Märit Mejhert

The epidemiology of heart failure, based on data for 2.1 million inhabitants in Sweden.

The epidemiology of congestive heart failure (CHF) is likely to have changed due to changes in demography, risk factors, diagnostic procedures, and medical care. Prevailing information is in part old, incomplete, and to some extent contradictory. We determined the current prevalence, incidence, mortality, and 5‐year survival rate of CHF, and possible temporal changes in Sweden.

Epidemiology of heart failure in Sweden--a national survey.

In Sweden heart failure is the most frequent discharge diagnosis within internal medicine. The prevalence of heart failure seems to be increasing, mainly due to an ageing population, but also because of improved survival in patients with cardiovascular diseases.

Limited long term effects of a management programme for heart failure

Objective: To evaluate the effects of a nurse based outpatient management programme for elderly patients discharged with heart failure from a university hospital. Design: Patients with heart failure (New York Heart Association class II–IV) and left ventricular systolic dysfunction aged 60 years or more were randomly assigned to follow up within the management programme or to conventional follow up, usually in primary care. Of the 208 participants, 58% were men, mean age was 75 years, and mean ejection fraction 34%. All patients were scheduled for three observational study visits at six month intervals. The primary end point was quality of life (QoL) and secondary end points were hospitalisation and mortality. Results: More patients achieved target doses of angiotensin converting enzyme (ACE) inhibitors in the intervention group than in the control group (82% v 69%, 88% v 69%, and 88% v 74% of recommended target doses at 6, 12, and 18 months of follow up, respectively, p < 0.05 for all). Patients with initial low QoL had a poor prognosis. After a mean 1122 days of follow up, 82% of all patients had been readmitted. There were on average 4.7 readmissions per patient and 66% were due to non-cardiac diagnoses. There were no differences in QoL or health care consumption between the two study groups during follow up. Conclusion: A nurse based management programme is more effective than follow up in primary care in optimising medication for elderly patients with heart failure. However, such a programme does not seem to have a favourable influence on QoL or readmission rate during long term follow up.

Ventilatory variables are strong prognostic markers in elderly patients with heart failure

Objective: To evaluate the safety and prognostic capacity of cardiopulmonary exercise testing in patients ≥ 60 years old who are hospitalised with heart failure caused by left ventricular dysfunction. Design: Prospective study. Setting: University hospital. Patients: Study participants were 67 patients (66% men) with clinical heart failure stabilised on medical treatment. The study is a part of a nursing intervention study. Mean (SD) age was 74 (6) years, New York Heart Association functional class II–III, and ejection fraction 0.36 (0.11). Interventions: Cardiopulmonary exercise testing and echocardiography. Main outcome measures: Peak oxygen consumption (V̇o2), peak ventilatory equivalents for carbon dioxide (V̇E/V̇co2) and oxygen (V̇E/V̇o2), left ventricular volumes, and mortality. Results: Mean (SD) peak V̇o2 was 11.7 (3.7) ml/kg/min, peak V̇E/V̇co2 43 (9), and peak V̇E/V̇o2 46 (11). During 12–59 months of follow up, 14 patients died. In univariate analyses peak V̇o2, V̇E/V̇o2, and V̇E/V̇co2 were all strongly related (p < 0.01) to mortality. In a multivariate Cox regression analysis, peak V̇E/V̇co2 was the strongest predictor of mortality (p < 0.001), followed by left ventricular end systolic volume (p < 0.001). A cut off of peak V̇E/V̇co2 at ≥ 45 gave a univariate hazard ratio of 6.7 for death during follow up. No adverse events occurred during the exercise test. Conclusion: These findings extend results found in selected middle aged patients to elderly patients with heart failure and show that ventilatory parameters from a cardiopulmonary exercise test, such as peak V̇o2, V̇E/V̇o2, and V̇E/V̇co2 are powerful predictors of mortality.

Diagnostic tests, treatment and follow-up in heart failure patients — is there a gender bias in the coherence to guidelines?

To relate clinical data in a consecutive cohort of patients admitted with heart failure in Sweden to demographic data and the use of diagnostic tests, medical treatment, care process and mortality.

Doppler tissue imaging in congestive heart failure patients due to diastolic or systolic dysfunction: a comparison with Doppler echocardiography and the atrio-ventricular plane displacement technique.

Doppler tissue imaging (DTI) is an echocardiographic technique by which regional contractility, relaxation properties and time intervals are obtained easily. DTI has been reported to be relatively pre‐load independent and could, in comparison with the commonly used mitral pulse wave Doppler (MPWD) method, be of clinical interest for identification of patients with diastolic dysfunction. The atrio‐ventricular plane displacement (AVPD) method is an established technique to assess left ventricular systolic function.

