‘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

Spatial variation of heart failure and air pollution in Warwickshire, UK : an investigation of small scale variation at the ward-level

Objectives To map using geospatial modelling techniques the morbidity and mortality caused by heart failure within Warwickshire to characterise and quantify any influence of air pollution on these risks. Design Cross-sectional. Setting Warwickshire, UK. Participants Data from all of the 105 current Warwickshire County wards were collected on hospital admissions and deaths due to heart failure. Results In multivariate analyses, the presence of higher mono-nitrogen oxide (NOx) in a ward (3.35:1.89, 4.99), benzene (Ben) (31.9:8.36, 55.85) and index of multiple deprivation (IMD; 0.02: 0.01, 0.03), were consistently associated with a higher risk of heart failure morbidity. Particulate matter (Pm; −12.93: −20.41, −6.54) was negatively associated with the risk of heart failure morbidity. No association was found between sulfur dioxide (SO2) and heart failure morbidity. The risk of heart failure mortality was higher in wards with a higher NOx (4.30: 1.68, 7.37) and wards with more inhabitants 50+ years old (1.60: 0.47, 2.92). Pm was negatively associated (−14.69: −23.46, −6.50) with heart failure mortality. SO2, Ben and IMD scores were not associated with heart failure mortality. There was a prominent variation in heart failure morbidity and mortality risk across wards, the highest risk being in the regions around Nuneaton and Bedworth. Conclusions This study showed distinct spatial patterns in heart failure morbidity and mortality, suggesting the potential role of environmental factors beyond individual-level risk factors. Air pollution levels should therefore be taken into account when considering the wider determinants of public health and the impact that changes in air pollution might have on the health of a population

Advanced chronic heart failure: A position statement from the Study Group on Advanced Heart Failure of the Heart Failure Association of the European Societyof Cardiology

Therapy has improved the survival of heart failure (HF) patients. However, many patients progress to advanced chronic HF (ACHF). We propose a practical clinical definition and describe the characteristics of this condition. Patients that are generally recognised as ACHF often exhibit the following characteristics: 1) severe symptoms (NYHA class III to IV); 2) episodes with clinical signs of fluid retention and/or peripheral hypoperfusion; 3) objective evidence of severe cardiac dysfunction, shown by at least one of the following: left ventricular ejection fraction1 HF hospitalisation in the past 6 months; 6) presence of all the previous features despite optimal therapy. This definition identifies a group of patients with compromised quality of life, poor prognosis, and a high risk of clinical events. These patients deserve effective therapeutic options and should be potential targets for future clinical research initiative

Biomarkers Beyond the Natriuretic Peptides for Chronic Heart Failure: Galectin-3 and Soluble ST2.

B-type natriuretic peptide (BNP) and NT-proBNP are widely used plasma biomarkers for the diagnosis of acute decompensated heart failure and prognosis for future cardiac disease. The clinical performance of these tests for management of chronic heart failure is somewhat limited by the markers' high biological variation. Biomarkers such as galectin-3 and soluble ST2 that reflect ongoing remodeling via cardiac fibrosis of the heart may provide complementary information to the natriuretic peptides in the management of chronic heart failure with regards to risk stratification for future adverse cardiac events (death, myocardial infarction, and need for heart transplantation). However, implementation of these biomarkers into routine clinical practice requires documentation that these tests will enable therapeutic decisions that can be made to improve clinical outcomes, and the availability of commercial assays. This report will discuss the need for novel heart failure biomarkers, ideal characteristics of assays, and review and compare the clinical performance of assays for galectin-3 and sST2 for chronic heart failure disease management

Mihai Gheorghiade, MD-Life and Concepts

How do you capture an idea, shape it, and then bring it into the world? Of his many talents, this ability was a fundamental characteristic of Mihai Gheorghiade. A quick glance through PubMed confirms his prodigious output, likely to overwhelm any novice or even expert scholar. His contribution to heart failure, especially acute heart failure (AHF), is profound, He authored several major concepts in acute heart failure, disseminated further by his students. Most concepts remained indelibly linked to his name: Digoxin trials research(1–3), AHFS (acute heart failure syndromes) definition(4), hemodynamic congestion(5), hospitalized heart failure (HHF) (6), the vulnerable phase(7,8), neutral hemodynamic agents(9), registries(10–12) and pre-trial registries(13), the “6-axis model”(14) and then the “8-axis model”(15). His work shaped the field of AHF

Physiological monitoring in the complex multimorbid heart failure patient - Conclusions.

