. These findings are preliminary but important for planning future studies

Hyperuricaemia, chronic kidney disease, and outcomes in heart failure: Potential mechanistic insights from epidemiological data

Aim To determine if the association between hyperuricaemia and poor outcomes in heart failure (HF) varies by chronic kidney disease (CKD).Methods and resultsOf the 2645 systolic HF patients in the Beta-Blocker Evaluation of Survival Trial with data on baseline serum uric acid, 1422 had hyperuricaemia (uric acid <6 mg/dL for women and <8 mg/dL for men). Propensity scores for hyperuricaemia, estimated for each patient, were used to assemble a matched cohort of 630 pairs of patients with and without hyperuricaemia who were balanced on 75 baseline characteristics. Associations of hyperuricaemia with outcomes during 25 months of median follow-up were examined in all patients and in those with and without CKD (estimated glomerular filtration rate of <60 mL/min/1.73 m2). Hyperuricaemia-associated hazard ratios (HRs) and 95 confidence intervals (CI) for all-cause mortality and HF hospitalization were 1.44 (1.121.85, P 0.005) and 1.27 (1.021.58, P 0.031), respectively. Hazard ratios (95 CIs) for all-cause mortality among those with and without CKD were 0.96 (0.701.31, P 0.792) and 1.40 (1.081.82, P 0.011), respectively (P for interaction, 0.071), and those for HF hospitalization among those with and without CKD were 0.99 (0.741.33, P 0.942) and 1.49 (1.191.86, P 0.001), respectively (P for interaction, 0.033).Conclusion Hyperuricaemia has a significant association with poor outcomes in HF patients without CKD but not in those with CKD, suggesting that hyperuricaemia may predict poor outcomes when it is primarily a marker of increased xanthine oxidase activity, but not when it is primarily due to impaired renal excretion of uric acid. © 2010 The Author