Riet Dierckx

Prevalence and Outcomes of Anemia and Hematinic Deficiencies in Patients With Chronic Heart Failure

IMPORTANCE Detailed information on the prevalence, associations, and consequences of anemia and iron deficiency in epidemiologically representative outpatients with chronic heart failure (HF) is lacking. OBJECTIVE To investigate the epidemiology of anemia and iron deficiency in a broad range of patients referred to a cardiology clinic with suspected HF. DESIGN, SETTING, AND PARTICIPANTS We collected clinical data, including hemoglobin, serum iron, transferrin saturation, and serum ferritin concentrations, on consecutive patients referred with suspected HF to a single outpatient clinic serving a local community from January 1, 2001, through December 31, 2010. Follow-up data were censored on December 13, 2011. Patients underwent phenotyping by echocardiography and plasma N-terminal pro-brain natriuretic peptide measurement and were followed for up to 10 years. MAIN OUTCOME MEASURES Prevalences of anemia and iron deficiency and their interrelationship, all-cause mortality, and cardiovascular mortality. RESULTS Of 4456 patients enrolled in the study, the median (interquartile range) age was 73 (65-79) years, 2696 (60.5%) were men, and 1791 (40.2%) had left ventricular systolic dysfunction (LVSD). Of those without LVSD, plasma N-terminal pro-brain natriuretic peptide concentration was greater than 400 pg/mL in 1172 (26.3%), less than 400 pg/mL in 841 (18.9%), and not measured in 652 (14.6%). Overall, 1237 patients (27.8%) had anemia, with a higher prevalence (987 [33.3%]) in patients who met the criteria for HF with or without LVSD. Depending on the definition applied, iron deficiency was present in 270 (43.2%) to 425 (68.0%) of patients with and 260 (14.7%) to 624 (35.3%) of patients without anemia. Lower hemoglobin (hazard ratio 0.92; 95% CI, 0.89-0.95; P < .001) and serum iron (hazard ratio 0.98; 95% CI, 0.97-0.99; P = .007) concentrations were independently associated with higher all-cause and cardiovascular mortality in multivariable analyses. CONCLUSIONS AND RELEVANCE Anemia is common in patients with HF and often associated with iron deficiency. Both anemia and iron deficiency are associated with an increase in all-cause and cardiovascular mortality and might both be therapeutic targets in this population.

Telemonitoring in heart failure: Big Brother watching over you

Abstract Heart failure (HF) is a leading cause of hospitalisations in older people. Several strategies, supported by novel technologies, are now available to monitor patients’ health from a distance. Although studies have suggested that remote monitoring may reduce HF hospitalisations and mortality, the study of different patient populations, the use of different monitoring technologies and the use of different endpoints limit the generalisability of the results of the clinical trials reported, so far. In this review, we discuss the existing home monitoring modalities, relevant trials and focus on future directions for telemonitoring.

Clinical Trials in Patients with Heart Failure and Preserved Left Ventricular Ejection Fraction

There is no robust evidence that any treatment can modify the natural history of patients with heart failure and preserved left ventricular ejection fraction (HFpEF), although most agree that diuretics can control congestion and improve symptoms. HFpEF is often complicated by systemic and pulmonary hypertension, atrial fibrillation, obesity, chronic lung and kidney disease, lack of physical fitness, and old age that can complicate both diagnosis and management. Further trials should phenotype patients precisely and create better definitions of HFpEF based on biomarkers.

What proportion of patients with chronic heart failure are eligible for sacubitril–valsartan?

The PARADIGM‐HF trial showed that sacubitril–valsartan, an ARB–neprilysin inhibitor, is more effective than enalapril for some patients with heart failure (HF). It is uncertain what proportion of patients with HF would be eligible for sacubitril–valsartan in clinical practice.

Prognostic significance of ultrasound-assessed jugular vein distensibility in heart failure

Aims Jugular venous distension is a classical sign of heart failure (HF) but it can be difficult to assess clinically. Methods and results Outpatients with HF and control subjects were assessed. Internal jugular vein diameter (JVD) was measured using a linear high-frequency ultrasound probe (10 MHz) at rest, after a Valsalva manoeuvre and during deep inspiration. JVD ratio was calculated as the maximum diameter during Valsalva to that measured at rest. 311 patients (mean age 71 years, mean left ventricular EF 42%, median (IQR) amino-terminal pro-brain natriuretic peptide 979 (441–2007) ng/L) and 66 controls were included. JVD (median and IQR range) at rest was smaller in controls (0.16 (0.14–0.20) cm) than in patients with HF (0.23 (0.17–0.33) cm; p<0.001) but similar during Valsalva (1.03 (0.90–1.16) cm vs 1.08 (0.90–1.25) cm; p=0.28). Consequently, JVD ratio was greater in controls (6.3 (4.9–7.6)) than in patients (4.5 (2.9–6.1); p<0.001). During a median follow-up of 516 (IQR 335–622) days, 48 patients (15%) with HF died or were hospitalised for HF. In multivariable models, among clinical, echocardiographic or biochemical variables, only increasing NT-proBNP and ultrasound assessment of internal jugular vein were independently associated with prognosis. Comparing top and bottom tertiles of JVD ratio (2.3 (IQR 1.7–2.9) versus 6.8 (6.1–7.7)), the tertile with lower values had a 10-fold greater risk of an adverse event (HR 10.05, 95% CI 3.07 to 32.93). Conclusions Ultrasound assessment of the internal jugular vein identifies outpatients with HF who have a higher risk of an adverse outcome. Clinical trial registration NCT01872299.

