Catherine Demers

Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: Diagnosis and management

Heart failure remains a common diagnosis, especially in older individuals. It continues to be associated with significant morbidity and mortality, but major advances in both diagnosis and management have occurred and will continue to improve symptoms and other outcomes in patients. The Canadian Cardiovascular Society published its first consensus conference recommendations on the diagnosis and management of heart failure in 1994, followed by two brief updates, and reconvened this consensus conference to provide a comprehensive review of current knowledge and management strategies. New clinical trial evidence and meta-analyses were critically reviewed by a multidisciplinary primary panel who developed both recommendations and practical tips, which were reviewed by a secondary panel. The resulting document is intended to provide practical advice for specialists, family physicians, nurses, pharmacists and others who are involved in the care of heart failure patients. Management of heart failure begins with an accurate diagnosis, and requires rational combination drug therapy, individualization of care for each patient (based on their symptoms, clinical presentation and disease severity), appropriate mechanical interventions including revascularization and devices, collaborative efforts among health care professionals, and education and cooperation of the patient and their immediate caregivers. The goal is to translate best evidence-based therapies into clinical practice with a measureable impact on the health of heart failure patients in Canada.

Effectiveness of comprehensive disease management programmes in improving clinical outcomes in heart failure patients. A meta-analysis

Disease management programmes (DMP) have been advocated to improve long term outcomes of heart failure (HF) patients.

Angiotensin receptor blockers in heart failure: meta-analysis of randomized controlled trials

OBJECTIVES We sought to determine the effect of angiotensin receptor blockers (ARBs) on mortality and hospitalization in patients with heart failure (HF). BACKGROUND There is uncertainty regarding the efficacy of ARBs as substitute or adjunctive therapy to angiotensin-converting enzyme inhibitors (ACEIs) in the treatment of HF. METHODS We conducted a meta-analysis of all randomized controlled trials that compared ARBs with either placebo or ACEIs in patients with symptomatic HF. The pooled outcomes were all-cause mortality and hospitalization for HF. RESULTS Seventeen trials involving 12,469 patients were included. Overall, ARBs were not superior to controls in the pooled rates of death (odds ratio: 0.96; 95% confidence interval: 0.75 to 1.23) or hospitalization (0.86; 0.69 to 1.06). Stratified analysis, however, showed a non-significant trend in benefit of ARBs over placebo in reducing mortality (0.68; 0.38 to 1.22) and hospitalization (0.67; 0.29 to 1.51) when given in the absence of background ACEI therapy. When compared directly with ACEIs, ARBs were not superior in reducing either mortality (1.09; 0.92 to 1.29) or hospitalization (0.95; 0.80 to 1.13). In contrast, the combination therapy of ARBs and ACEIs was superior to ACEIs alone in reducing hospitalization (0.74; 0.64 to 0.86) but not mortality (1.04; 0.91 to 1.20). CONCLUSIONS This meta-analysis cannot confirm that ARBs are superior in reducing all-cause mortality or HF hospitalization in patients with symptomatic HF, particularly when compared with ACEIs. However, the use of ARBs as monotherapy in the absence of ACEIs or as combination therapy with ACEIs appears promising.

Preferences of patients with heart failure for prognosis communication

BACKGROUND Communication about prognosis is fundamental to discussions and planning for end-of-life (EOL) care for patients with advanced heart failure (HF). Little is known about the preferences of patients that could guide communication about prognosis. OBJECTIVES To identify the preferences of patients with advanced HF regarding communication about their prognosis and its implications. METHODS A qualitative study using a grounded theory methodology, based on one-to-one interviews with 20 patients recruited from Heart Function Clinic at the McMaster University Medical Centre in Hamilton, Ontario. RESULTS The following four main themes about patient preferences were identified: level of wellness--patients wanted to learn about their prognosis and its implications at a time of optimal cognitive function, and not when their capacity for EOL decision making was diminished; opportunity to be informed--patients preferred physicians to initiate discussions about prognosis at the time of diagnosis; tell the truth--there was a strong preference for physicians to disclose prognostic possibilities, treatments and outcomes associated with HF, including the possibilities of deterioration and death; and maintain hope--there was a need for truth to be balanced with hope. Hope for quality of life, symptom control and control over EOL decisions were important to participants. CONCLUSIONS The findings suggested that communication about prognosis between patients and physicians may be difficult and deferred. Preferences identified by patients offer guidance to physicians in planning and initiating dialogue about prognosis.

