Andrew Sindone

Continuous home ambulatory intravenous inotropic drug therapy in severe heart failure: Safety and cost efficacy

Some patients with dilated cardiomyopathy who are inotrope dependent but remain well by undergoing infusions can be managed by ambulatory infusions at home. We report our results in 20 patients awaiting heart transplantation, unable to be weaned from intravenous inotropic therapy on 2 or more occasions, but who were well while receiving inotropes and received home ambulatory infusions. The patients were treated with ACE inhibitors, digoxin, diuretics, vasodilators, close electrolyte management, and low-dose amiodarone for those with more than four-beat ventricular tachycardia. Infusions were delivered by a tunneled subclavian catheter and syringe driver. Thirteen patients received dopamine, four received dobutamine, and three received both. Mean duration of inotropic therapy was 5 months with 70% of the time spent as an outpatient. Eleven patients received transplants, two remain on the waiting list, and seven died after being removed from the list because of general deterioration or renal dysfunction. There were no sudden deaths. Actuarial survival was 71% at 3 months, which is not less than that expected for an inotrope-dependent population. All patients with idiopathic dilated cardiomyopathy survived to transplantation. In contrast, all three with right heart failure caused by pulmonary vascular disease and four of seven with ischemic cardiomyopathy died. Inpatient days were reduced by 70%, leading to considerable cost savings. Home ambulatory inotropic therapy is safe, cost-effective, best suited to those with idiopathic dilated cardiomyopathy, and dramatically reduces inpatient hospital duration.

Addressing the burden of heart failure in australia: the scope for home-based interventions

The growing burden of heart failure (HF) challenges health practitioners to implement and evaluate models of care to facilitate optimal health related outcomes. Australia supports a publicly funded universal health insurance system with a strong emphasis on primary care provided by general practitioners. The burden of chronic HF, and a social and political framework favoring community-based, noninstitutionalized care, represents an ideal environment in which home-based HF programs can be implemented successfully. Cardiovascular nurses are well positioned to champion and mentor implementation of evidence-based, patient-centered programs in Australian communities. This paper describes the facilitators and barriers to implementation of best practice models in the Australian context. These include the challenge of providing care in a diverse, multicultural society and the need for clinical governance structures to ensure equal access to the most effective models of care.

Is risk-benefit of warfarin for atrial fibrillation with heart failure determined by heart failure severity?

Is risk-benefit of warfarin for atrial fibrillation with heart failure determined by heart failure severity? -

Cardiac Electronic Implantable Devices in the Treatment of Heart Failure

Heart failure is a condition which has an increasing incidence as the population ages, leading to increasing prevalence globally and in Australia. This condition also carries very high morbidity and mortality rates, attributed in part to electrical conduction disturbances which lead to sudden cardiac death or pathophysiological cardiac changes due to delayed activation of the left free wall and mechanical dyssynchrony. Current pharmacologic therapy has made impressive advances in improving survival rates in this population, but morbidity and mortality rates still remain high. Additionally, there is also a population of heart failure patients on optimal medical therapy who still suffer from functionally debilitating symptoms of heart failure. Device therapy comprising of implantable cardioverter-defibrillator (ICD) and cardiac resynchronisation therapy (CRT) are used to treat heart rhythm disturbances in a broad range of patients with heart disease and have now become established therapies in patients with heart failure receiving standard medical therapy. This review examines current evidence for the use of implantable cardioverter-defibrillators in the reduction of sudden cardiac death in patients with advanced systolic dysfunction and the use of cardiac resynchronisation therapy in improving ventricular performance as well as mortality and morbidity rates.

Management and outcomes following an acute coronary event in patients with chronic heart failure 1999-2007

The outcome of patients with chronic heart failure (CHF) following an ischaemic event is poorly understood. We evaluated the management and outcomes of CHF patients presenting with an acute coronary syndrome (ACS) and explored changes in outcomes over time.

