Karen Hogg

Heart failure with preserved left ventricular systolic function: a hospital cohort study

Objective: To investigate how patients with heart failure with preserved left ventricular systolic function (LVSF) compare with patients with reduced LVSF. Design: Cohort study. Setting: Urban university hospital. Patients: 528 index emergency admissions with heart failure during the year 2000. Information on LVSF and follow up was available for 445 (84%) of these patients. Results: 130 (29%) patients had preserved LVSF (defined as an ejection fraction > 40%). The median follow up was 814 days (range 632–978 days). The average (SD) age was 72 (13) years. Women accounted for 62% and 45% of patients with preserved and reduced LVSF, respectively (p  =  0.001). Patients with preserved LVSF (compared with those with reduced LVSF) had a higher prevalence of left ventricular hypertrophy (56% v 29%) and aortic valve disease (mean gradient > 20 mm Hg; 31% v 9%). Fewer patients with preserved LVSF received an angiotensin converting enzyme inhibitor (65% v 78%, p  =  0.008) or spironolactone (12% v 21%, p  =  0.027). Anaemia tended to occur more often in patients with preserved LVSF than in those with reduced LVSF (43% v 33% for women, p  =  0.12; 59% v 49% for men, p  =  0.22). There was a similarly high prevalence of significant renal dysfunction in both groups (estimated glomerular filtration rate < 60 ml/min/1.73 m2 in 68% with preserved and 64% with reduced LVSF, p  =  0.40). Mortality was similar in both groups (preserved versus reduced 51 (39%) v 132 (42%), p  =  0.51). Compared with patients with reduced LVSF, patients with preserved LVSF tended to have a lower risk of death or hospital admission for heart failure (56 (42%) v 165 (53%), p  =  0.072) but a similar rate of death or readmission for any reason. Conclusion: Patients with preserved LVSF had more co-morbid problems than those with reduced LVSF; however, prognosis was similar for both groups.

Palliative care for people with heart failure: Summary of current evidence and future direction

Background: Heart failure is a common condition with a significant physical and psychological burden for patients and their families. The need for supportive and palliative care: It is well recognised that palliative care is important in patients with advanced heart failure. What is known: Heart failure patients have limited access to palliative care services. Barriers to palliative care include difficult prognostication due to the unpredictable disease trajectory and inadequate initiation of conversations about end-of-life care. What is not known: There are gaps in the evidence for symptom control, especially for symptoms other than pain or dyspnoea, but recommendations are becoming increasingly evidence based. Implications for research, policy and practice: There are challenges to research in this area although progress is being made with increasing numbers of trials and use of novel research methods. Integrated models of care based on symptom triggers rather than prognosis are recommended. At the centre is excellent communication both with the patient and between services to ensure the best possible care.

The treatment of heart failure with preserved ejection fraction ("diastolic heart failure")

Unlike heart failure with a low ejection fraction, there is no evidence-based treatment for heart failure with preserved ejection fraction which improves clinical outcomes. Indeed, the only evidence for any treatment effect comes from small studies with verapamil where this drug increased exercise capacity and reduced a heart failure score. Large trials are presently underway which are examining the effect of treatment with an ACE inhibitor, ARB and aldosterone antagonist in patients with heart failure and preserved ejection fraction.

ICDs in end-stage heart failure

Implantable cardioverter defibrillators (ICDs) reduce mortality in selected patients with chronic heart failure but prognostic benefit is likely to attenuate with progression to end-stage heart failure. The incidence of multiple futile ICD shocks before death is uncertain. Only individual patients, supported by their healthcare professionals, can decide when ICD therapy becomes futile in end-stage heart failure. Despite consensus that ICD deactivation should be routinely discussed, this rarely occurs in clinical practice for many reasons including uncertainty about when to initiate these discussions and reluctance to confront death and dying. Patient and carer opinions about end-stage heart failure and ICD deactivation may not meet professional expectations. Future research should focus on these opinions and examine interventions that bridge the gap between best practice and the reality of current clinical practice.

