Charles Cline

Cost effective management programme for heart failure reduces hospitalisation

Objective To study the effects of a management programme on hospitalisation and health care costs one year after admission for heart failure. Design Prospective, randomised trial. Setting University hospital with a primary catchment area of 250 000 inhabitants. Patients 190 patients (aged 65–84 years, 52.3% men) hospitalised because of heart failure. Intervention Two types of patient management were compared. The intervention group received education on heart failure and self management, with follow up at an easy access, nurse directed outpatient clinic for one year after discharge. The control group was managed according to routine clinical practice. Main outcome measures Time to readmission, days in hospital, and health care costs during one year. Results The one year survival rate was 71.8% (n = 79) in the control group and 70.0% (n = 56) in the intervention group (NS). The mean time to readmission was longer in the intervention group than in the control group (141 (87) v106 (101); p < 0.05) and number of days in hospital tended to be fewer (4.2 (7.8) v 8.2 (14.3); p = 0.07). There was a trend towards a mean annual reduction in health care costs per patient of US

Non-compliance and knowledge of prescribed medication in elderly patients with heart failure.

1300 (US

Left ventricular atrioventricular plane displacement: an echocardiographic technique for rapid assessment of prognosis in heart failure.

1 = SEK 7.76) in the intervention group compared with costs in the controls (US

Effects on quality of life, symptoms and daily activity 6 months after termination of an exercise training programme in heart failure patients

3594 v 2294; p = 0.07). Conclusions A management programme for patients with heart failure discharged after hospitalisation reduces health care costs and the need for readmission.

Simplified Echocardiography in the Diagnosis of Heart Failure

To determine the extent of non‐compliance to prescribed medication in elderly patients with heart failure and to determine to what extent patients recall information given regarding their medication.

Prognostic significance of changes in left ventricular systolic function in elderly patients with congestive heart failure

OBJECTIVE: To assess the prognostic value of atrioventricular plane displacement in heart failure patients. DESIGN: Patients were followed prospectively for one year after atrioventricular plane displacement determination. SETTING: Malmö University Hospital, with a primary catchment area of 250,000 inhabitants. PATIENTS: 181 patients with a clinical diagnosis of heart failure; age 75.7 (SD 5.2) years, duration of heart failure 2.7 (5.7) years; 100 men, 81 women. MAIN OUTCOME MEASURES: Mortality in relation to atrioventricular plane displacement. RESULTS: Total mortality was 22.7% (41/181), and was highly significantly (P = 0.001) related to atrioventricular plane displacement. Mortality within prospectively defined categories of displacement was: > or = 10.0 mm, 0% (0/19); 8.2 to 9.9 mm, 10.3% (3/29); 6.4 to 8.1 mm, 19.4% (12/62); and < 6.4 mm, 36.6% (26/71). The groups were similar in age, sex, angiotensin converting enzyme inhibitor and beta blocker treatment, and cause and duration of heart failure. CONCLUSIONS: Mortality in heart failure is strongly related to atrioventricular plane displacement.

Angiotensin converting enzyme (ACE) inhibitors and heart failure. The consequences of underprescribing.

BACKGROUND Exercise training in heart failure patients improves exercise capacity, physical function, and quality-of-life. Prior studies indicate a rapid loss of these effects following termination of the training. We wanted to assess any sustained post-training effects on patients global assessment of change in quality-of-life (PGACQoL) and physical function. METHODS Fifty-four stable heart failure patients were randomised to exercise or control. The 4-month exercise programme consisted of bicycle training at 80% of maximal intensity three times/week, and 49 patients completed the active study period. At 10 months (6 months post training) 37 patients were assessed regarding PGACQoL, habitual physical activity, and dyspnea-fatigue-index. RESULTS Both post-training patients (n=17) and controls (n=20) deteriorated PGACQoL during the 6-month extended follow-up, although insignificantly. However, post-training patients improved PGACQoL slightly but significantly from baseline to 10 months (P=0.006), differing significantly (P=0.023) from controls who were unchanged. Regarding dyspnea-fatigue-index, post-training patients were largely unchanged and controls deteriorated insignificantly, during the extended follow-up as well as from baseline to 10 months. Both groups decreased physical activity insignificantly during the extended follow-up, and from baseline to 10 months post-training patients tended to decrease whereas controls significantly (P=0.007) decreased physical activity. CONCLUSION There was no important sustained benefit 6 months after termination of an exercise training programme in heart failure patients. A small, probably clinically insignificant sustained improvement in PGACQoL was seen in post-training patients. Controls significantly decreased the habitual physical activity over 10 months and post-training patients showed a similar trend. Exercise training obviously has to be continuing to result in sustained benefit.