Long term health care consumption and cost expenditure in systolic heart failure

BACKGROUND The prevalence, health care consumption, and mortality increase in elderly patients with heart failure. This study aimed to analyse long term cost expenditure and predictors of health care consumption in these patients. METHODS We included 208 patients aged 60 years or older and hospitalised with heart failure (NYHA class II-IV and left ventricular systolic dysfunction); 58% were men, mean age 76 years, and mean ejection fraction 0.34. Data on all hospital admissions, discharge diagnoses, lengths of stay, and outpatient visits were collected from the National Board of Health and Welfare. We obtained data of all health care consumption for each individual. RESULTS After 8-12 years of prospective follow up 72% were dead (median survival 4.6 years). Main drivers of health care expenditure were non-cardiac (40%) and cardiac (29%) hospitalizations, and visits to primary care centres (16%), and hospital outpatient clinics (15%). On average, health care expenditures were € 36,447 per patient during follow up. The average yearly cost per patient was about 5,700€, in contrast to the estimated consumption of primary and hospital care in the general population: € 1,956 in 65-74 year olds and € 2,701 in 75-84 year olds. Poor quality of life (Nottingham Health Profile) was the strongest independent predictor of total health care consumption and costs (p<0.001; by multivariate analyses). CONCLUSION Health care costs in chronic systolic heart failure are at least two-fold higher than in the general population. Quality of life is a strong independent predictor of health care consumption.

Biomarkers of collagen type I metabolism are related to B-type natriuretic peptide, left ventricular size, and diastolic function in heart failure.

Aims Myocardial collagen metabolism can be assessed indirectly by circulating biomarkers. We aimed to examine associations between myocardial collagen type I synthesis and degradation, and echocardiographic, clinical, and B-type natriuretic peptide (BNP) findings in heart failure. Methods We studied 57 women and 75 men 60 years or older with systolic heart failure (New York Heart Association II–IV and an ejection fraction ⩽45%). Mean age was 75 years, blood pressure 134/80 mmHg, ejection fraction 34%, and median BNP 210 ng/l. Analyses of the carboxy-terminal propeptide of procollagen type I (PICP, biomarker of collagen type I synthesis) and the serum carboxy-terminal telopeptide of collagen type I (CITP, biomarker of collagen type I degradation) were measured. Extensive echocardiographic examinations were performed, including variables of dyssynchrony. Results Increased collagen synthesis (PICP) was independently related to increased BNP levels (r = 0.24, P = 0.018). Furthermore, independent associations were found between PICP and left ventricular size, isovolumic relaxation time, and relative wall thickness. Increased collagen degradation (CITP) was independently related to increased BNP levels (r = 0.35, P < 0.001). Also, univariable, but not multivariable, associations were found between CITP and E/E’ septal and QRS duration. Conclusion Biomarkers of collagen type I synthesis and degradation are independently related to BNP and to indices of left ventricular size and diastolic function in systolic heart failure. It is proposed that BNP may contribute to alterations in collagen type I metabolism in systolic heart failure.

Quality of life in chronic disease: a comparison between patients with heart failure and patients with aphasia after stroke

OBJECTIVES This study aimed to describe the impact of heart failure and of stroke with aphasia on quality of life (QoL) and to compare the different domains of QoL in these groups. BACKGROUND The prevalence of chronic conditions has increased during the last decades, and chronic diseases such as stroke and heart failure may have a great impact on QoL. DESIGN Comparative study of patients from two randomised controlled studies. METHOD Seventy-nine patients with heart failure and 70 patients with aphasia after stroke were evaluated concerning the severity of their disease and by QoL, as measured with the Nottingham Health Profile, in the acute phase and after six months. RESULTS The severity of the disease improved between baseline and six month for both groups. Correlations between New York Heart Association (NYHA) class and all QoL domains were seen in patients with heart failure after six months. The degree of aphasia correlated to mobility, social, emotional and total score after six month. QoL in patients with heart failure was more affected in the domains of sleep and energy in the acute phase and in the energy domain at six months. CONCLUSION Although low energy is more frequent among patients with heart failure, both groups report poor QoL. Improvement in severity of the disease is not necessarily accompanied by improvement in QoL. RELEVANCE TO CLINICAL PRACTICE Nottingham Health Profile can easily be used as a screening instrument, aiming to identify patients at risk for adverse effects on QoL. A better understanding of the subjective QoL of patients with chronic disease is fundamental for health care professionals to be able to identify and support vulnerable patients.

Atrial fibrillation and biomarkers of myocardial fibrosis in heart failure

Abstract Objectives. Alterations of collagen metabolism present in heart failure promote the fibrotic substrate for the development of atrial fibrillation (AF). Myocardial collagen I synthesis and degradation can be assessed indirectly by circulating biomarkers such as the carboxy terminal propeptide (PICP) and carboxy-terminal telopeptide (CITP), respectively. Design. We examined myocardial collagen type-I metabolism in 143 patients with systolic heart failure (New York Heart Association Class 2–4) in relation to coexisting AF. Results. Mean age was 75 years, blood pressure 134/80 mm Hg, ejection fraction 34%, serum PICP 81 μg/L and CITP 8.3 μg/L, and median plasma brain natriuretic peptide 215 pg/L; 77 were in AF. PICP and CITP were related to left atrial diameter (r = 0.22, P = 0.013, and r = 0.26, P = 0.003) and CITP to pulmonary capillary wedge pressure and C-reactive protein (r = 0.19, P = 0.044, and r = 0.29, P = 0.003). A logistic regression suggested that PICP (odds ratio per 1 μg/L change 1.01, P = 0.012) and left ventricular end-diastolic volume (odds ratio per 1 mL change 0.98, P < 0.001) were independently associated with coexisting AF. Conclusion. Collagen type-I metabolism is associated to left atrial size. Heart failure patients with coexisting AF exhibit more altered collagen type-I metabolism than patients in sinus rhythm. This might represent more severe atrial and ventricular fibrosis. Trial registration: ClinicalTrials.gov identifier: NCT01671995.