Relationship between the place of living and mortality in patients with advanced heart failure

Social and environmental factors in advanced heart failure (HF) patients may be crucial to cope with the end stages of the disease. This study analyzes health inequalities and mortality according to place of residence (rural vs urban) in HF patients at advanced stages of the disease. Population-based cohort study including 1148 adult patients with HF attended in 279 primary care centers. Patients were followed for at least 1 year after reaching New York Heart Association IV functional class, between 2010 and 2014. Data came from primary care electronic medical records. Cox regression models were applied to determine the hazard ratios (HR) of mortality. Mean age was 81.6 (SD 8.9) years, and 62% were women. Patients in rural areas were older, particularly women aged > 74 years (p = 0.036), and presented lower comorbidity. Mortality percentages were 59 and 51% among rural and urban patients, respectively (p = 0.030). Urban patients living in the most socio-economically deprived neighborhoods presented the highest rate of health service utilization, particularly with primary care nurses (p-trend < 0.001). Multivariate analyses confirmed that men (HR 1.60, 95% confidence interval (CI) 1.34-1.90), older patients (HR 1.05, 95% CI 1.04-1.06), Charlson comorbidity index (HR 1.16, 95% CI 1.11-1.22), and residing in rural areas (HR 1.35, 95% CI 1.09 to 1.67) was associated with higher mortality risk. Living in rural areas determines an increased risk of mortality in patients at final stages of heart failure

Mortalidad a corto plazo en los pacientes con insuficiencia cardiaca en estadios finales

Objectives: This study is aimed at analyzing the impact of the main factors contributing to short and long-term mortality in patients at final stages of heart failure (HF). Setting: Patients attended at any of the 279 primary health care centers belonging to the Institut Català de la Salut, in Catalonia (Spain). Participants: Patients with Advanced HF. Design: Multicenter cohort study including 1148 HF patients followed for one-year after reaching New York Heart Association (NYHA) IV. Main measurements: The primary outcome was all-cause mortality. Multivariate logistic regression models were performed to assess the outcomes at 1, 3, 6, and 12 months. Results: Mean age of patients was 82 (SD 9) years and women represented 61.7%. A total of 135 (11.8%) and 397 (34.6%) patients died three months and one year after inclusion, respectively. Male gender, age, and decreased body mass index were associated with higher mortality at three, six and twelve months. In addition, low systolic blood pressure levels, severe reduction in glomerular filtration, malignancy, and higher doses of loop diuretics were related to higher mortality from 6 to 12 months. The most important risk factor over the whole period was presenting a body mass index lower than 20 kg/m2 (three months OR 3.06, 95% CI: 1.58–5.92; six months OR 4.42, 95% CI: 2.08–9.38; and 12 months OR 3.68, 95% CI: 1.76–7.69). Conclusions: We may conclude that male, age, and decreased body mass index determined higher short-term mortality in NYHA IV. In addition, low systolic blood pressure, reduced glomerular filtration, malignancy, and higher doses of loop diuretics contribute to increasing the risk of mortality at medium and long-term. Such variables are easily measurable and can help to decide the best way to face the most advances stages of the disease.Objetivos: Analizar los factores que contribuyen a la mortalidad de pacientes en las etapas finales de la insuficiencia cardiaca (IC). Ámbito: Centros de atención primaria del Institut Català de la Salut, Cataluña, España. Participantes: Pacientes con IC avanzada. Diseño: Estudio de cohortes multicéntrico. Incluyó 1.148 pacientes de IC seguidos durante un año tras el registro de estadio funcional NYHA IV. Mediciones principales: El resultado principal fue la mortalidad por todas las causas. Se realizaron modelos de regresión logística multivariada (1, 3, 6 y 12 meses). Resultados: Edad media 82 años (DE 9), las mujeres representaron el 61,7%. Un total de 135 (11,8%) y 397 (34,6%) pacientes murieron 3 meses y un año después de su inclusión. El sexo masculino, la edad y el índice de masa corporal (IMC) < 20 kg/m2 se asociaron con una mayor mortalidad a los 3, 6 y 12 meses. Bajos niveles de presión arterial sistólica, reducción severa en el filtrado glomerular, malignidad y dosis altas de diuréticos fueron relacionadas con una mortalidad más alta de 6 a 12 meses. El factor de riesgo más importante fue un IMC < 20 kg/m2 (3 meses OR: 3,06; IC 95%: 1,58-5,92; 6 meses OR: 4,42; IC 95%: 2,08-9,38 y 12 meses OR: 3,68; IC 95%: 1,76-7,69). Conclusiones: Los varones, la edad avanzada y un IMC disminuido determinaron una mortalidad a corto plazo más alta en pacientes NYHA IV. La baja presión arterial sistólica, la reducción del filtrado glomerular, la malignidad y las dosis altas de diuréticos aumentan el riesgo de mortalidad a medio y largo plazo. Estas variables son fáciles de obtener, y pueden ayudar a decidir las mejores estrategias para afrontar los estadios más avanzados de la enfermedad

