Heart failure : studies of prognosis and advanced therapy

Background Heart failure (HF) is a major health problem affecting 2-3% of the Western population. The clinical syndrome of HF is associated with reduced (HFrEF) or preserved (HFpEF) ejection fraction. Around 50% of the patients have HFrEF and despite advances in treatment, prognosis remains poor and treatments are underutilized. In HFpEF the prognosis is comparable to in HFrEF, but there is no evidence-based therapy. Aims -to investigate 1 The use of evidence-based therapy and survival over time in patients with HFrEF 2 The use of the inotropic drug levosimendan in HF in Sweden 3 a) Contemporary prognosis in patients with severe HFrEF 3 b) If simple predictors of prognosis can be identifid and used as criteria for referral to a HF center 4 Predictors of mortality in patients hospitalized with acute decompensated HFpEF Evidence-based therapy and survival We studied 5,908 HFrEF patients with New York Heart Association (NYHA) class II-IV registered in the Swedish Heart Failure registry (SwedeHF) between 2003 and 2012. The use of beta-blockers and renin angiotensin system (RAS) blockers was >85% and stable over time. There was a decrease in the use of mineralocorticoid receptor antagonists (MRA) from 53 to 42%. The use of cardiac resynchronization therapy (CRT) and implantable cardioverter defirillators (ICD) increased over time, but absolute numbers were low, less than 11% for both. In 2003 vs. 2012, the 30-day, oneyear, and 3-year survival was 92 vs. 94%, 81 vs. 77% and 58 vs. 54% respectively. The changes in survival were not statistically signifiant. Reported numbers are risk-adjusted. The use of levosimendan in Sweden In SwedeHF, 655 registrations were confimed with use of inotropes. Levosimendan alone was the inotropic drug of choice in 91% of the registrations. Of all levosimendan registrations, 38% were planned repetitive treatment. The proportion of planned repetitive to all levosimendan registrations ranged from 0 to 65% between hospitals. Who should be referred to a heart failure center? We studied 10,062 HFrEF patients with NYHA class III-IV from SwedeHF. One-year survival in the age groups ≤65 years, 66-80 years, and >80 years was 90, 79, and 61% respectively. Five prespecifid risk factors were assessed as potential triggers for referral to a HF center: systolic blood pressure ≤90 mmHg; creatinine ≤160 mmol/L; hemoglobin ≤120 g/L; no use of RAS antagonist; and no use of beta-blocker. In patients <80 years of age, the presence of 1, 2, or 3-5 of these risk factors were associated with a one-year survival of 79, 60, and 39% respectively. Risk prediction in HFpEF HF Surveillance data from four different communities in the United States were used to study 2,304 hospitalizations of HFpEF. Mortality at 28 days and one year was 11 and 34% respectively. The most powerful predictors of mortality were higher age, hypoxia, higher blood urea nitrogen and lower hemoglobin. Conclusions Patients with HF face a high risk of death. In HFpEF novel interventions are urgently called for, whereas improving implementation of existing evidence-based treatments should be emphasized in HFrEF. Specifially, the poor use of ICD and CRT needs to be recognized. Levosimendan was the dominant choice of inotrope in Sweden. Effects of the frequent use of planned repetitive levosimendan treatment in a non-acute setting need to be further evaluated. Few and simple risk factors used as referral criteria to a HF center, may increase the number of patients who can benefi from further therapy. In HFpEF, risk predictors may be used for discrimination of high risk patients and contribute to further characterization of this population

Focusing on Referral Rather than Selection for Advanced Heart Failure Therapies

Despite advances in heart failure treatment, advanced heart failure affects 5–10% of people with the condition and is associated with poor prognosis. Selection for heart transplantation and left ventricular assist device implantation is a rigorous and validated process performed by specialised heart failure teams. This entails comprehensive assessment of complex diagnostic tests and risk scores, and selecting patients with the optimal benefit-risk profile. In contrast, referral for advanced heart failure evaluation is an arbitrary and poorly studied process, performed by generalists, and patients are often referred too late or not at all. The study elaborates on the differences between selection and referral and proposes some simple strategies for optimising timely referral for advanced heart failure evaluation

