Jochem Hogenhuis

Effect of Moderate or Intensive Disease Management Program on Outcome in Patients With Heart Failure: Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH)

BACKGROUND Heart failure (HF) disease management programs are widely implemented, but data about their effect on outcome have been inconsistent. METHODS The Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH) was a multicenter, randomized, controlled trial in which 1023 patients were enrolled after hospitalization because of HF. Patients were assigned to 1 of 3 groups: a control group (follow-up by a cardiologist) and 2 intervention groups with additional basic or intensive support by a nurse specializing in management of patients with HF. Patients were studied for 18 months. Primary end points were time to death or rehospitalization because of HF and the number of days lost to death or hospitalization. RESULTS Mean patient age was 71 years; 38% were women; and 50% of patients had mild HF and 50% had moderate to severe HF. During the study, 411 patients (40%) were readmitted because of HF or died from any cause: 42% in the control group, and 41% and 38% in the basic and intensive support groups, respectively (hazard ratio, 0.96 and 0.93, respectively; P = .73 and P = .52, respectively). The number of days lost to death or hospitalization was 39 960 in the control group, 33 731 days for the basic intervention group (P = .81), and 34 268 for the intensive support group (P = .49). All-cause mortality occurred in 29% of patients in the control group, and there was a trend toward lower mortality in the intervention groups combined (hazard ratio, 0.85; 95% confidence interval, 0.66-1.08; P = .18). There were slightly more hospitalizations in the 2 intervention groups (basic intervention group, P = .89; and intensive support group, P = .60). CONCLUSIONS Neither moderate nor intensive disease management by a nurse specializing in management of patients with HF reduced the combined end points of death and hospitalization because of HF compared with standard follow-up. There was a nonsignificant, potentially relevant reduction in mortality, accompanied by a slight increase in the number of short hospitalizations in both intervention groups. Clinical Trial Registry http://trialregister.nl Identifier: NCT 98675639.

Design and methodology of the COACH study: a multicenter randomised Coordinating study evaluating Outcomes of Advising and Counselling in Heart failure.

While there are data to support the use of comprehensive non‐pharmacological intervention programs in patients with heart failure (HF), other studies have not confirmed these positive findings. Substantial differences in the type and intensity of disease management programs make it impossible to draw definitive conclusions about the effectiveness, optimal timing and frequency of interventions.

Influence of age on natriuretic peptides in patients with chronic heart failure: a comparison between ANP/NT-ANP and BNP/NT-proBNP

Natriuretic peptides are currently used in the diagnosis and follow‐up of patients with Chronic Heart Failure (CHF). However, it is unknown whether there are different influences of age on atrial natriuretic peptide (ANP)/N‐terminal‐ANP (NT‐ANP) or B‐type natriuretic peptide (BNP)/N‐terminal‐proBNP (NT‐proBNP).

BNP and functional status in heart failure.

In the current era of growing incidence and prevalence of chronic heart failure (CHF) the functional status assessment of CHF patients is increasingly needed, as it is one of the tools to investigate severity of CHF. Btype natriuretic peptide (BNP) is gradually more used in the diagnosis, prognosis and management of CHF patients. Since BNP is an easy, cheap and readily available test, an investigation that evaluates the value of BNP in functional status assessment is important. In their recent paper in Cardiovascular Drugs and Therapy Abdulla et al. evaluate the potential of BNP as a surrogate marker for traditional methods of assessing functional status of patients with left ventricular systolic dysfunction [1]. The authors describe a meta analysis of four articles that all reported the correlation between BNP and functional status as assessed by either peak VO2 or 6-minute walk test. Because the meta analysis showed only a moderate correlation (r = − 0.59), the authors carefully concluded that the traditional methods should still be considered as standard methods in assessing functional capacity. We agree with this conclusion, but we would like to add some strength to it and support the notion that BNP is not a good marker for measuring functional capacity. Also we would like to make a few comments. First, we noticed that two relevant papers were not included in the meta analysis. These studies by Brunner-La Rocca et al. [2] and Kinugawa et al. [3] also described the correlation between BNP and peak VO2 in a tertiary care centre and an outpatient clinic setting respectively. Both studies reported a very low correlation coefficient between BNP and peak VO2 (r ≤ −0.33), and adding these studies would have further weakened the moderate correlation as found in the meta analysis by Abdulla et al. Second, the authors do not mention the clinical setting of the studies they reviewed. The studies were all performed in an outpatient clinic setting, making the results difficult to generalize to the total CHF population. We recently studied a group of 120 CHF patients at time of discharge after admission for CHF (age 70 ± 12 years, 58% males, left ventricular ejection fraction 34% ± 14%, 41% ischemic aetiology of CHF). BNP was assessed and 6-minute walk test was performed on the day before discharge from the hospital. No correlation between BNP and functional status (6 minute walk test) was found (r = 0.005, P = 0.95) [4]. Therefore we argue that the clinical setting should be taken into account when conclusions are drawn about the correlation between BNP and functional status. As stated by the authors BNP is a very valuable marker in the management of CHF, but its plasma levels can change due to several variables like age, gender, renal function, use of medication, body weight. We want to stress the importance of the clinical setting, especially when evaluating the relationship between BNP and functional status.

1242: Coordinating Study Evaluating Outcomes of Advising and Counselling in Heart Failure (COACH): Methodology and Design

Purpose: In seeking evidence to support the local practice of keeping patients on bed rest fo r 6 h following cardiac catheterisation and percutaneous coronary intervention (PCI), very little literature was found. In order to establish the safety of reducing bed rest, practice was benchmarked and audited. Methods: A benchmarking exercise was undertaken against nine other cardiac centres, which revealed an average bed rest time of 5–6 h. A baseline audit of current practice was conducted to establish complication rates related to femoral wound site and length of bed rest. Using a convenience sample of consecutive patients, a total number of 200 data sets (195 complete ) were obtained using a specifically designed audit tool. The audit was repeated following a reduction in bed rest t o 3 h and a further 200 data sets were collected(176 complete ) using the same tool. Results: 358 (96.2%) of cases used six French sheath and only 120(32.3%) used an arterial closure device, all others used manual compression (average time s10 min) to achieve haemostasis. Similar ratios of male yfemale and diagnosticyinterventional cases were documented pre and post change. Numbers of haematomas reduced from 29 prechange(14.8%) to 19 post-change(10.8%). Number of oozing or bleeding incidents increased from 5 (2.6%) to 11 (6.3%). Conclusion: Femoral wound site complication rates were not significantly affected by reducing bed rest time for diagnostic or interventional procedures. Practice can now be based on best available evidence thus ensuring high standards of care.