Soluble Transferrin Receptor as Iron Deficiency Biomarker: Impact on Exercise Capacity in Heart Failure Patients

The soluble transferrin receptor (sTfR) is a marker of tissue iron status, which could indicate an increased iron demand at the tissue level. The impact of sTfR levels on functional capacity and quality of life (QoL) in non-anemic heart failure (HF) patients with otherwise normal systemic iron status has not been evaluated. We conducted an observational, prospective, cohort study of 1236 patients with chronic HF. We selected patients with normal hemoglobin levels and normal systemic iron status. Tissue iron deficiency (ID) was defined as levels of sTfR > 75th percentile (1.63 mg per L). The primary endpoints were the distance walked in the 6 min walking test (6MWT) and the overall summary score (OSS) of the Minnesota Living with Heart Failure Questionnaire (MLHFQ). The final study cohort consisted of 215 patients. Overall QoL was significantly worse (51 +/- 27 vs. 39 +/- 20, p-value = 0.006, respectively), and the 6 MWT distance was significantly worse in patients with tissue ID when compared to patients without tissue ID (206 +/- 179 m vs. 314 +/- 155, p-value < 0.0001, respectively). Higher sTfR levels, indicating increased iron demand, were associated with a shorter distance in the 6 MWT (standardized beta = -0.249, p < 0.001) and a higher MLHFQ OSS (standardized fi = 0.183, p-value = 0.008). In this study, we show that in patients with normal systemic iron parameters, higher levels of sTfR are strongly associated with an impaired submaximal exercise capacity and with worse QoL