Congestion and Diuretic Resistance in Acute or Worsening Heart Failure

Hospitalisation for acute heart failure (AHF) is associated with high mortality and high rehospitalisation rates. In the absence of evidence-based therapy, treatment is aimed at stabilisation and symptom relief. The majority of AHF patients have signs and symptoms of fluid overload, and, therefore, decongestion is the number one treatment goal. Diuretics are the cornerstone of therapy in AHF, but the treatment effect is challenged by diuretic resistance and poor diuretic response throughout the spectrum of chronic to worsening to acute to post-worsening HF. Adequate dosing and monitoring and evaluation of diuretic effect are important for treatment success. Residual congestion at discharge is a strong predictor of worse outcomes. Therefore, achieving euvolaemia is crucial despite transient worsening renal function

Innovation policy in the Norwegian aquaculture industry: Reshaping aquaculture production innovation networks

While aquaculture production in a number of countries has been highly successful in terms of production growth, there is also a number of instances where the rapid growth has been curtailed due to sustainability challenges. In response, fostering sustainable aquaculture production has become a key policy and research agenda. The point of departure for this paper is the radical technological innovations based sustainable restructuring dynamics of the Norwegian salmon farming industry, which despite becoming one of the most profitable aquaculture industries in the world, has in recent years seen its growth curtailed due to sustainability challenges. To address these challenges and to enable the use of new areas currently inaccessible by the incumbent aquaculture technology, the Norwegian authorities launched in 2015 a new type of innovation policy instrument, known as development licences. Based on a mapping of the aquaculture production technology development projects as well as in-depth interviews, this paper elucidates how the targeted innovation policy instrument has instigated the sustainable restructuring process of the Norwegian aquaculture industry. Our findings indicate that in the short term, the innovation policy appears to have succeeded in the reconfiguration, and more precisely, the ’renewal’ process of the aquaculture production technology innovation networks (ecosystems) thanks to the entry of the new capable actors into the segment. However, we emphasise that the overall success of the innovation policy instrument will ultimately hinge upon sufficiently addressing certain aspects of the institutional failures in the sector.Innovation policy in the Norwegian aquaculture industry: Reshaping aquaculture production innovation networkspublishedVersio

Eligibility for dapagliflozin and empagliflozin in a real-world heart failure population

Background: We investigated eligibility for dapagliflozin and empagliflozin in a real-world heart failure (HF) cohort based on selection criteria of DAPA-HF, DELIVER, and EMPEROR trials. Methods and Results: Selection criteria were applied to the Swedish HF registry out-patient population according to three scenarios: (i) a “trial scenario” applying all selection criteria; (ii) a “pragmatic scenario” applying the most clinically relevant criteria; (iii) a “label scenario” following the regulatory agencies labels. Of 49,317 patients, 55% had ejection fraction (EF)&lt;40% and were assessed for eligibility based on DAPA-HF and EMPEROR-Reduced, 45% had EF≥40% and were assessed based on EMPEROR-Preserved and DELIVER. Eligibility using trial, pragmatic and label scenarios was: 35%, 61% and 80% for DAPA-HF; 31%, 55% and 81% for EMPEROR-Reduced; 30%, 61% and 74% for DELIVER; 32%, 59% and 75% for EMPEROR-Preserved. Main selection criteria limiting eligibility were HF duration and NT-proBNP. Eligible patients had more severe HF, more comorbidities, higher use of HF treatments and higher mortality/morbidity. Conclusions: In a real-world HF setting, eligibility for SGLT2i was similar whether selection criteria from DAPA-HF or EMPEROR-Reduced were applied in HFrEF, or EMPEROR-Preserved or DELIVER in HFpEF. These data might help stakeholders assessing the consequences of future trial eligibility

The making of a louse- Constructing governmental technology for sustainable aquaculture

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Certifying the public image? Reputational gains of certification in Norwegian salmon aquaculture

