Prevalence, correlates, effects and detection of left ventricular systolic dysfunction in an urban population

The prevalence of chronic heart failure (CHF) in most epidemiological studies has been determined by using clinical criteria.In this thesis, in contrast, left ventricular systolic function was assessed objectively by echocardiography in a cross -sectional survey of 2000 men and women aged 25 -74, randomly sampled from a geographical area. Left ventricular ejection fraction (LVEF) was measured using the Biplane Simpson's Rule Method. Its aims were to document the prevalence of both symptomatic and asymptomatic left ventricular systolic dysfunction; ascertain the correlates of left ventricular systolic dysfunction; assess its effects on effort capacity; determine the usefulness of the natriuretic peptides in detecting systolic dysfunction; and to explore the possibility of a genetic component to left ventricular systolic dysfunction by examining the relationship between left ventricular systolic dysfunction and the angiotensinconverting enzyme insertion /deletion polymorphism (ACE I /D).In the 1640 subjects who attended (83%), the mean left ventricular ejection fraction was 47.3%. The prevalence of `definite' left ventricular systolic dysfunction (a LVEF ≤30%) was 2.9%: it was 0.7% in men aged 35-44 years and 6.4% in men >65 years being also higher in men (4%) than women (2%). One point five percent (1.5%) had symptomatic left ventricular systolic dysfunction and 1.4% asymptomatic left ventricular systolic dysfunction.In those with left ventricular systolic dysfunction, 83% had evidence of ischaemic heart disease (IHD), in contrast to 21% of those without left ventricular systolic dysfunction (p<0.001). Hypertension was more common in those with an abnormal ejection fraction (60% compared to 22%), p <0.001) but hypertension unaccompanied by IHD was not significantly more common in those with left ventricular systolic dysfunction.Left systolic ventricular dysfunction was associated with a significant reduction in exercise duration. In subjects in whom this was asymptomatic there was a trend towards decreased effort capacity.Plasma concentrations of the natriuretic peptides were significantly higher in those with left ventricular systolic dysfunction (the median concentration (interquartile range) of N-ANP was 2.8 [1.8,4.6] ng /ml and BNP; 24 [18,33]pg/ml) than in those without (N-ANP; 1.3[0.9,1.8] ng/ml and BNP; 7.7pg/mI[3.4,13], p <0.001). The area under the Receiver Operator Characteristic Curves (SD) was greater using BNP; 0.88 (0.03) for all, 0.841 (0.03) in those with IHD, 0.86(0.03) for subjects ≥55 years and 0.84 (0.04) for those ≥55 years with IHD. The same areas under the curve for N-ANP were 0.75(0.05), 0.71(0.05), 0.72 (0.05) and 0.70 (0.06), respectively. A BNP concentration of ≥17.9pg /ml gave a sensitivity of 77% (specificity 87 %) for detecting left ventricular systolic dysfunction in all subjects, improving to 92% (specificity 72 %) when the analysis was restricted to individuals ≥ 55 with IHD.The DD genotype of the ACE I/D polymorphism was significantly more common in subjects with electrocardiographic evidence of myocardial infarction (MI) or major ischaemia. (Using II as a reference, the odds ratios normal versus major ischaemia or MI were: DD 1.53, ID 1.18:p =0.03 for 10 trend). In older patients (≥51 yr.) with an ECG MI or major abnormality, LVEF was higher in those with the DD genotype (LVEF%: DD 44.6, ID 42.9, II 40;p <0.02). LVEF was also greater in older patients with a systolic blood pressure (SBP) > than the median value (LVEF%: DD 47.5, ID 45.8, Il 44.6; p= 0.012).This work has shown that left ventricular systolic dysfunction is at least as twice as common than previous studies based on clinical criteria of CHF would suggest; about half is asymptomatic. Only 18% of subjects with definite left ventricular systolic dysfunction were taking an ACE inhibitor. Its main risk factors are IHD and hypertension in the presence of IHD; screening such high risk groups for left ventricular systolic dysfunction is worthy of consideration. Using a test such as BNP and targetting its use to individuals at high risk would lead to the identification of many more patients with left ventricular systolic dysfunction and, therefore, to the uptake of effective treatment. It would also lead to a more cost effective use of further investigation.This thesis also provides a mechanistic insight into the development of left ventricular systolic dysfunction by suggesting that while the DD genotype confers a higher risk of MI, it is associated with better preservation of LV function post MI, possibly by enabling more adequate compensatory hypertrophy. The ACE gene I/D polymorphism may, therefore, have a bidirectional importance in determining both the risk of MI and post MI LV systolic dysfunction

Chronic heart failure: epidemiology, investigation and management

Heart failure (HF) is a clinical syndrome characterized by dyspnoea, fatigue and fluid retention accompanied by objective evidence of cardiac dysfunction. The syndrome affects around 2% of the adult population, men more commonly than women (&lt;80 years old), with the incidence and prevalence rising steeply with age. HF causes substantial morbidity and reduced life expectancy, and coronary artery disease accounts for two-thirds of cases in developed countries. Investigation is important to ascertain the diagnosis, identify the aetiology (which may be reversible) and give some indication of prognosis. The diagnosis of HF confers a significantly increased risk of hospital admission and death. Treatment has been revolutionized by large randomized controlled clinical trials studying the effects of antagonists of the renin–angiotensin–aldosterone, neutral endopeptidase and sympathetic nervous systems, and the effects of device therapy. Cardiac transplantation remains an option for patients who are severely symptomatic (and at high risk) despite optimal use of such therapy

The year in cardiology: heart failure

No abstract available

In-hospital worsening heart failure: a clinically relevant endpoint?