Burden of heart failure in primary healthcare

Objectives: To determine the epidemiology of heart failure registered in primary healthcare clinical records in Catalunya, Spain, between 2010 and 2014, focusing on incidence, mortality, and resource utilization. Design: Retrospective observational cohort study. Setting: Study was carried out in primary care setting. Participants and interventions: Patients registered as presenting a new heart failure diagnosis. The inclusion period ran from 1st January 2010 to 31st December 2013, but patients were followed until 31st December 2013 in order to analyze mortality. Main measures: Information came from electronic medical records. Results: A total of 64 441 patients were registered with a new diagnosis of heart failure (2.76 new cases per 1000 persons-year). Among them, 85.8% were ≥65 years. The number of cases/1000 persons-year was higher in men in all age groups. Incidence ranged from 0.04 in women <45 years to 27.61 in the oldest group, and from 0.08 in men <45 years to 28.52 in the oldest group. Mortality occurred in 16 305 (25.3%) patients. Primary healthcare resource utilization increased after the occurrence of heart failure, especially the number of visits made by nurses to the patients’ homes. Conclusion: Heart failure incidence increases with age, is greater in men, and remains stable. Mortality continues to be high in newly diagnosed patients in spite of the current improvements in treatment. Home visits represent the greatest cost for the management of this disease in primary care setting. Resumen: Objetivo: Determinar la epidemiología de la insuficiencia cardíaca registrada en las historias clínicas de atención primaria en Cataluña, España, entre 2010 y 2014, centrándose en la incidencia, la mortalidad y la utilización de recursos sanitarios. Diseño: Estudio de cohorte observacional retrospectivo. Emplazamiento: El estudio se llevó a cabo en atención primaria. Participantes e intervenciones: Pacientes registrados con nuevo diagnóstico de insuficiencia cardíaca en el período de estudio. El período de inclusión fue del 1 de enero de 2010 al 31 de diciembre de 2013, pero los pacientes se siguieron hasta el 31 de diciembre de 2014 para poder determinar la mortalidad. Mediciones principales: La información se obtuvo de la historia clínica electrónica de los participantes. Resultados: Se registraron un total de 64.441 pacientes con nuevo diagnóstico de insuficiencia cardíaca (2,76 nuevos casos/1000 personas-año). De ellos, el 85,8% tenían ≥65 años. El número de casos/1000 personas-año fue mayor en hombres en todos los grupos de edad. La incidencia varió de 0,04 en mujeres <45 años a 27,61 en el grupo de mayor edad, y de 0,08 en hombres <45 años a 28,52 en el grupo de mayor edad. La mortalidad se produjo en 16.305 (25,3%) pacientes. La utilización de los recursos de atención primaria aumentó tras el diagnóstico de insuficiencia cardíaca, especialmente el número de visitas realizadas por las enfermeras a los pacientes en su domicilio. Conclusión: La incidencia de insuficiencia cardíaca aumenta con la edad, es mayor en hombres y se mantiene estable en el tiempo. La mortalidad continúa siendo alta en pacientes recién diagnosticados a pesar de las mejoras actuales en el tratamiento. Las visitas domiciliarias representan el mayor coste para el manejo de esta enfermedad en el ámbito de atención primaria

Short-term mortality in end-stage heart failure patients

This study is aimed at analyzing the impact of the main factors contributing to short and long-term mortality in patients at final stages of heart failure (HF). Patients attended at any of the 279 primary health care centers belonging to the Institut Català de la Salut, in Catalonia (Spain). Patients with Advanced HF. Multicenter cohort study including 1148 HF patients followed for one-year after reaching New York Heart Association (NYHA) IV. The primary outcome was all-cause mortality. Multivariate logistic regression models were performed to assess the outcomes at 1, 3, 6, and 12 months. Mean age of patients was 82 (SD 9) years and women represented 61.7%. A total of 135 (11.8%) and 397 (34.6%) patients died three months and one year after inclusion, respectively. Male gender, age, and decreased body mass index were associated with higher mortality at three, six and twelve months. In addition, low systolic blood pressure levels, severe reduction in glomerular filtration, malignancy, and higher doses of loop diuretics were related to higher mortality from 6 to 12 months. The most important risk factor over the whole period was presenting a body mass index lower than 20 kg/m 2 (three months OR 3.06, 95% CI: 1.58-5.92; six months OR 4.42, 95% CI: 2.08-9.38; and 12 months OR 3.68, 95% CI: 1.76-7.69). We may conclude that male, age, and decreased body mass index determined higher short-term mortality in NYHA IV. In addition, low systolic blood pressure, reduced glomerular filtration, malignancy, and higher doses of loop diuretics contribute to increasing the risk of mortality at medium and long-term. Such variables are easily measurable and can help to decide the best way to face the most advances stages of the disease

Interplay between psychosocial and heart failure related factors may partially explain limitations in self-efficacy in patients with heart failure and poor self-care behaviour: insights from a real-world cohort of 1,123 patients