Remote telemonitoring for patients with heart failure: might monitoring pulmonary artery pressure become routine?

Heart failure is one of the most important medical problems facing societies in developed economies and its prevalence is predicted to rise inexorably in the next few decades as longevity increases. Worsening heart failure leading to hospitalization is associated with a poor prognosis and imposes a substantial burden on health care resources and budgets. Interventions that can stabilize patients should reduce the need for hospitalization and improve prognosis. This might be facilitated by frequent self-monitoring of clinical and physiological variables by patients themselves at home. Rising pulmonary artery pressure is an early sign of cardiac decompensation that may be more sensitive than conventional methods of patient assessment and thus allow early adjustment of medical therapy to avoid hospitalizations and improve patient outcomes. Remote monitoring of pulmonary artery pressure is now possible using devices that can be implanted percutaneously. This innovative technology could become a routine part of the management of heart failure in the next few decades.

Telemedicine in heart failure: new insights from the Cochrane meta‐analyses

1Cardiovascular Centre, OLV Hospital, Aalst, Belgium; 2Faculty of Health, University of Technology Sydney, Sydney, Australia; 3School of Nursing and Midwifery, The Flinders University of South Australia, Adelaide, Australia; 4Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK; and 5Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow and National Heart and Lung Institute, Imperial College London, London, UK

Xanthine oxidase inhibition for the treatment of cardiovascular disease: an updated systematic review and meta‐analysis

Previous studies have shown that xanthine oxidase inhibitors (XOI) might improve outcome for patients with cardiovascular disease. However, more evidence is required.

If home telemonitoring reduces mortality in heart failure, is this just due to better guideline-based treatment?

To investigate, in a ‘real-world’ setting, the impact of home telemonitoring (HTM) compared to usual care on achieved dose of guideline-recommended medication, hospitalisation rate and mortality in patients with heart failure (HF). Methods: We retrospectively analyzed data on 333 patients with HF referred to a HTM service supported by a nurse-specialist (mean age 71±12 years, mean left ventricular ejection fraction (LVEF) 36 ± 11% and median N-Terminal pro B-type Natriuretic Peptide (NT-proBNP) 2,972 ng/L (interquartile range (IQR): 1,447–7,801 ng/L)). Most patients (n = 278) accepted HTM (HTM-group) but 55 refused and received usual care (UC-group). In the HTM-group, weight, heart rate, blood pressure and symptom severity were measured daily. Results: At referral, respectively 90%, 90%, 67% and 94% of patients with LVEF ≤40% (n = 229) were treated with β-blockers (BB), angiotensin converting enzyme-inhibitors (ACE-I) or angiotensin receptor blockers (ARB), mineralocorticoid receptor antagonists (MRA) and diuretics, with rates similar between groups. After 6 months, prescription of BB (92% vs 83%), ACE-I/ARB (92% vs 90%) and MRA (68% vs 67%) did not differ significantly between groups. The proportions of patients who achieved ≥50% and ≥100% of target doses of BB, ACE-I/ARB and MRA were also similar in each group. However, during a median follow-up of 1094 days (IQR 767–1419) fewer patients who chose HTM died (33% vs 49%; P = 0.002). Conclusion: Patients who choose HTM have a better prognosis than those who do not but this does not appear to be mediated through greater prescription of key HF medications.

Xanthine Oxidase Inhibition for the Treatment of Cardiovascular Disease: A Systematic Review and Meta-Analysis

MeSH Antioxidants /therapeutic use; Biomarkers /blood; Cardiovascular Agents /therapeutic use; Cardiovascular Diseases /blood /drug therapy /enzymology /physiopathology; Endothelium, Vascular /drug effects /metabolism /physiopathology; Enzyme Inhibitors /therapeutic use; Exercise Tolerance /drug effects; Hemodynamics /drug effects; Humans; Inflammation Mediators /blood; Myocardial Contraction /drug effects; Oxidative Stress /drug effects; Ventricular Function, Left /drug effects; Xanthine Oxidase /antagonists & inhibitors /metabolism