Prognostication or identification of palliative needs in advanced heart failure: where should the focus lie?

Heart failure (HF) is a significant public health issue with high morbidity and mortality despite persistent advances in therapeutic strategies. HF is physically and psychologically burdensome for patients and their families and costly to the NHS; the latter driven primarily by repeated prolonged hospital admissions.1 The greatest incidence and prevalence of HF is in older patients. The multiple and often complex comorbidities associated with this cohort impact on management strategies and prognosis.2 The 1-year survival following a new diagnosis of HF is invariably poor, but the decline towards death is often unpredictable. This chaotic illness trajectory contributes to what has previously been termed, ‘prognostic paralysis’.3 Consequently, anticipatory management is extremely difficult and so a ‘revolving door’ clinical pattern often ensues. It is now accepted that the morbidity and mortality for patients with HF is similar to or worse than many cancers with the first HF hospitalisation in particular heralding a very poor prognosis.4 Despite this, end of life care in HF remains uncoordinated and inadequate for many. As such the development and validation of a HF score to permit accurate identification and prognostication in this group is an attractive prospect clinically and in terms of resource allocation. In this issue of Heart , Haga et al 5 identified two scores for comparison: the qualitative Gold Standards Framework Prognostic Indicator Guide (GSF)6 and the better …

Evaluating dyspnoea in acute heart failure: progress at last!

This editorial refers to ‘The impact of early standard therapy on dyspnoea in patients with acute heart failure: the URGENT-dyspnoea study’[†][1], by A. Mebazaa et al. on page 832 It is remarkable how little we know about dyspnoea, the most common symptom experienced by patients with acute heart failure.1,2 The innovative and important study reported by Mebazaa et al. makes for fascinating reading and raises important questions for clinical research and also for clinical practice.3 We simply do not know how to measure dyspnoea in acute heart failure and whether the commonly used instruments are sensitive to change, i.e. able to detect the effect of treatment.1 Indeed, there are few studies on this question in chronic heart failure either.4 Despite this, the scientific community, industry, and regulators have already tested and rejected new treatments, at least partly on the basis of failing to improve dyspnoea more … *Corresponding author. Tel: +44 141 330 3479, Fax: +44 141 330 6955, Email: j.mcmurray{at}bio.gla.ac.uk [1]: #fn-1

Phase 2 Randomised Controlled Trial and Feasibility Study of Future Care Planning in Patients with Advanced Heart Disease

Future Care Planning (FCP) rarely occurs in patients with heart disease until close to death by which time the potential benefits are lost. We assessed the feasibility, acceptability and tested a design of a randomised trial evaluating the impact of FCP in patients and carers. 50 patients hospitalised with acute heart failure or acute coronary syndrome and with predicted 12 month mortality risk of >20% were randomly allocated to FCP or usual care for 12 weeks upon discharge and then crossed-over for the next 12 weeks. Quality of life, symptoms and anxiety/distress were assessed by questionnaire. Hospitalisation and mortality events were documented for 6 months post-discharge. FCP increased implementation and documentation of key decisions linked to end-of-life care. FCP did not increase anxiety/distress (Kessler score -E 16.7 (7.0) vs D 16.8 (7.3), p = 0.94). Quality of life was unchanged (EQ5D: E 0.54(0.29) vs D 0.56(0.24), p = 0.86) while unadjusted hospitalised nights was lower (E 8.6 (15.3) vs D 11.8 (17.1), p = 0.01). Qualitative interviews indicated that FCP was highly valued by patients, carers and family physicians. FCP is feasible in a randomised clinical trial in patients with acute high risk cardiac conditions. A Phase 3 trial is needed urgently.

Palliative care needs in patients hospitalized with heart failure (PCHF) study: rationale and design.

