Waarde van lichte en intensieve begeleiding van patienten met hartfalen; resultaten van het COACH-onderzoek.

OBJECTIVE: To determine the efficacy of 2 nurse-directed programmes of different intensity for the counselling and follow-up of patients hospitalised for heart failure, compared with standard care by a cardiologist. DESIGN: Multicentre randomised clinical trial (www.trialregister.nl: NCT 98675639). METHOD: A total of 1023 patients were randomized after hospitalisation for heart failure to 1 of 3 treatment strategies: standard care provided by a cardiologist, follow-up care from a cardiologist with basic counselling and support by a nurse specialising in heart failure, or follow-up care from a cardiologist with intensive counselling and support by a nurse specialising in heart failure. Primary end points were the time to rehospitalisation due to heart failure or death and the number of days lost to rehospitalisation or death during the 18-month study period. Data were analysed on an intent-to-treat basis. RESULTS: Mean patient age was 71 years, 38% were women, 50% had mild heart failure and 50% had severe heart failure. During the study, 411 patients (40%) were rehospitalised due to heart failure or died from any cause: 42% in the control group, and 41% and 38% in the basic and intensive support groups, respectively (differences not significant). The time to rehospitalisation or death was similar in the 3 groups: hazard ratios for the basic and intensive support groups versus the control group were 0.96 (95% CI: 0.76-1.21; p = 0.73) and 0.93 (95% CI: 0.73-1.17; p = 0.53), respectively. The number of days lost to rehospitalisation or death was 39,960 in the control group; this number was 15% less in the intervention groups, but the difference was not significant. However, there was a trend toward lower mortality in the intervention groups. In all 3 groups, more visits occurred than planned, which may have had a considerable effect on care, notably in the control group. CONCLUSION: The results of this study indicated that the provision of additional counselling and support by a nurse specialising in heart failure as an adjuvant to intensive follow-up care provided by a cardiologist does not always lead to a reduction in rehospitalisation frequenc

Hereditary deficiency of protein C or protein S confers increased risk of arterial thromboembolic events at a young age: results from a large family cohort study.

Contains fulltext : 70054.pdf (publisher's version ) (Closed access)BACKGROUND: Whether hereditary protein S, protein C, or antithrombin deficiency is associated with arterial thromboembolism (ATE) and whether history of venous thromboembolism in these subjects predisposes them to subsequent ATE have yet to be determined. METHODS AND RESULTS: On the basis of pedigree analysis, we enrolled a total of 552 subjects (52% women; mean age, 46+/-17 years), belonging to 84 different kindreds, in this retrospective family cohort study. Detailed information on previous episodes of venous thromboembolism, ATE, anticoagulant use, and atherosclerosis risk factors was collected. Primary study outcome was objectively verified symptomatic ATE. Of 552 subjects, 308 had protein S (35%), protein C (39%), or antithrombin (26%) deficiency. Overall, annual incidences of ATE were 0.34% (95% confidence interval [CI], 0.23 to 0.49) in deficient versus 0.17% (95% CI, 0.09 to 0.28) in nondeficient subjects; the hazard ratio was 2.3 (95% CI, 1.2 to 4.5). Because the risk hazards varied over lifetime, we performed a time-dependent analysis. After adjusting for atherosclerosis risk factors and clustering within families, we found that deficient subjects had a 4.7-fold (95% CI, 1.5 to 14.2; P=0.007) higher risk for ATE before 55 years of age versus 1.1 (95% CI, 0.5 to 2.6) thereafter compared with nondeficient family members. For separate deficiencies, the risks were 4.6- (95% CI, 1.1 to 18.3), 6.9- (95% CI, 2.1 to 22.2), and 1.1- (95% CI, 0.1 to 10.9) fold higher in protein S-, protein C-, and antithrombin-deficient subjects, respectively, before 55 years of age. History of venous thromboembolism was not related to subsequent ATE (hazard ratio, 1.1; 95% CI, 0.5 to 2.2). CONCLUSIONS: Compared with nondeficient family members, subjects with protein S or protein C deficiency but not antithrombin deficiency have a higher risk for ATE before 55 years of age that is independent of prior venous thromboembolism

Comparison of late (four years) functional health status between percutaneous transluminal angioplasty intervention and off-pump left internal mammary artery bypass grafting for isolated high-grade narrowing of the proximal left anterior descending corona

In a 4-year follow-up study, we compared functional health status (FHS) in patients randomized to surgery (n = 51) or angioplasty (n = 51) for an isolated narrowing of the proximal left anterior descending coronary artery. FHS was assessed with the Short Form-36 and the Minnesota Living with Heart Failure questionnaires. Although the occurrence of angina (p = 0.036) and major adverse cardiac and cerebrovascular events (p = 0.02) was significantly higher 4 years after angioplasty, FHS did not differ between treatments and was comparable to a healthy reference population

Depression and the usefulness of a disease management program in heart failure: insights from the COACH (Coordinating study evaluating Outcomes of Advising and Counseling in Heart failure) study