Outcome measures used for the clinical evaluation of patients with acute heart failure differ between studies and may neither adequately address the characteristic presenting symptoms and signs nor reflect the pathophysiological processes involved. In‐hospital worsening of heart failure (WHF) is associated with poor outcomes and thus a potential endpoint conveying clinically meaningful prognostic information.Current definitions of WHF are based on the combination of worsening symptoms and signs and the intensification of treatment during admission. Definitions vary across studies and do not fully account for baseline therapy or circumstances in which there is failure to respond to treatment. Further, there are limited data to inform healthcare professionals as to which patients are most at risk of developing in‐hospital WHF.In this opinion piece, we review the definitions for WHF used in recent and ongoing clinical trials and propose a novel definition, which captures failure to respond to treatment as well as clinical worsening (deterioration of symptoms and signs) of the patient's condition. Such a definition, applied consistently across studies, would help clarify the characteristics of patients likely to develop in‐hospital WHF, allow comparative assessments of the effectiveness of interventions, and help guide appropriate patient management in order to improve outcomes

Reshaping care in the aftermath of the pandemic. Implications for cardiology health systems

In the last two years, the COVID-19 pandemic has undeniably changed everyday life and significantly reshaped the healthcare systems. Besides the direct effect on daily care leading to significant excess mortality, several collateral damages have been observed during the pandemic. The impact of the pandemic led to staff shortages, disrupted education, worse healthcare professional well-being, and a lack of proper clinical training and research. In this review we highlight the results of these important changes and how can the healthcare systems can adapt to prevent unprecedented events in case of future catastrophes

Referral for specialist follow-up and its association with post-discharge mortality among patients with systolic heart failure (from the National Heart Failure Audit for England and Wales)

For patients admitted with worsening heart failure, early follow-up after discharge is recommended. Whether outcomes can be improved when follow-up is done by cardiologists is uncertain. We aimed to determine the association between cardiology follow-up and risk of death for patients with heart failure discharged from hospital. Using data from the National Heart Failure Audit (England &amp; Wales), we investigated the effect of referral to cardiology follow-up on 30-day and one-year mortality in 68 772 patients with heart failure and a reduced left ventricular ejection fraction (HFREF) discharged from 185 hospitals between 2007 to 2013. The primary analyses used instrumental variable analysis complemented by hierarchical logistic and propensity matched models. At the hospital level, rates of referral to cardiologists varied from 6% to 96%. The median odds ratio (OR) for referral to cardiologist was 2.3 (95% confidence interval [CI] 2.1, 2.5), suggesting that, on average, the odds of a patient being referred for cardiologist follow-up after discharge differed approximately 2.3 times from one randomly selected hospital to another one. Based on the proportion of patients (per region) referred for cardiology follow-up, referral for cardiology follow-up was associated with lower 30-day (OR 0.70; CI 0.55, 0.89) and one-year mortality (OR 0.81; CI 0.68, 0.95) compared with no plans for cardiology follow-up (i.e., standard follow-up done by family doctors). Results from hierarchical logistic models and propensity matched models were consistent (30-day mortality OR 0.66; CI 0.61, 0.72 and 0.66; CI 0.58, 0.76 for hierarchical and propensity matched models, respectively). For patients with HFREF admitted to hospital with worsening symptoms, referral to cardiology services for follow-up after discharge is strongly associated with reduced mortality, both early and late

The year in cardiology 2019: heart failure

No abstract available

Model-based cost-effectiveness analysis of B-type natriuretic peptide-guided care in patients with heart failure

OBJECTIVE: Monitoring B-type natriuretic peptide (BNP) to guide pharmacotherapy might improve survival in patients with heart failure with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF). However, the cost-effectiveness of BNP-guided care is uncertain and guidelines do not uniformly recommend it. We assessed the cost-effectiveness of BNP-guided care in patient subgroups defined by age and ejection fraction. METHODS: We used a Markov model with a 3-month cycle length to estimate the lifetime health service costs, quality-adjusted life years (QALYs) and incremental net monetary benefits (iNMBs) of BNP-guided versus clinically guided care in 3 patient subgroups: (1) HFrEF patients <75 years; (2) HFpEF patients <75 years; and (3) HFrEF patients ≥75 years. There is no evidence of benefit in patients with HFpEF aged ≥75 years. We used individual patient data meta-analyses and linked primary care, hospital and mortality data to inform the key model parameters. We performed probabilistic analysis to assess the uncertainty in model results. RESULTS: In younger patients (<75 years) with HFrEF, the mean QALYs (5.57 vs 5.02) and costs (£63 527 vs £58 139) were higher with BNP-guided care. At the willingness-to-pay threshold of £20 000 per QALY, the positive iNMB (£5424 (95% CI £987 to £9469)) indicates that BNP-guided care is cost-effective in this subgroup. The evidence of cost-effectiveness of BNP-guided care is less strong for younger patients with HFpEF (£3155 (−£10 307 to £11 613)) and older patients (≥75 years) with HFrEF (£2267 (−£1524 to £6074)). BNP-guided care remained cost-effective in the sensitivity analyses, albeit the results were sensitive to assumptions on its sustained effect. CONCLUSIONS: We found strong evidence that BNP-guided care is a cost-effective alternative to clinically guided care in younger patients with HFrEF. It is potentially cost-effective in younger patients with HFpEF and older patients with HFrEF, but more evidence is required, particularly with respect to the frequency, duration and BNP target for monitoring. Cost-effectiveness results from trials in specialist settings cannot be generalised to primary care