Dariusz Korczyk

A systematic approach to chronic heart failure care: a consensus statement

The National Heart Foundation of Australia assembled an expert panel to provide guidance on policy and system changes to improve the quality of care for people with chronic heart failure (CHF). The recommendations have the potential to reduce emergency presentations, hospitalisations and premature death among patients with CHF. Best‐practice management of CHF involves evidence‐based, multidisciplinary, patient‐centred care, which leads to better health outcomes. A CHF care model is required to achieve this. Although CHF management programs exist, ensuring access for everyone remains a challenge. This is particularly so for Aboriginal and Torres Strait Islander peoples, those from non‐metropolitan areas and lower socioeconomic backgrounds, and culturally and linguistically diverse populations. Lack of data and inadequate identification of people with CHF prevents efficient patient monitoring, limiting information to improve or optimise care. This leads to ineffectiveness in measuring outcomes and evaluating the CHF care provided. Expanding current cardiac registries to include patients with CHF and developing mechanisms to promote data linkage across care transitions are essential. As the prevalence of CHF rises, the demand for multidisciplinary workforce support will increase. Workforce planning should provide access to services outside of large cities, one of the main challenges it is currently facing. To enhance community‐based management of CHF, general practitioners should be empowered to lead care. Incentive arrangements should favour provision of care for Aboriginal and Torres Strait Islander peoples, those from lower socioeconomic backgrounds and rural areas, and culturally and linguistically diverse populations. Ongoing research is vital to improving systems of care for people with CHF. Future research activity needs to ensure the translation of valuable knowledge and high‐quality evidence into practice.

The Self-care Educational Intervention for Patients With Heart Failure: A Study Protocol

Background: A variety of educational interventions have been implemented to assist patients with heart failure (HF) to maintain their own health, develop self-care behaviors, and decrease readmissions. The most effective approach to education has yet to be established. Objective: The aim of this study is to determine the effectiveness of a multimedia educational intervention for patients with HF in reducing hospital readmissions. Secondary outcomes include changes in knowledge and self-care behaviors. Methods: A randomized controlled trial in a large tertiary referral hospital in Australia has recruited 200 patients and will follow them for 12 months. Patients diagnosed with HF have been randomly allocated 1:1 to either usual education or a multimedia educational intervention. Framed by the principles of adult learning, this individualized intervention was delivered face to face by a specialized HF nurse, with a targeted educational assessment and subsequent development of an educational plan. The multimedia approach combined viewing a DVD and verbal discussion supported by a written manual. The teach-back strategy at the conclusion of the intervention evaluated the patient’s learning through 5 key questions about self-management of HF. Readmissions are assessed at 28 days, 3 months, and 12 months. Knowledge and self-care behavior are assessed at baseline, 3 months, and 12 months. Conclusions: This study evaluates the effectiveness of a targeted multimedia educational intervention. Study results may inform the design of in-hospital education for HF patients.

The Utility of 99mTc-DPD Scintigraphy in the Diagnosis of Cardiac Amyloidosis: An Australian Experience

BACKGROUND The uptake of bone-seeking radiotracers in the amyloid heart is well recognised. 99mTc-DPD has been shown to be highly sensitive for cardiac transthyretin (ATTR) amyloid in an overseas population, but is not registered for use in Australia. We explored its utility as a diagnostic tool within our population. METHODS Patients diagnosed with AL and ATTR (wild-type and inherited) cardiac amyloidosis were prospectively recruited from the Princess Alexandra Hospital Amyloidosis Centre. Patients underwent injection with 99mTc-DPD then planar whole body imaging was performed at 5 minutes post-injection (soft tissue phase) and 3 hours (bone phase). A myocardial SPECT and low amperage CT were acquired after the late whole-body scan. Scans were analysed by two nuclear imaging specialists. Intensity of cardiac 99mTc-DPD uptake was graded as 0 to 3 in accordance with previous criteria, and semiquantitative analysis was performed using a heart to whole body ratio (H:WB) on the 3-hour scan. Patients also underwent electrocardiography and transthoracic echocardiography, and blood samples were taken for troponin I and brain natriuretic peptide levels, to assess for any correlation with DPD uptake. RESULTS Twenty-one patients (8 AL and 13 ATTR) completed the study. Median age was 58 and 70 years for AL and ATTR patients respectively, and 19 (90.5%) were male. 99mTc-DPD scintigraphy was positive in 2 (25%) of AL, and 13 (100%) of ATTR patients. Grade of cardiac uptake, and mean H:WB (0.1249 v. 0.0794) was greater in the ATTR cohort (p-value<0.001 and 0.001 respectively). No statistically significant correlation was identified between H:WB and echocardiographic parameters. There was a significant positive correlation between H:WB and the PR interval on ECG (p=0.026). CONCLUSIONS 99mTc-DPD scintigraphy is highly sensitive for the diagnosis of cardiac ATTR amyloid, but less so for AL amyloid.

