Robin J. Trupp

Continuous Hemodynamic Monitoring in Patients With Mild to Moderate Heart Failure: Results of the Reducing Decompensation Events Utilizing Intracardiac Pressures in Patients With Chronic Heart Failure (REDUCEhf) Trial

Clinical trial results support the hypothesis that implantable hemodynamic monitoring (IHM) systems may reduce hospitalizations among patients with chronic heart failure (HF). The Reducing Decompensation Events Utilizing Intracardiac Pressures in Patients With Chronic Heart Failure (REDUCE hf  ) study was a prospective, randomized, multicenter, single-blinded trial that enrolled patients with New York Heart Association class II or III symptoms, an indication for an implantable cardioverter-defibrillator (ICD), and a previous HF hospitalization. A combination IHM-ICD was implanted and patients were randomly assigned to a treatment group in which hemodynamic information was used or a control group in which hemodynamic information was not available. Patients were followed for 12 months to evaluate the primary efficacy end point of HF hospitalizations, emergency department visits, or urgent clinic visits. The trial was designed to enroll 1300 patients, but stopped at 400 patients because of IHM lead failures experienced from previous trials. A total of 202 treatment patients and 198 controls were randomized for 12-month follow-up. The primary safety end point was met, but the rate of HF equivalents was not different between groups. REDUCE hf was unable to test clinical efficacy end points adequately. The device combining IHM-ICD technology was safe and functioned appropriately. Patients at high risk for decompensated HF have high baseline filling pressures and demonstrate consistent increases as the process of congestion worsens to the time of hospitalization.

The Impact of Educational Message Framing on Adherence to Continuous Positive Airway Pressure Therapy

Although of proven health benefit to persons with obstructive sleep apnea (OSA), adherence to continuous positive airway pressure (CPAP) therapy is suboptimal, with patterns of use that are established early and that are not easily altered after the initial experience. In a randomized controlled trial, 70 participants with OSA and cardiovascular disease were assigned to receive either positively or negatively framed education about CPAP. Objective adherence was measured following 30 days of home CPAP therapy. Daytime sleepiness, dispositional optimism, self-efficacy, and depression were also evaluated at baseline and after 30 days. CPAP use was greater in the group receiving negative message framing (p = .015).

Nesiritide in Acute Decompensated Heart Failure: A Pooled Analysis of Randomized Controlled Trials

Previous randomized controlled trials (RCTs) evaluating nesiritide for the treatment of acute decompensated heart failure (ADHF) have reported wide variances in mortality hazard ratios for nesiritide vs controls, but these individual trials were neither designed nor powered to evaluate mortality. This study used relevant data from all RCTs of nesiritide in ADHF completed as of June 2006 to independently estimate the effect of nesiritide on 30‐ and 180‐day mortality.

Nesiritide for the treatment of congestive heart failure

Nesiritide (Natrecor®) is a recombinant form of the human B-type natriuretic peptide (BNP) that has been shown, through several studies, to have beneficial natriuretic, diuretic and vasodilatory effects in the treatment of congestive heart failure (CHF). Nesiritide mimics the actions of endogenous BNP by binding to and stimulating receptors in the heart, kidney and vasculature. Nesiritide functions as both a potent venous and arterial vasodilator and has been shown to improve cardiac haemodynamics more rapidly and to a greater extent than intravenous nitroglycerin, as well as having fewer side effects. When compared in an open-label trial, nesiritide has also been shown to be less proarrhythmic than dobutamine. The major adverse effect of nesiritide, as with other vasodilators, is symptomatic hypotension, which occurred infrequently in clinical trials. Overall, nesiritide represents an effective and safe therapeutic option for the treatment of decompensated CHF.

Future therapies for heart failure

The treatment of heart failure has changed as the understanding of the disease evolves. Heart failure remains the only cardiovascular disease that continues to rise in both incidence and prevalence, despite recent advances in treating symptoms and thwarting disease progression. Many opportunities exist for improving patient outcomes with pharmaceutical agents and technologies available now or in the near future. This article discusses recently approved drugs and devices and clinical trials that may affect the management of this challenging disease.