OBJECTIVES: Our aim was to study the possible role of depressive symptoms in the effectiveness of a disease management program (DMP) in heart failure (HF) patients. BACKGROUND: Disease management programs are recommended in current HF guidelines, but certain patient groups, such as those with depression, might be less responsive to such programs. METHODS: From the data of a large multicenter study, in which we examined the effect of a DMP in HF patients, we investigated a potential interaction between depressive symptoms at baseline and the effect of such a program. RESULTS: Of the 958 HF patients (37% female; age 71 +/- 11 years; New York Heart Association functional class II to IV), 377 (39%) reported depressive symptoms at baseline. During 18 months of follow-up, the primary end point (composite of all-cause mortality and HF readmission) occurred in 39% of the nondepressed patients and 42% of depressed patients. In the overall sample, there was no significant effect of DMP on the composite primary end point. The effect of the DMP was significantly different in nondepressed than in depressed HF patients. A significant effect modification by depressive symptoms was observed in evaluating the effect of the DMP on all-cause mortality and HF readmission (p = 0.03). In patients without depressive symptoms, DMP resulted in a trend for lower incidence of the primary end point (hazard ratio: 0.8, 95% confidence interval: 0.61 to 1.04), whereas the reverse was observed in patients with depressive symptoms (hazard ratio: 1.3, 95% confidence interval: 0.95 to 1.98). CONCLUSIONS: Depressive symptoms in patients with HF have a major effect on the usefulness of DMP. Identification of depressive symptoms before enrollment in a DMP might lead to more accurate use of a DMP, because depressive patients might not benefit from a general program. (Netherlands Heart Foundation Coordinating study evaluating Outcomes of Advising and Counselling in Heart Failure; ISRCTN98675639)

The relevance of comorbidities for heart failure treatment in primary care: A European survey

Aim: To assess the impact of comorbidities on chronic heart failure (CHF) therapy. Methods: The IMPROVEMENT-HF survey included 11,062 patients from 100 primary care practices in 14 European countries. The influence of patient characteristics on drug regimes was assessed with multinomial logistical regression. Results: Combined drug regimes were given to 48% of CHF patients, consisting of 2.2 drugs on average. Patient characteristics accounted for 35%, 42% and 10% of the variance in one-, two- and three-drug regimes, respectively. Myocardial infarction (Ml), atrial fibrillation (AF), diabetes, hypertension, and lung disease influenced prescribing most. AF made all combinations containing beta-blockers more likely. Thus for single drug regimes, Ml increased the likelihood for non-recommended beta-blocker monotherapy (OR 1.3; 95% CI 1.2-1.4), while for combination therapy recommended regimes were most likely. For both hypertension and diabetes, ACE-inhibitors were the most likely single drug, while the most likely second drugs were beta-blockers in hypertension and digoxin in diabetes. Conclusions: Patient characteristics have a clear impact on prescribing in European primary care. Up to 56% of drug regimes were rational taking patient characteristics into account. Situations of insufficient prescribing, such as patients post Ml, need to be addressed specifically. (c) 2005 European Society of Cardiology. Published by Elsevier B.V. All rights reserved

High long-term absolute risk of recurrent venous thromboembolism in patients with hereditary deficiencies of protein S, protein C or antithrombin.

Hereditary deficiencies of protein S, protein C and antithrombin are known risk factors for first venous thromboembolism. We assessed the absolute risk of recurrence, and the contribution of concomitant thrombophilic defects in a large cohort of families with these deficiencies. Annual incidence of recurrence was estimated in 130 deficient patients, with separate estimates for those with each of protein S, protein C, and antithrombin deficiency, and in eight non-deficient patients with prior venous thromboembolism. All patients were also tested for factor V Leiden, prothrombin G20210A, high levels of factors VIII, IX and XI, and hyperhomocysteinemia. There were 81 recurrent events among 130 deficient patients. Median follow-up was 4.6 years. Annual incidences (95% confidence interval) of recurrent venous thromboembolism were 8.4% (5.8-11.7) for protein S deficiency, 6.0% (3.9-8.7) for protein C deficiency, 10.0% (6.1-15.4) for antithrombin deficiency, and overall 7.7% (6.1-9.5). Relative risk of recurrence in patients with a spontaneous versus provoked first event was 1.5 (0.95-2.3). Cumulative recurrence rates at 1, 5 and 10 years were 15%, 38% and 53%. Relative risk of recurrence with concomitant defects was 1.4 (0.7-2.6) (1 defect) and 1.4 (0.8-2.7) (> or =2 defects). Annual incidence was 1.0% (0.03-5.5) in eight non-deficient patients. Annual incidence of major bleeding in deficient patients on oral anticoagulant treatment was 0.5% (0.2-1.0). We conclude that patients with a hereditary protein S, protein C or antithrombin deficiency appear to have a high absolute risk of recurrence. This risk is increased after a first spontaneous event, and by concomitance of other thrombophilic defects