Cognitive function and self-care management in older patients with heart failure

Aims: People with heart failure have difficulty with self-care management. We do not know if patients with heart failure have difficulty with self-care management due to underlying, mild cognitive impairment (MCI). The purpose of this study was to determine whether MCI, as identified on a simple screening tool, is significantly associated with self-care management in a sample of community dwelling older patients with heart failure. Methods and results: Using a cross-sectional design, heart failure patients (n=100, mean age 72 SD 10 years) attending an outpatient heart failure clinic completed the Montreal Cognitive Assessment tool (MoCA), Self-Care in Heart Failure Index (SCHFI) and Geriatric Depression Scale. The presence of MCI, as defined by a MoCA score <26, was present in 73% patients; 21% had an adequate self-care management SCHFI score; and 12% reported symptoms of depression. Participants with a MoCA score <26 vs. ≥ 26 scored significantly lower on the self-care management subscale of the SCHFI (48.1 SD 24 vs. 59.3 SD 22 respectively, p=0.035). Using backward regression, the final model was fitted to self-care management while controlling for age and sex and was significant, with (F= 7.04 df (3, 96), and p<0.001), accounting for 18% of the total variance in self-care management (R2 = 18.03%). The MoCA score was the only variable which remained in the model significantly with p= 0.001. Conclusion: Findings from this study highlight the difficulty older heart failure patients have with self-care management and the need to include formal screening for MCI when exploring variables contributing to self-care management in heart failure patients.

Shared electronic vascular risk decision support in primary care: Computerization of Medical Practices for the Enhancement of Therapeutic Effectiveness (COMPETE III) randomized trial.

BACKGROUND Computerized decision support systems (CDSSs) linked with electronic medical records (EMRs) are promoted as an effective means of improving patient care. However, very few high-quality studies are set in routine, community-based clinical care, and no consistent evidence of an effect on patient outcomes has been found. METHODS A randomized controlled trial among EMR-using primary care practices in Ontario, Canada. Patients 55 years or older with previous vascular events, diabetes mellitus, hypertension, or hypercholesterolemia were randomized to the Computerization of Medical Practices for the Enhancement of Therapeutic Effectiveness (COMPETE III) CDSS intervention or to usual care. The intervention included personally tailored electronic vascular risk monitoring and treatment advice shared between the physician and patient, risk calculation, and a clinical resource. The primary outcome was a composite score of 8 recommended process outcomes at 1 year. Data collectors were blinded to group allocation. Analysis used the intention-to-treat principle with multiple imputation for missing data. RESULTS We randomized and included in the analysis 1102 patients in 49 community-based physician practices (53.4% female; mean age, 69.1 years; 28.0% with a previous vascular event). The intervention group (545 [49.5%]) had a significantly greater improvement in mean process composite, with a difference of 4.70 (P < .001) on a 27-point scale. Intervention patients had significantly higher odds of rating their continuity of care (4.18; P < .001) and their ability to improve their vascular health (3.07; P < .001) as improved. Despite this improvement, the clinical outcomes-vascular events, clinical variables, and quality of life-were not improved. CONCLUSION Despite favorable reviews and important improvements in the complex processes required to reduce vascular risk, clinical outcomes remain unchanged.

Online self-management interventions for chronically ill patients: cognitive impairment and technology issues.