AIMS The primary aim of this study is to provide data to inform the design of a randomized controlled clinical trial (RCT) of a palliative care (PC) intervention in heart failure (HF). We will identify an appropriate study population with a high prevalence of PC needs defined using quantifiable measures. We will also identify which components a specific and targeted PC intervention in HF should include and attempt to define the most relevant trial outcomes. METHODS An unselected, prospective, near-consecutive, cohort of patients admitted to hospital with acute decompensated HF will be enrolled over a 2-year period. All potential participants will be screened using B-type natriuretic peptide and echocardiography, and all those enrolled will be extensively characterized in terms of their HF status, comorbidity, and PC needs. Quantitative assessment of PC needs will include evaluation of general and disease-specific quality of life, mood, symptom burden, caregiver burden, and end of life care. Inpatient assessments will be performed and after discharge outpatient assessments will be carried out every 4 months for up to 2.5 years. Participants will be followed up for a minimum of 1 year for hospital admissions, and place and cause of death. Methods for identifying patients with HF with PC needs will be evaluated, and estimates of healthcare utilisation performed. CONCLUSION By assessing the prevalence of these needs, describing how these needs change over time, and evaluating how best PC needs can be identified, we will provide the foundation for designing an RCT of a PC intervention in HF.The primary aim of this study is to provide data to inform the design of a randomized controlled clinical trial (RCT) of a palliative care (PC) intervention in heart failure (HF). We will identify an appropriate study population with a high prevalence of PC needs defined using quantifiable measures. We will also identify which components a specific and targeted PC intervention in HF should include and attempt to define the most relevant trial outcomes.

Future Care Planning for patients approaching end-of-life with advanced heart disease: an interview study with patients, carers and healthcare professionals exploring the content, rationale and design of a randomised clinical trial

Objective To explore the optimal content and design of a clinical trial of an end-of-life intervention for advanced heart disease with patients, carers and healthcare professionals. Design Qualitative interview and focus group study. Setting Community and hospital-based focus groups and interviews. Participants Stable community-dwelling patients, informal carers (PC, n=15) and primary and secondary care based healthcare professionals (HCP, n=11). Results PC highlighted fragmentation of services and difficulty in accessing specialist care as key barriers to good care. They felt that time for discussion with HCP was inadequate within current National Health Service (NHS) healthcare systems. HCP highlighted uncertainty of prognosis, explaining mortality risk to patients and switching from curative to palliative approaches as key challenges. Patient selection, nature of the intervention and relevance of trial outcomes were identified by HCP as key challenges in the design of a clinical trial. Conclusions PC and HCP expressed a number of concerns relevant to the nature and content of an end-of-life intervention for patients with advanced heart disease. The findings of this study are being used to support a phase II randomised clinical trial of Future Care Planning in advanced heart disease.

Cardiovascular implanted electronic devices in people towards the end of life, during cardiopulmonary resuscitation and after death: guidance from the Resuscitation Council (UK), British Cardiovascular Society and National Council for Palliative Care

The Resuscitation Council (UK), the British Cardiovascular Society (including the British Heart Rhythm Society and the British Society for Heart Failure) and the National Council for Palliative Care recognise the importance of providing clear and consistent guidance on management of cardiovascular implanted electronic devices (CIEDs) towards the end of life, during cardiorespiratory arrest and after death. This document has been developed to provide guidance for the full range of healthcare professionals who may encounter people with CIEDs in the situations described and for healthcare managers and commissioners. The authors recognise that some patients and people close to patients may also wish to refer to this document. It is intended as an initial step to help to ensure that people who have CIEDs, or are considering implantation of one, receive explanation of and understand the practical implications and decisions that this entails; to promote a good standard of care and service provision for people in the UK with CIEDs in the circumstances described; to offer relevant ethical and legal guidance on this topic; to offer guidance on the delivery of services in relation to deactivation of CIEDs where appropriate; to offer guidance on whether any special measures are needed when a person with a CIED receives cardiopulmonary resuscitation; and to offer guidance on the actions needed when a person with a CIED dies.