The Norwegian aquaculture industry faces pressure from stakeholders, the public, and government to ensure sustainable production. Sustainability is closely linked with solving key environmental challenges. Standards such as those created by the Aquaculture Stewardship Council (ASC) are universal and generally provide what is known as additionality to state regulation, such as more comprehensive requirements, with the goal of enhancing sustainability. Acquiring certification can be expensive, but it has been shown that the industry spends large amounts of time and resources to voluntarily become ASC certified. In this article, we study the motivations for ASC certification. In line with previous work, we find several motivations for obtaining certification, even though it is no guarantee for financial gains like premium prices or better market access. Still, it may be just as valuable for industry actors to use certification to create room to maneuver so as to be prepared for future market claims, changes in regulations, and increased pressure for more sustainable production. Furthermore, certification is perceived as having the potential to improve producers' and retailers' reputation and standing both locally and globally. Certification and the use of labels can be tools in reputational management. By reducing complexity and uncertainty in communication, certification labelling can help consumers improve their product choices in terms of sustainability. Industry actors in this study express approval of certification and desire the potential reputational gain that comes from it; however, our findings suggest that this potential has not been fully realized. The industry experiences challenges in communicating with the local and global public and lacks influence on what is communicated to consumers through retailers. Therefore, it appears that those actually reaping the potential reputational gains of ASC certification are the non-governmental organizations behind the creation of the ASC and the retailers that demand ASC-certified salmon

Certifying the public image? Reputational gains of certification in Norwegian salmon aquaculture

The Norwegian aquaculture industry faces pressure from stakeholders, the public, and government to ensure sustainable production. Sustainability is closely linked with solving key environmental challenges. Standards such as those created by the Aquaculture Stewardship Council (ASC) are universal and generally provide what is known as additionality to state regulation, such as more comprehensive requirements, with the goal of enhancing sustainability. Acquiring certification can be expensive, but it has been shown that the industry spends large amounts of time and resources to voluntarily become ASC certified. In this article, we study the motivations for ASC certification. In line with previous work, we find several motivations for obtaining certification, even though it is no guarantee for financial gains like premium prices or better market access. Still, it may be just as valuable for industry actors to use certification to create room to maneuver so as to be prepared for future market claims, changes in regulations, and increased pressure for more sustainable production. Furthermore, certification is perceived as having the potential to improve producers' and retailers' reputation and standing both locally and globally. Certification and the use of labels can be tools in reputational management. By reducing complexity and uncertainty in communication, certification labelling can help consumers improve their product choices in terms of sustainability. Industry actors in this study express approval of certification and desire the potential reputational gain that comes from it; however, our findings suggest that this potential has not been fully realized. The industry experiences challenges in communicating with the local and global public and lacks influence on what is communicated to consumers through retailers. Therefore, it appears that those actually reaping the potential reputational gains of ASC certification are the non-governmental organizations behind the creation of the ASC and the retailers that demand ASC-certified salmon.publishedVersio

The making of a louse - Constructing governmental technology for sustainable aquaculture

Salmon production, and aquaculture in general, entails certain environmental risks that must be managed and controlled. In Norway, as in other aquaculture-producing countries, governments seek means of improving the industry and encouraging sustainable conduct. In Norwegian aquaculture regulation, the salmon louse has become an important indicator and regulatory instrument – a governmental technology. The louse is a proxy for the environmental impact of the industry and as a governmental technology, it is used to regulate and incite behavior. In this paper, we draw on results from both interviews and an analysis of responses to a consultation round for a governmental White Paper proposing new means for regulating the growth of the aquaculture industry. Based on these results, we investigate the becoming of the salmon louse as a regulatory instrument, and how this is perceived among relevant stakeholders. The political significance of the salmon louse serves to illuminate how a governmental technology is created to instill control from a distance. The history of how the salmon louse has become a governable object additionally elucidates disagreements and uncertainties surrounding modern salmon farming and demonstrates that the creation of governmental technologies persists in the face of resistance