Impact of sleep disordered breathing severity on hemodynamics, autonomic balance and cardiopulmonary functional status in chronic heart failure

BACKGROUND Despite advances in medical therapy, sleep disordered breathing (SDB) remains highly prevalent in chronic heart failure (CHF). The impact of severity of SDB on sympathovagal balance, central hemodynamic responses and cardiopulmonary functional status in these patients is uncertain. METHODS Thirteen patients with stable CHF (mean age+/-10 years; 12 NYHA Class II, 1 Class III) identified with SDB (apnoea-hypopnoea index [AHI] >or=5) by polysomnography underwent echocardiography, standard hemodynamic and functional assessment, heart rate variability analysis and treadmill cardiopulmonary testing. RESULTS Mean AHI of study cohort was 32+/-19, with predominant hypopnoea. Anthropomorphic measurements of obesity correlated positively with increasing AHI severity (p<0.05). NYHA functional class, 6-minute walk distance, measures of left ventricular systolic and diastolic function, serum brain natriuretic peptide levels, cardiac output and VO(2)peak at baseline did not differ with SDB severity. Although SDB severity did not impact on VE/VCO(2)-slope, patients in the highest AHI tertile (AHI>35) demonstrated significantly greater respiratory effort (VE), despite similar VO(2)peak during exercise. Increasing SDB severity was associated with higher resting and post-exercise heart rates, reduced heart rate variability, and possibly slower post-exercise heart rate recovery, consistent with autonomic imbalance. CONCLUSIONS SDB severity was most closely associated with the degree of autonomic dysfunction, and abnormal ventilatory response during and post-exercise in a group of stable ambulant patients with similar severity of CHF on contemporary therapy.

High mortality in patients presenting with acute pulmonary embolism and elevated INR not on anticoagulant therapy

The prognostic significance of patients presenting with pulmonary embolism (PE) and elevated International Normalised Ratio (INR) not on anticoagulant therapy has not been described. We investigated whether these patients had higher mortality compared to patients with normal INR. A retrospective study of patients admitted to a tertiary hospital with acute PE from 2000 to 2012 was undertaken, with study outcomes tracked using a state-wide death registry. Patients were excluded if they were taking anticoagulants or had inadequate documentation of their INR and medication status. Of the 1,039 patients identified, 94 (9 %) had an elevated INR (> 1.2) in the absence of anticoagulant use. These patients had higher mortality at six months follow-up (26 % vs 6 %, p< 0.001) compared to controls (INR ≤ 1.2). An INR > 1.2 at diagnosis was an independent predictor of death at six months post-PE (hazard ratio [HR] 2.9, 95 % confidence interval [CI] 1.8-4.7, p< 0.001). The addition of INR to a multivariable model that included the simplified pulmonary embolism severity index (sPESI), chest pain, and serum sodium led to a significant net reclassification improvement estimated at 8.1 %. The final models C statistic increased significantly by 0.04 (95 % CI 0.01-0.08, p=0.03) to 0.83 compared to sPESI alone (0.79). In summary, patients presenting with acute PE and elevated INR while not on anticoagulant therapy appear to be at high risk of death. Future validation studies in independent cohorts will clarify if this novel finding can be usefully incorporated into clinical decision making in patients with acute PE.

Cardiovascular risk reduction in hypertension: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers. Where are we up to?

Previously, management of hypertension has concentrated on lowering elevated blood pressure. However, the target has shifted to reducing absolute cardiovascular (CV) risk. It is estimated that two in three Australian adults have three or more CV risk factors at the same time. Moderate reductions in several risk factors can, therefore, be more effective than major reductions in one. When managing hypertension, therapy should be focused on medications with the strongest evidence for CV event reduction, substituting alternatives only when a primary choice is not appropriate. Hypertension management guidelines categorise angiotensin‐converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) interchangeably as first‐line treatments in uncomplicated hypertension. These medications have different mechanisms of action and quite different evidence bases. They are not interchangeable and their prescription should be based on clinical evidence. Despite this, currently ARB prescriptions are increasing at a higher rate than those for ACEI and other antihypertensive classes. Evidence that ACEI therapy prevents CV events and death, in patients with coronary artery disease or multiple CV risk factors, emerged from the European trial on reduction of cardiac events with perindopril in stable coronary artery disease (EUROPA) and Heart Outcomes Prevention Evaluation (HOPE) trials respectively. The consistent benefit has been demonstrated in meta‐analyses. The clinical trial data for ARB are less consistent, particularly regarding CV outcomes and mortality benefit. The evidence supports the use of ACEI (Class 1a) compared with ARB despite current prescribing trends.

Iron Deficiency in Heart Failure: Looking Beyond Anaemia

Iron is an essential micronutrient in many cellular processes. Iron deficiency, with or without anaemia, is common in patients with chronic heart failure. Observational studies have shown iron deficiency to be associated with worse clinical outcomes and mortality. The treatment of iron deficiency in chronic heart failure patients using intravenous iron alone has shown promise in several clinical trials, although further studies which include larger populations and longer follow-up times are needed.

National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018

Published by Elsevier B.V. on behalf of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.