Background and aims: Worse self-care is associated with a higher risk of readmission and mortality in patients with heart failure (HF). Little is known about how the interplay between clinical and psycho-social factors may modulate self-care behaviours in these patients. The aim of our study was to identify clinical, and particularly psycho-social factors associated with worse self-care and assess their interaction inpatients with heart failure. Methods and results: We conducted an observational, prospective, cohort study of 1,123 consecutive patients with chronic heart failure.. Self-care was assessed with the modified European Heart Failure Self-care Behavior Scale 9-item version (EHFSCBS-9), and both clinical and psycho-social profile of the patients included were also meticulously evaluated. A total of 484 patients (43%) were women, mean age was 72 years, and mean left ventricular ejection fraction was 44.5%. In multivariable analyses combining clinical and psycho-social factors, low social support (OR 3.53, 95% CI [2.13-5.86]; p-value <0.001), absence of caregiver support (OR 2.16, 95% CI [1.34 -3.48]; p-value 0.001) and depressive symptoms (OR 2.40, 95% CI [1.53-3.77]; p-value <0.001) were independent determinants of impaired global self-care. Advanced functional class was associated with better self-care (OR 0.43, 95%CI [0.26-0.70]; p-value 0.001). No other clinical factors remained significantly associated with self-care in these joint models. In discrimination analyses, models containing psycho-social determinants outperformed models only containing heart failure -related (clinical) variables (all p-values<0.001). Conclusion: Impairment in self-care behaviour is strongly determined by psycho-social factors. Specifically, low social support, the lack of caregiver support and the presence of depressive symptoms are the main drivers of the risk of impairment of self-care in heart failure patients. Evaluation of self-care and self-care interventions should be complemented by a comprehensive psycho-social assessment in patients with heart failure

Impact on clinical events and healthcare costs of adding telemedicine to multidisciplinary disease management programmes for heart failure: Results of a randomized controlled trial

BACKGROUND: The role of telemedicine in the management of patients with chronic heart failure (HF) has not been fully elucidated. We hypothesized that multidisciplinary comprehensive HF care could achieve better results when it is delivered using telemedicine./nMETHODS AND RESULTS: In this study, 178 eligible patients with HF were randomized to either structured follow-up on the basis of face-to-face encounters (control group, 97 patients) or delivering health care using telemedicine (81 patients). Telemedicine included daily signs and symptoms based on telemonitoring and structured follow-up by means of video or audio-conference. The primary end-point was non-fatal HF events after six months of follow-up. The median age of the patients was 77 years, 41% were female, and 25% were frail patients. The hazard ratio for the primary end-point was 0.35 (95% confidence interval (CI), 0.20-0.59; p-value  0.05). The telemedicine group experienced a significant mean net reduction in direct hospital costs of €3546 per patient per six months of follow-up. CONCLUSIONS:/nAmong patients managed in the setting of a comprehensive HF programme, the addition of telemedicine may result in better outcomes and reduction of costs.This study was financially supported by Telefonica Soluciones S.A and Hospital del Mar Medical Research Institute (IMIM) upon Research and innovation agreement signed in 2008 between both institutions

Impact of implementing electronic clinical practice guidelines for the diagnosis, control and treatment of cardiovascular risk factors: A pre-post controlled study

OBJECTIVE: To evaluate the impact of computerized clinical practice guidelines on the management, diagnosis, treatment, control, and follow-up of the main cardiovascular risk factors: hypertension, hypercholesterolaemia, and type 2 diabetes mellitus. DESIGN: Pre-post controlled study. SETTING: Catalonia, autonomous community located in north-eastern Spain. PARTICIPANTS: Individuals aged 35-74 years assigned to general practitioners of the Catalan Health Institute. INTERVENTION: The intervention group consisted of individuals whose general practitioners had accessed the computerized clinical practice guidelines at least twice a day, while the control group consisted of individuals whose general practitioner had never accessed the computerized clinical practice guidelines platform. MAIN OUTCOMES: The Chi-squared test was used to detect significant differences in the follow-up, control, and treatment variables for all three disorders (hypertension, hypercholesterolaemia, and type 2 diabetes mellitus) between individuals assigned to users and non-users of the computerized clinical practice guidelines, respectively. RESULTS: A total of 189,067 patients were included in this study, with a mean age of 56 years (standard deviation 12), and 55.5% of whom were women. Significant differences were observed in hypertension management, treatment and control; type 2 diabetes mellitus management, treatment and diagnoses, and the management and control of hypercholesterolaemia in both sexes. CONCLUSIONS: omputerized clinical practice guidelines are an effective tool for the control and follow-up of patients diagnosed with hypertension, type 2 diabetes mellitus, and hypercholesterolaemia. The usefulness of computerized clinical practice guidelines to diagnose and adequately treat individuals with these disorders remains unclear