Self-care educational intervention to reduce hospitalisations in heart failure: A randomised controlled trial

Background: A variety of educational interventions have been implemented to assist patients with heart failure to maintain their own health, develop self-care behaviours and decrease readmissions. Aims: The purpose of this study was to determine the effectiveness of a multimedia educational intervention for patients with heart failure in reducing unplanned hospital readmissions. Methods: The study, a randomised controlled trial in a large tertiary referral hospital in Australia, recruited 200 patients. Patients diagnosed with heart failure were randomly allocated 1:1 to usual education or a multimedia educational intervention. The multimedia approach began with an individual needs assessment to develop an educational plan. The educational intervention included viewing a DVD, and verbal discussion supported by a written manual with a teach-back evaluation strategy. The primary outcome was all-cause unplanned hospital readmission at 28 days, three months and 12 months post-recruitment. The secondary outcomes were changes in knowledge and self-care behaviours at three months and 12 months post-recruitment. Results: At 12 months, data on 171 participants were analysed. There were 24 participants who had an unplanned hospital readmission in the intervention group compared to 44 participants in the control group (p=0.005). The self-care educational intervention reduced the risk of readmission at 12 months by 30% (relative risk: 0.703; 95% confidence interval: 0.548–0.903). Conclusion: A targeted multimedia educational intervention can be effective in reducing all-cause unplanned readmissions for people with heart failure.

Cardiac Sarcoidosis, Left Ventricular Impairment and Chronic Right Ventricular Pacing: Pacing or Pathology?

BACKGROUND Cardiac sarcoidosis (CS) is an uncommon and under-recognised disease which most frequently presents with atrioventricular (AV) block and may also present with ventricular arrhythmias and left ventricular (LV) systolic dysfunction. Because of its protean clinical manifestations, confirming a diagnosis of CS is often challenging. METHODS We report two cases where patients presented with atrioventricular (AV) block without evidence of underlying myocardial disease, underwent chronic dual-chamber pacing, and presented several years later with severe LV systolic dysfunction. RESULTS Both patients were referred for assessment of pacing-induced cardiomyopathy with a view to upgrading their device to cardiac resynchronisation therapy (CRT). Subsequent investigation revealed features consistent with CS and appropriate immunosuppressive therapy resulted in improvement in LV function avoiding the requirement for CRT. CONCLUSION We present a review of the diagnosis of cardiac sarcoidosis, the importance of imaging modalities and current treatment recommendations.

Characterisation and comparison of acute haemodynamic, cardiac biochemical and hormonal response to different ventricular pacing sites in the normal heart

BACKGROUND Acute cardiac response to right ventricular pacing is unknown. We aimed to assess the acute haemodynamic, biochemical and hormonal response to asynchronous right ventricular pacing and investigate whether there is a difference between an apical and outflow tract site. METHODS In 21 patients with normal cardiac function, haemodynamics, brain natriuretic peptide and high sensitive troponin T were measured in response to 10minutes of pacing at each site in a randomised crossover fashion and compared. RESULTS Pacing both sites there were significant increases in pulmonary capillary wedge pressures (p<0.001) and QRS width (p< 0.01). In comparison to baseline, apical pacing demonstrated significant (p<0.05) increases in arterial peptide and troponin levels and venous peptide levels. Outflow tract pacing compared to baseline demonstrated significant (p<0.05) increases in arterial peptide and venous, arterial and coronary sinus troponin. There were no significant differences in responses between sites. CONCLUSION Asynchronous right ventricular pacing demonstrated significant increases in filling pressures, cardiac hormonal and biochemical response above baseline with very short durations of pacing (10minutes). There was no difference in response between sites. These findings imply that even very short periods of right ventricular based pacing are potentially deleterious.

Assessing functional exercise capacity using telehealth: Is it valid and reliable in patients with chronic heart failure?

