Do patients with suspected heart failure and preserved left ventricular systolic function suffer from "diastolic heart failure" or from misdiagnosis? A prospective descriptive study

OBJECTIVES: To characterise the clinical features of patients with suspected heart failure but preserved left ventricular systolic function to determine if they have other potential causes for their symptoms rather than being diagnosed with 'diastolic heart failure.' DESIGN: Prospective descriptive study. SETTING: Outpatient based direct access echocardiography service. PARTICIPANTS: 159 consecutive patients with suspected heart failure referred by general practitioners. MAIN OUTCOME MEASURES: Symptoms (including shortness of breath, ankle oedema, and paroxysmal nocturnal dyspnoea) and history of coronary heart disease and chronic pulmonary disease. Transthoracic echocardiography, body mass index, pulmonary function tests, and electrocardiography. RESULTS: 109 of 159 participants had suspected heart failure in the absence of left ventricular systolic dysfunction, valvular heart disease, or atrial fibrillation. Of these 109, 40 were either obese or very obese, 54 had a reduction in forced expiratory volume in 1 second to </=70%, and 97 had a peak expiratory flow rate </=70% of normal. Thirty one patients had a history of angina, 12 had had a myocardial infarction, and seven had undergone a coronary artery bypass graft. Only seven patients lacked a recognised explanation for their symptoms. CONCLUSIONS: For most patients with a diagnosis of heart failure but preserved left ventricular systolic function there is an alternative explanation for their symptoms-for example, obesity, lung disease, and myocardial ischaemia-and the diagnosis of diastolic heart failure is rarely needed. These alternative diagnoses should be rigorously sought and managed accordingly

‘Hearts and minds’: association, causation and implication of cognitive impairment in heart failure

The clinical syndrome of heart failure is one of the leading causes of hospitalisation and mortality in older adults. An association between cognitive impairment and heart failure is well described but our understanding of the relationship between the two conditions remains limited. In this review we provide a synthesis of available evidence, focussing on epidemiology, the potential pathogenesis, and treatment implications of cognitive decline in heart failure. Most evidence available relates to heart failure with reduced ejection fraction and the syndromes of chronic cognitive decline or dementia. These conditions are only part of a complex heart failure-cognition paradigm. Associations between cognition and heart failure with preserved ejection fraction and between acute delirium and heart failure also seem evident and where data are available we will discuss these syndromes. Many questions remain unanswered regarding heart failure and cognition. Much of the observational evidence on the association is confounded by study design, comorbidity and insensitive cognitive assessment tools. If a causal link exists, there are several potential pathophysiological explanations. Plausible underlying mechanisms relating to cerebral hypoperfusion or occult cerebrovascular disease have been described and it seems likely that these may coexist and exert synergistic effects. Despite the prevalence of the two conditions, when cognitive impairment coexists with heart failure there is no specific guidance on treatment. Institution of evidence-based heart failure therapies that reduce mortality and hospitalisations seems intuitive and there is no signal that these interventions have an adverse effect on cognition. However, cognitive impairment will present a further barrier to the often complex medication self-management that is required in contemporary heart failure treatment

Intention and Actuality in the Fiction of William Dean Howells

This study of Howells\u27 fiction is a discussion of representative novels of the author\u27s from A Foregone Conclusion in 1875 through his last novel, The Vacation of the Kelwyns, in 1920. The arrangement of the novels in chronological order is primarily for convenience; no attempt has been made to trace the literary development of the author. My purpose, rather, has been to show that Howells, throughout the greater part of his career as a novelist, was consistent in his literary method. To understand that method is to have a better understanding of meaning in the novels. Finally, in demonstrating that there exists a genuine relationship between method and meaning in the novels, I have suggested that Howells\u27 fiction embodies an attitude which, as later formulated in the philosophy of William James, came to be known as pragmatism

Working Through Ideological Conflict: Utility of Authentic Leadership to Build Community

Many people find it difficult to communicate across ideological differences, particularly if those differences are politically-charged. An abundance of research describes the differences between the two dominant political philosophies of the United States, liberalism and conservatism, but little research has been conducted on how to develop and maintain a community inclusive of these ideological differences. This qualitative research project gathered information from six self-identified leaders and 41 survey participants of varying ages, genders, political affiliations, races, and religions over the summer of 2021. Three categories of findings emerged: (a) how ideological differences make community-building challenging; (b) when and how people engage in ideological conflict; and (c) using skills and strategies to make ideological conflict constructive. Data analysis using Authentic Leadership Development Theory revealed that the characteristics of authentic leadership (“internalized regulatory processes, balanced processing of information, relational transparency, and authentic behavior” (Avolio & Gardner, 2005, p. 322)) are well-suited to facilitate conflict dialogue involving ideological issues. In order to support one’s desire to live among and respond to differences, recommendations and implications are provided

Prevalence, incidence, primary care burden and medical treatment of angina in Scotland: age, sex and socioeconomic disparities: a population-based study