Impact of telemedicine on the clinical outcomes and healthcare costs of patients with chronic heart failure and mid-range or preserved ejection fraction managed in a multidisciplinary chronic heart failure programme: a sub-analysis of the iCOR randomized trial

Background The efficacy of telemedicine in the management of patients with chronic heart failure and left ventricular ejection fraction ≥40% is poorly understood. The aim of our analysis was to evaluate the efficacy of a telemedicine-based intervention specifically in these patients, as compared to standard of care alone. Methods The Insuficiència Cardiaca Optimització Remota (iCOR) study was a single centre, randomised, controlled trial, designed to evaluate a telemedicine intervention added to an existing hospital/primary care multidisciplinary, integrated programme for chronic heart failure patients. 178 participants were randomised to telemedicine or usual care, and were followed for six months. For the present sub-analysis, only iCOR participants (n = 116) with left ventricular ejection fraction ≥40% were included. The primary study endpoint was the incidence of an acute non-fatal heart failure event, defined as a new episode of worsening of symptoms and signs consistent with acute heart failure requiring intravenous diuretic therapy. The healthcare-related costs in each study group were also evaluated. Results The incidence of the first occurrence of the primary endpoint was significantly lower in the telemedicine arm (22% vs 56%, p<0.001), with a hazard ratio of 0.33 comparing to the usual care arm (95% confidence interval 0.17-0.64). Telemedicine was also associated with lower mean overall chronic heart failure care-related costs compared to usual care (8163€ vs 4993€, p=0.001). The results were consistent in both left ventricular ejection fraction of 40-49% and left ventricular ejection fraction ≥50% patients. Conclusions Our results suggest that telemedicine is a promising strategy for the management of chronic heart failure patients with left ventricular ejection fraction ≥40%. These findings should be replicated in larger cohorts

Short-Term Mortality in Patients with Heart Failure at the End-of-Life Stages: Hades Study

Background: Information regarding short-term vital prognosis in patients with heart failure at advanced stages of the disease is scarce. Objective: To develop a three-month mortality predictive model for patients with advanced heart failure. Methods: Prospective observational study carried out in primary care and a convalescence community facility. Heart failure patients either New York Heart Association (NYHA) III with at least two HF hospitalizations during the previous six months or NYHA IV with/without previous recent hospitalization were included in the study. Multivariable predictive models using Cox regression were performed. Results: Of 271 patients included, 55 (20.3%) died during the first three months of follow-up. Mean age was 84.2 years (SD 8.3) and 59.8% were women. Predictive model including NT-proBNP had a C-index of 0.78 (95% CI 0.71; 0.85) and identified male gender, low body mass index, high potassium and NT-proBNP levels, and moderate-to-severe dependence for daily living activities (Barthel index < 40) as risk factors of mortality. In the model without NT-proBNP, C index was 0.72 (95% CI 0.64; 0.79) and, in addition to gender, body mass index, low Barthel index, and severe reductions in glomerular filtration rate showed the highest predictive hazard ratios for short-term mortality. Conclusions: In addition to age, male gender, potassium levels, low body mass index, and low glomerular filtration, dependence for activities of daily living add strong power to predict mortality at three months in patients with advanced heart failur