Comorbidities are increasingly recognized as crucial components of the heart failure syndrome. Main specific challenges are polypharmacy, poor adherence to treatments, psychological aspects, and the need of monitoring after discharge. The chronic multimorbid patient therefore represents a specific heart failure phenotype that needs an appropriate and continuous management over time. This supplement issue covers the key points of a series of meeting coordinated by the Heart Failure Association of the European Society of Cardiology (ESC), that have discussed the issues surrounding the effective monitoring of our ever more complex and multimorbid heart failure patients. Here, we present an overview of the complex issues from a healthcare delivery perspective

Randomised controlled trial of specialist nurse intervention in heart failure

<p>Objectives. To determine whether specialist nurse intervention improves outcome in patients with chronic heart failure.</p> <p>Design. Randomised controlled trial.</p> <p>Setting. Acute medical admissions unit in a teaching hospital.</p> <p>Participants. 165 patients admitted with heart failure due to left ventricular systolic dysfunction. The intervention started before discharge and continued thereafter with home visits for up to 1 year.</p> <p>Main outcome measures. Time to first event analysis of death from all causes or readmission to hospital with worsening heart failure.</p> <p>Results. 31 patients (37%) in the intervention group died or were readmitted with heart failure compared with 45 (53%) in the usual care group (hazard ratio=0.61, 95% confidence interval 0.33 to 0.96).Compared with usual care, patients in the intervention group had fewer readmissions for any reason (86 v 114, P=0.018), fewer admissions for heart failure (19 v 45, P<0.001) and spent fewer days in hospital for heart failure (mean 3.43 v 7.46 days, P=0.0051).</p> <p>Conclusions. Specially trained nurses can improve the outcome of patients admitted to hospital with heart failure.</p&gt

Temporal trends and patterns in heart failure incidence: a population-based study of 4 million individuals

Background: Large-scale and contemporary population-based studies of heart failure incidence are needed to inform resource planning and research prioritisation but current evidence is scarce. We aimed to assess temporal trends in incidence and prevalence of heart failure in a large general population cohort from the UK, between 2002 and 2014. Methods: For this population-based study, we used linked primary and secondary electronic health records of 4 million individuals from the Clinical Practice Research Datalink (CPRD), a cohort that is representative of the UK population in terms of age and sex. Eligible patients were aged 16 years and older, had contributed data between Jan 1, 2002, and Dec 31, 2014, had an acceptable record according to CPRD quality control, were approved for CPRD and Hospital Episodes Statistics linkage, and were registered with their general practice for at least 12 months. For patients with incident heart failure, we extracted the most recent measurement of baseline characteristics (within 2 years of diagnosis) from electronic health records, as well as information about comorbidities, socioeconomic status, ethnicity, and region. We calculated standardised rates by applying direct age and sex standardisation to the 2013 European Standard Population, and we inferred crude rates by applying year-specific, age-specific, and sex-specific incidence to UK census mid-year population estimates. We assumed no heart failure for patients aged 15 years or younger and report total incidence and prevalence for all ages (>0 years). Findings: From 2002 to 2014, heart failure incidence (standardised by age and sex) decreased, similarly for men and women, by 7% (from 358 to 332 per 100 000 person-years; adjusted incidence ratio 0·93, 95% CI 0·91–0·94). However, the estimated absolute number of individuals with newly diagnosed heart failure in the UK increased by 12% (from 170 727 in 2002 to 190 798 in 2014), largely due to an increase in population size and age. The estimated absolute number of prevalent heart failure cases in the UK increased even more, by 23% (from 750 127 to 920 616). Over the study period, patient age and multi-morbidity at first presentation of heart failure increased (mean age 76·5 years [SD 12·0] to 77·0 years [12·9], adjusted difference 0·79 years, 95% CI 0·37–1·20; mean number of comorbidities 3·4 [SD 1·9] vs 5·4 [2·5]; adjusted difference 2·0, 95% CI 1·9–2·1). Socioeconomically deprived individuals were more likely to develop heart failure than were affluent individuals (incidence rate ratio 1·61, 95% CI 1·58–1·64), and did so earlier in life than those from the most affluent group (adjusted difference −3·51 years, 95% CI −3·77 to −3·25). From 2002 to 2014, the socioeconomic gradient in age at first presentation with heart failure widened. Socioeconomically deprived individuals also had more comorbidities, despite their younger age. Interpretation: Despite a moderate decline in standardised incidence of heart failure, the burden of heart failure in the UK is increasing, and is now similar to the four most common causes of cancer combined. The observed socioeconomic disparities in disease incidence and age at onset within the same nation point to a potentially preventable nature of heart failure that still needs to be tackled. Funding: British Heart Foundation and National Institute for Health Research

A simple prognostic index in acute heart failure

Background Rapid effective triage is integral to emergency care in patients hospitalized for heart failure, to guide the type and intensity of therapy. Several indexes and scores have been proposed to predict outcome; most of the them are complex and unfit to use at the bedside. Methods We propose a new prognostic index for in hospital mortality in acute heart failure. The index was built according to the formula; 220 – age – heart rate + systolic blood pressure – ( creatinine X 10). The index was tested in 1628 patients admitted for acute heart failure and enrolled, from November 2007 to December 2009, in the Italian Registry on Heart Failure Outcome ( IN-HF); a prospective, multicentre, observational study. Results The prognostic index was an independent predictor for in hospital mortality risk ( c statistic= 0.74) (p<0.0001), together with left ventricular ejection fraction (p= 0.001), Glycemia ( p= 0.019) and hemoglobin concentration (p = 0.002). Conclusion A simple prognostic index based on variables easily assessed can be useful to predict mortality in acute heart failure at the first arrival in hospital