Aparna Shankar

Predicting the Long-Term Effects of Cardiac Resynchronization Therapy on Mortality From Baseline Variables and the Early Response: A Report From the CARE-HF (Cardiac Resynchronization in Heart Failure) Trial

OBJECTIVESnThis study was designed to investigate whether selected baseline variables and early response markers predict the effects of cardiac resynchronization therapy (CRT) on long-term mortality.nnnBACKGROUNDnCardiac resynchronization therapy reduces long-term morbidity and mortality in patients with moderate or severe heart failure and markers of cardiac dyssynchrony, but not all patients respond to a similar extent.nnnMETHODSnIn the CARE-HF (Cardiac Resynchronization in Heart Failure) study, 813 patients with heart failure and markers of cardiac dyssynchrony were randomly assigned to receive or not receive CRT in addition to pharmacological treatment and were followed for a median of 37.6 months. A model including assigned treatment, 15 pre-specified baseline variables, and 8 markers of response at 3 months was constructed to predict all-cause mortality.nnnRESULTSnOn multivariable analysis, plasma concentration of amino terminal pro-brain natriuretic peptide (univariate and multivariable model chi-square test: 105.0 and 48.4; both p < 0.0001) and severity of mitral regurgitation (chi-square test: 44.0 and 17.9; both p < 0.0001) at 3 months, regardless of assigned treatment, were the strongest predictors of mortality. Ischemic heart disease as the cause of ventricular dysfunction (chi-square test: 34.9 and 7.4; p < 0.0001 and p = 0.0066), being in New York Heart Association functional class IV (chi-square test: 18.8 and 9.6; p < 0.0001 and p = 0.0020), or having less interventricular mechanical delay (chi-square test: 29.8 and 8.8; p < 0.0001 and p = 0.0029) at baseline all predicted a worse outcome. However, the reduction in mortality in patients assigned to CRT was similar before (hazard ratio: 0.602; 95% confidence interval: 0.468 to 0.774) and after (hazard ratio: 0.679; 95% confidence interval: 0.494 to 0.914) adjustment for variables measured at baseline and at 3 months.nnnCONCLUSIONSnPatients who have more severe mitral regurgitation or persistently elevated amino terminal pro-brain natriuretic peptide despite treatment for heart failure, including CRT, have a higher mortality. However, patients assigned to CRT had a lower mortality even after adjusting for variables measured before and 3 months after intervention. The effect of CRT on mortality cannot be usefully predicted using such information. (CARE-HF CArdiac Resynchronization in Heart Failure; NCT00170300).

Surface electrocardiogram to predict outcome in candidates for cardiac resynchronization therapy: a sub‐analysis of the CARE‐HF trial

In CARE‐HF, cardiac resynchronization therapy (CRT) lowered morbidity and mortality in patients with moderate to severe heart failure. We examined whether baseline and follow‐up electrocardiographic characteristics might predict long‐term outcome.

Long-term left ventricular reverse remodelling with cardiac resynchronization therapy: results from the CARE-HF trial.

The aim of the present study was to assess the long‐term effects of cardiac resynchronization therapy (CRT) on the reverse remodelling of the left ventricle (LV).

Evaluation of the management of heart failure in primary care

BACKGROUNDnThe extent to which guidelines for the treatment of heart failure are currently followed in primary care in the UK is unclear.nnnOBJECTIVEnTo evaluate the prevalence of heart failure and the pharmacological management of heart failure in relation to European Society of Cardiology (ESC) and National Institute for Health and Clinical Excellence guidelines.nnnMETHODSnRetrospective cohort study using routinely collected data from 163 general practices across Great Britain contributing data to the Doctors Independent Network (DIN-LINK) database over a 5-year period until December 31, 2006.nnnRESULTSnFrom a patient population of nearly 1.43 million, 9311 patients with heart failure were identified [mean age 78 years (SD 12)], giving an estimated prevalence of 0.7%. Of these, 7410 (79.6%) were prescribed a loop diuretic, 6620 (71.1%) were prescribed an angiotensin-converting enzyme (ACE) inhibitor or ARB, 3403 (36.6%) were prescribed beta-blockers but only 2732 (29.3%) were prescribed an ACE inhibitor or ARB and a beta-blocker in combination. Thirty-five per cent of patients prescribed ACE inhibitor and 11.5% of those prescribed beta-blockers met ESC guideline target doses. Age, gender and comorbidity predicted whether patients received beta-blocker or ACE inhibitor with younger males being more likely to receive maximal therapy.nnnCONCLUSIONSnThese data suggest that while most patients with heart failure receive an ACE inhibitor/ARB in primary care, few are titrated to target dose and many do not receive a beta-blocker. Optimum treatment appears to be most likely for young men. New strategies are required to ensure equitable and optimal treatment for all.