INTRODUCTION As the fraction of the population with chronic diseases continues to grow, methods and/or technologies must be found to help the chronically ill to take more responsibility to self-manage their illnesses. Internet based and/or mobile support for disease self-management interventions have often proved effective, but patients with chronic illnesses may have co-occurring cognitive impairment, making it more difficult for them to cope with technologies. Many older patients are also not familiar with technologies or they may have cognitive disabilities or dementia that reduce their ability to self-manage their healthcare. On-line solutions to the needs of chronically ill patients must be investigated and acted upon with care in an integrated manner, since resources invested in these solutions will be lost if patients do not adopt and continue to use them successfully. OBJECTIVES To review the capabilities of online and mobile support for self-management of chronic illnesses, and the impacts that age and disease-related issues have on these interventions, including cognitive impairment and lack of access or familiarity with Internet or mobile technologies. METHODS This study includes a review of the co-occurrence of cognitive impairment with chronic diseases, and discusses how cognitive impairment, dyadic caregiver patient support, patient efficacy with technology, and smart home technologies can impact the effectiveness and sustainability of online support for disease self-management. RESULTS Disease self-management interventions (SMIs) using online patient centered support can often enable patients to manage their own chronic illnesses. However, our findings show that cognitive impairment often co-occurs in patients with chronic disease. This, along with age-related increases in multiple chronic illnesses and lack of technology efficacy, can be obstacles to Internet and mobile support for chronic disease self-management. CONCLUSION Patients with chronic diseases may have greater than expected difficulties in using Internet and mobile technologies for disease self-management, often due to cognitive impairment or unfamiliarity with technology. Approaches to dealing with such barriers include suitable integration of solutions involving patient-caregiver dyads, better design of online applications, careful attention to technology adoption and sustainability, and smart home technologies.

The role of digitalis in the treatment of heart failure.

Over the past 200 years, digoxin has been commonly used to treat patients with congestive heart failure. Clinical trials have demonstrated the benefits of the use of digoxin on exercise tolerance, ejection fraction, and neurohormone production. The Digoxin Investigators Group trial has recently provided strong evidence for the long-term benefits of digoxin on morbidity for patients with heart failure. This article will review the evidence of the benefits of digoxin and its current role in the treatment of patients with congestive heart failure.

Barriers to goals of care discussions with hospitalized patients with advanced heart failure: feasibility and performance of a novel questionnaire

Good end‐of‐life communication and decision‐making are important to patients with advanced heart failure (HF) and their families, but their needs remain unmet. In this pilot study, we describe the feasibility and performance of a novel questionnaire aimed at identifying barriers and solutions to improve communication and decision‐making about goals of care for hospitalized patients with advanced HF.

Barriers to Technology Use Among Older Heart Failure Individuals in Managing Their Symptoms After Hospital Discharge

BACKGROUND In North America, heart failure (HF) is the leading cause for hospital readmission. Supportive technology, such as computers and tablets, could potentially assist patients with self-care to manage their condition after hospital discharge; however, older individuals have difficulties in adopting technology to manage their condition. METHOD This study used a mixed methods design to identify barriers to technology use in HF self-care. In the qualitative phase, semi-structured interviews were conducted with 18 HF patients and 10 informal caregivers or care partners (CP). In the quantitative phase, five questionnaires were administered to 15 patients and 8 CP: Montreal Cognitive Assessment; Short Literacy Survey and Subjective Numeracy Scale; Self-Care of HF Index; Knowledge Assessment Questionnaire; and Patient Activation Measure. RESULTS In the qualitative phase, five themes emerged regarding engagement in self care and technology use: knowledge level of HF; level of willingness to ask questions related to HF; confidence level in making health-related decisions individually; level of technology usage in daily activities; and self-recording of health measurements. Quantitative analysis found that most HF patients had mild cognitive impairment (MCI), adequate health numeracy levels to understand and manage their health condition, high confidence levels in managing their condition and willingness to engage in self-care. There was variation in willingness to adopt technology. CONCLUSION Patients were willing to engage in HF self-care however they relied on CPs who were more willing to ask questions about HF. Technology tools may assist in HF self-care, but they must be tailored for use among older individuals.