Introduction This study aimed to determine the validity and reliability of video-based telerehabilitation assessments in patients with heart failure. Methods Seventeen consecutive participants (mean age 69 years, SD 12 years and 88% males) undertook assessments of three functional tests via both telerehabilitation and face-to-face approaches, on the same day. The assessment order was randomised and conducted by independent assessors. Outcome measures included functional tests: timed up and go (time), six-minute walk (distance), grip strength (kilograms); system usability scale to rate participant experience with telerehabilitation assessment; and number of technical issues encountered. Validity and inter- and intra-rater reliability of telerehabilitation assessments were examined using limits of agreement, intra-class correlation coefficients (ICC), and paired t-tests. Results The limits of agreement for telerehabilitation assessments were within the clinically acceptable limits for timed up and go and grip strength. Telerehabilitation assessments for all functional tests were strongly associated with face-to-face assessments, with ICCs of between 0.85 and 0.96. Inter- and intra-rater reliability of telerehabilitation assessments for all functional tests were excellent (all ICC > 0.95). The mean (SD) system usability scale score was 85 (15)/100. Some incidences of Internet drop-outs, video freezing and auditory fading occurred. Discussion The use of telehealth for the assessment of functional exercise capacity appears to be valid and reliable in patients with heart failure.

Exploring patient experiences and perspectives of a heart failure telerehabilitation program: a mixed methods approach

Objectives To describe patient experiences and perspectives of a group‐based heart failure (HF) telerehabilitation program delivered to the homes via online video‐conferencing. Background Limited information currently exists on patient experiences of telerehabilitation for HF. Patient feedback and end‐user perspectives provide important information regarding the acceptability of this new delivery model which may have a substantial impact on future uptake. Methods We used mixed‐methods design with purposive sampling of patients with HF. We used self‐report surveys and semi‐structured interviews to measure patient experiences and perspectives following a 12‐week telerehabilitation program. The telerehabilitation program encompassed group‐based exercise and education, and were delivered in real‐time via videoconferencing. Interviews were transcribed and coded, with thematic analysis undertaken. Results Seventeen participants with HF (mean age [SD] of 69 [12] years and 88% males) were recruited. Participants reported high visual clarity and ease of use for the monitoring equipment. Major themes included motivating and inhibiting influences related to telerehabilitation and improvement suggestions. Participants liked the health benefits, access to care and social support. Participants highlighted a need for improved audio clarity and connectivity as well computer training for those with limited computer experience. The majority of participants preferred a combined face‐to‐face and online delivery model. Conclusion Participants in this study reported high visual clarity and ease‐of‐use, but provided suggestions for further improvements in group‐based video telerehabilitation for HF.

Multimodality imaging of a rare case of cardiac lipomatosis

A 39-year-old female from the Philippines was referred to our cardiology service following work-up by her local medical practitioner for atypical chest pain. Computed tomography coronary angiogram (CTCA) was negative for coronary artery disease but suspicious for an infiltrative cardiomyopathy, with increased left ventricular wall thickness and myocardial hypoattenuation streaks of −25HU ( Panels A and B ). Transthoracic echocardiography (TTE) revealed an increased basal biventricular wall thickness (RV-free wall 10 mm) with hyper-echogenicity ( Panels C and D ). Cardiovascular magnetic resonance (CMR) steady-state-free precession …

Brain Natriuretic Peptide Clearance in Patients with Obesity and InsulinResistance - a Mechanistic Study

Introduction: Brain Natriuretic Peptide (BNP) is secreted from cardiac myocytes in response to the wall stress. BNP is eliminated via Natriuretic Peptide Receptor C (NPR-C) and degradation by extracellular proteases including neprilysin (NEP). Obesity and insulin resistance predispose to lower circulating natriuretic peptide levels. Raised NEP activity and an elevated NPR-C gene expression have been described in obese individuals with insulin resistance and lower circulating levels of natriuretic peptide. Methods: We assessed the relationship between markers of peptide production and pulmonary clearance with indices of insulin resistance and body weight. The cardiac, peripheral and pulmonary Extraction Ratio (ER) has been quantified to assess BNP synthesis and clearance. Twenty one individuals admitted for EP study were consented. Simultaneous sampling of serum BNP level was performed from femoral artery and vein, coronary sinus and femoral artery and pulmonary artery and pulmonary wedge position. Results: The mean serum BNP level was 37 ng/L. The mean cardiac ER was 1.20, pulmonary and peripheral ER was 0.13. There was a tendency for lower cardiac and pulmonary ER in males. Pulmonary ER correlated with age (r=0.495, p=0.023) and systolic BP (r=0.58, p=0.006) only. However there was no correlation between cardiac and pulmonary ER with BMI, waist circumference and HOMA-IR. Conclusions: We found no correlation between the marker of BNP pulmonary clearance with body size and insulin resistance. Induction of the adipose tissue specific NPR-C pathway (rather than NEP clearance) is more likely the cause of the lower level of BNP in patients with obesity and insulin resistance.