Heart failure clinics: a possible means of improving care

Echocardiography is essential in the diagnosis of heart failure, but insufficient resources limit its use. We compared swift (five minutes) simplified echocardiography, using elementary equipment, with standard echocardiography (45 minutes), using advanced equipment. Visual semi-quantification of cardiac dimensions, valvular stenosis, and left ventricular ejection fraction (LVEF) was performed in 100 consecutive patients with suspected or known heart failure. Agreement between simplified and standard echocardiography was 78-89% regarding semi-quantification of cardiac dimensions, and 95-98% for valvular stenosis (present/not present). Sensitivity and specificity for simplified echocardiography to identify patients with LVEF < 0.40 was 86 and 89%, respectively. Simplified echocardiography using elementary equipment could be an alternative to standard echocardiography in the diagnosis of heart failure. The cost and time saved by using simplified echocardiography allows for more patients to be examined, which should be weighed against its accuracy.

Cheyne-Stokes respiration is not related to quality of life or sleepiness in heart failure

Background and designThe prognostic significance of changes in left ventricular systolic function over time is unknown in elderly patients with heart failure We prospectively examined the relation between 1 -year changes in left ventricular systolic function by echocardiographic determination of atrioventricular plane displacement (AVPD), and subsequent 2-year mortality and morbidity in elderly patients with heart failure. AVPD determination allows for left ventricular function to be adequately assessed even when image quality is poor, as IS common in the elderly MethodsAVPD was measured at baseline and 1 year in 123 patients with heart failure (age 76.0 ± 5.4 years). An AVPD change of 1 mm or more (corresponding to an ejection fraction change of 0.05) was considered significant. ResultsAVPD decreased in 26 patients (21%), increased in 46 (37%), and was unchanged in 51 (42%) During a 2-year follow-up (from the 1 -year examination) mortality. total hospitalizations, and hospitalizations for heart failure (35% of all hospitalizations) did not differ significantly between the three groups. Patients (n =80) with AVPD of 8.2 mm or less (corresponding to left ventricular ejection fraction of 0.40 or less) at the 1 -year examination demonstrated a higher mortality than patients with AVPD greater than 8.2 mm (43.8 versus 23.3%, P= 0.031), and also had more hospitalizations and days in hospital due to heart failure (1.0 ± 1.5 versus 0.4 ± 0.8, P= 0.020 and 10.4 ± 15.6 versus 4.6 ± 10.6, P =0.033, respectively). ConclusionsLeft ventricular function was readily assessed in all patients by determination of AVPD. Our results indicate that single but not serial assessment of left ventricular systolic function by determination of AVPD is of value in assessing the prognosis in elderly patients with heart failure.

Exercise training in heart failure improves quality of life and exercise capacity

Heart failure (HF) is a common and expensive cardiovascular disease, in economic terms as well as in lives lost. Angiotensin converting enzyme (ACE) inhibitors have been shown to significantly reduce mortality and hospitalisation in HF. However, recent surveys show that the prescription rate of ACE inhibitors for HF is far below what is considered to be optimal. Furthermore, prescribed dosages are usually lower than those recommended based on evidence from clinical trials.This article estimates the consequences, both economic and human, of underprescribing ACE inhibitors in patients with HF. The indication for prescribing an ACE inhibitor varies, and clinical trials have included different categories of patients; it is inappropriate to assess costs in all eligible patients without taking these factors into account. Therefore, we analysed the data with respect to 4 different groups: (i) asymptomatic left ventricular systolic dysfunction (LVSD)–an early stage leading to chronic HF; (ii) chronic HF; and post–myocardial infarction (MI) LVSD differentiated into (iii) post-MI asymptomatic LVSD and (iv) post-MI chronic HF. We also estimated the cost effectiveness of adding an ACE inhibitor to the treatment of patients with HF for whom an ACE inhibitor is not currently prescribed.If only patient populations in which large trials have shown a significant effect of ACE inhibition on mortality are included in the analysis (i.e. excluding asymptomatic patients with LVSD), increasing the number of Swedish patients receiving an ACE inhibitor could save in excess of 3700 lives each year, in addition to reducing the annual number of hospitalisations by 8400. The additional cost would be 101.5 million Swedish kronor (SEK), a cost per life saved of SEK27 200. Chronic HF is the most cost-effective patient population to treat, generating cost savings under certain assumptions. A further 6700 hospitalisations can be avoided should the use of ACE inhibitors be extended to asymptomatic patients with LVSD. Increasing dosages to those used in the large clinical trials may generate additional savings in lives and hospitalisations.In conclusion, the use of ACE inhibitors in HF and LVSD has clearly been proven to be cost effective, and compares favourably with the cost effectiveness of treating hypertension or hypercholesterolaemia. At present, however, ACE inhibitors are not optimally utilised.Given the increasingly constrained resources for healthcare, every effort should be made to increase the use of cost-effective treatments, such as ACE inhibitors in chronic HF and post-MI LVSD.