Access to interpreting services in England: secondary analysis of national data

BackgroundOvercoming language barriers to health care is a global challenge. There is great linguistic diversity in the major cities in the UK with more than 300 languages, excluding dialects, spoken by children in London alone. However, there is dearth of data on the number of non-English speakers for planning effective interpreting services. The aim was to estimate the number of people requiring language support amongst the minority ethnic communities in England.MethodsSecondary analysis of national representative sample of subjects recruited to the Health Surveys for England 1999 and 2004.Results298,432 individuals from the four main minority ethnic communities (Indian, Pakistani, Bangladeshi and Chinese) who may be unable to communicate effectively with a health professional. This represents 2,520,885 general practice consultations per year where interpreting services might be required.ConclusionEffective interpreting services are required to improve access and health outcomes of non-English speakers and thereby facilitate a reduction in health inequalities.

What factors predict differences in infant and perinatal mortality in primary care trusts in England? A prognostic model

Objective To identify predictors of perinatal and infant mortality variations between primary care trusts (PCTs) and identify outlier trusts where outcomes were worse than expected. Design Prognostic multivariable mixed models attempting to explain observed variability between PCTs in perinatal and infant mortality. We used these predictive models to identify PCTs with higher than expected rates of either outcome. Setting All primary care trusts in England. Population For each PCT, data on the number of infant and perinatal deaths, ethnicity, deprivation, maternal age, PCT spending on maternal services, and “Spearhead” status. Main outcome measures Rates of perinatal and infant mortality across PCTs. Results The final models for infant mortality and perinatal mortality included measures of deprivation, ethnicity, and maternal age. The final model for infant mortality explained 70% of the observed heterogeneity in outcome between PCTs. The final model for perinatal mortality explained 80.5% of the between-PCT heterogeneity. PCT spending on maternal services did not explain differences in observed events. Two PCTs had higher than expected rates of perinatal mortality. Conclusions Social deprivation, ethnicity, and maternal age are important predictors of infant and perinatal mortality. Spearhead PCTs are performing in line with expectations given their levels of deprivation, ethnicity, and maternal age. Higher spending on maternity services using the current configuration of services may not reduce rates of infant and perinatal mortality.

Relationships between cardiac resynchronization therapy and N-terminal pro-brain natriuretic peptide in patients with heart failure and markers of cardiac dyssynchrony: an analysis from the Cardiac Resynchronization in Heart Failure (CARE-HF) study

AIMSnThe Cardiac Resynchronization in Heart Failure (CARE-HF) study showed that cardiac resynchronization therapy (CRT) reduces mortality in HF patients with markers of dyssynchrony. Plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) might predict which patients benefit most from CRT. We evaluated whether the prognostic value of NT-proBNP was influenced by CRT and the effects of CRT stratified according to NT-proBNP.nnnMETHODS AND RESULTSnA total of 813 patients were enrolled in CARE-HF. Baseline log-transformed NT-proBNP independently predicted all-cause mortality, sudden death, and death from pump failure. In a multivariable model including log-transformed NT-proBNP, assignment to CRT remained independently associated with better prognosis without evidence of interaction. Stratifying patients according to the median NT-proBNP and to CRT treatment allocation, all-cause mortality was 12% if or= median + CRT, and 51% if >or= median + control group. There was no evidence of a difference in the relative effect of CRT across different values of NT-proBNP.nnnCONCLUSIONnNT-proBNP retains its prognostic value in HF patients with CRT. Deploying CRT before the patients have reached end-stage HF may maximize the benefit of treatment.