Objective: To examine the epidemiology, primary care burden and treatment of angina in Scotland. Design: Cross-sectional data from primary care practices participating in the Scottish continuous morbidity recording scheme between 1 April 2001 and 31 March 2002. Setting: 55 primary care practices (362 155 patients). Participants: 9508 patients with angina. Results: The prevalence of angina in Scotland was 28/1000 in men and 25/1000 in women (p < 0.05) and increased with age. The prevalence of angina also increased with increasing socioeconomic deprivation from 18/1000 in the least deprived category to 31/1000 in the most deprived group (p < 0.001 for trend). The incidence of angina was higher in men (1.8/1000) than in women (1.4/1000) (p = 0.004) and increased with increasing age and socioeconomic deprivation. Socioeconomically deprived patients (0.48 contacts/patient among the most deprived) were less likely than affluent patients (0.58 contacts/patient among the least deprived) to see their general practitioner on an ongoing basis p = 0.006 for trend). Among men, 52% were prescribed ß blockers, 44% calcium channel blockers, 72% aspirin, 54% statins and 36% angiotensin converting enzyme inhibitors or angiotensin receptor blockers. The corresponding prescription rates for women were 46% (p < 0.001), 41% (p = 0.02), 69% (p < 0.001), 45% (p < 0.001) and 30% (p < 0.001). Among patients < 75 years old 52% were prescribed a β blocker and 58% a statin. The corresponding figures for patients ≥ 75 years were 42% (p < 0.001) and 31% (p < 0.001). Conclusions: Angina is a common condition, more so in men than in women. Socioeconomically deprived patients are more likely to have angina but are less likely to consult their general practitioner. Guideline-recommended treatments for angina are underused in women and older patients. These suboptimal practice patterns, which are worst in older women, are of particular concern, as in Scotland more women (and particularly older women) than men have angina

Relation between socioeconomic deprivation and death from a first myocardial infarction in Scotland: population based analysis

No abstract available

The interface between intrapreneurship, innovation and IT governance

The purpose of this conceptual paper is to examine the links, as reported in the international literature, between intrapreneurship, innovativeness and IT governance within medium to large organizations. A cross disciplinary literature review was conducted and yielded a theoretical framework for identifying and understanding the critical elements underpinning and driving innovation and intrapreneurship performance and their relationship with key aspects of IT governance within organizations.<br /

Association is not causation: treatment effects cannot be estimated from observational data in heart failure

Aims: Treatment ‘effects’ are often inferred from non-randomized and observational studies. These studies have inherent biases and limitations, which may make therapeutic inferences based on their results unreliable. We compared the conflicting findings of these studies to those of prospective randomized controlled trials (RCTs) in relation to pharmacological treatments for heart failure (HF). Methods and results: We searched Medline and Embase to identify studies of the association between non-randomized drug therapy and all-cause mortality in patients with HF until 31 December 2017. The treatments of interest were: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, mineralocorticoid receptor antagonists (MRAs), statins, and digoxin. We compared the findings of these observational studies with those of relevant RCTs. We identified 92 publications, reporting 94 non-randomized studies, describing 158 estimates of the ‘effect’ of the six treatments of interest on all-cause mortality, i.e. some studies examined more than one treatment and/or HF phenotype. These six treatments had been tested in 25 RCTs. For example, two pivotal RCTs showed that MRAs reduced mortality in patients with HF with reduced ejection fraction. However, only one of 12 non-randomized studies found that MRAs were of benefit, with 10 finding a neutral effect, and one a harmful effect. Conclusion: This comprehensive comparison of studies of non-randomized data with the findings of RCTs in HF shows that it is not possible to make reliable therapeutic inferences from observational associations. While trials undoubtedly leave gaps in evidence and enrol selected participants, they clearly remain the best guide to the treatment of patients

National survey of the prevalence, incidence, primary care burden, and treatment of heart failure in Scotland

Objective: To examine the epidemiology, primary care burden, and treatment of heart failure in Scotland, UK. Design: Cross sectional data from primary care practices participating in the Scottish continuous morbidity recording scheme between 1 April 1999 and 31 March 2000. Setting: 53 primary care practices (307 741 patients). Subjects: 2186 adult patients with heart failure. Results: The prevalence of heart failure in Scotland was 7.1 in 1000, increasing with age to 90.1 in 1000 among patients 85 years. The incidence of heart failure was 2.0 in 1000, increasing with age to 22.4 in 1000 among patients 85 years. For older patients, consultation rates for heart failure equalled or exceeded those for angina and hypertension. Respiratory tract infection was the most common co-morbidity leading to consultation. Among men, 23% were prescribed a ß blocker, 11% spironolactone, and 46% an angiotensin converting enzyme inhibitor. The corresponding figures for women were 20% (p = 0.29 versus men), 7% (p = 0.02), and 34% (p &lt; 0.001). Among patients &lt; 75 years 26% were prescribed a &#946; blocker, 11% spironolactone, and 50% an angiotensin converting enzyme inhibitor. The corresponding figures for patients 75 years were 19% (p = 0.04 versus patients &lt; 75), 7% (p = 0.04), and 33% (p &lt; 0.001). Conclusions: Heart failure is a common condition, especially with advancing age. In the elderly, the community burden of heart failure is at least as great as that of angina or hypertension. The high rate of concomitant respiratory tract infection emphasises the need for strategies to immunise patients with heart failure against influenza and pneumococcal infection. Drugs proven to improve survival in heart failure are used less frequently for elderly patients and women