Hemodynamic Monitoring in Heart Failure: A Nursing Perspective

Managing patients who have heart failure is challenging and requires the integration of inpatient and outpatient care. Until evidence from clinical trials of implantable hemodynamic monitors (IHMs) is available and approval from the Food and Drug Administration is received, the best available model seems to be telemonitoring in conjunction with a comprehensive heart failure disease management program. A number of issues, including established processes for data review and interpretation, must be addressed before IHMs are widely adopted and accepted. Nurses, as the most frequent and common contact for patients, have the ability and opportunity to lead this change.

Nursing considerations for the management of heart failure in the emergency department.

Despite a lack of trials examining the impact of educational interventions in the emergency department and observation unit, there is ample evidence in other health care settings supporting its use in the management of patients with heart failure. The challenge for the emergency department and observation unit nurse is to adapt these interventions to fit realistically within the fast-paced environment. This article addresses nursing considerations for the management of heart failure in the emergency department setting.

An integrated approach to managing sleep disordered breathing and cardiovascular disease

Despite its prevalence, most cases of sleep disordered breathing (SDB) go unrecognized by the medical community, creating a mismatch between disease pervasiveness and medical appreciation of its impact. Of particular importance is that 30% of those with cardiovascular disease (CVD) have some type of sleep disorder. One explanation for this lack of recognition and under-appreciation is that common symptoms seen with SDB are non-specific and are present in many acute and chronic conditions. This article will present a brief review of current processes used to diagnose and treat SDB, followed by a discussion of the overlap that exists between CVD and SDB, and present an argument that these chronic conditions should not be considered and managed as separate entities.

THE TIME OF MY LIFE

That old adage ‘‘time flies’’ seemed so strange when I was younger, but now it seems like a way of life. It is hard to believe that my tenure as President of AAHFN has ended and that this is my last President’s Column. This final column will recap my Presidential Address, entitled ‘‘Raising the Bar of Heart Failure Care: It’s Our Duty and Responsibility,’’ as presented at the 4th Annual Meeting in Boston, MA on June 27, 2008. In 2001, the Institute of Medicine published ‘‘Crossing the Quality Chasm’’ and stressed the importance of quality health care for patients and populations within the United States. Quality was defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Using examples of the documented disconnect between what is known to be quality care and the actual norm in clinical practice, a number of attributes for improving quality were proposed, including patient-centered, safe, effective, efficient, equitable, and timely care. Since then, a vast number of quality initiatives have been implemented, including but not limited to, the Department of Health and Human Services National Quality Initiative (2001), the Joint Commission ORYX discharge criteria (2002), the Medicare Prescription Drug, Improvement, and Modernization Act (2003), the Centers for Medicare and Medicaid Services Deficit Reduction Act (2005), and the Tax Relief and Health Care Act (2006). Public reporting and financial incentives were implemented as tools to drive improvements in clinical quality, patient-centeredness, and efficiency. While these initiatives initially focused on the care provided to hospitalized patients, they have been expanded to outpatient care as well. Today, hospitals are ranked by the relative value of the care provided, and these rankings are expected to effect reimbursement as our government moves toward pay for performance. But have these quality initiatives closed the quality chasm? The answer is somewhat, depending on what parameter is evaluated and what metric is used to measure it. As an example, from Optimize-HF, having an established process for addressing the ORYX criteria and the ACC/AHA measures in heart failure results in performance improvement over time, as measured by improved adherence to the quality standards of care. However, research has demonstrated that not all of these measures translate into improved outcomes (reduced mortality and/ or hospitalization) posthospitalization. In fact, use of an ACE inhibitor or an angiotensin receptor blocker at the time of discharge was the only item associated with a reduction in these clinical outcomes 60 to 90 days postdischarge. The importance and efficacy of b-blockers in heart failure to halt and/or reverse disease progression is well known, and yet none of the current performance measures include b-blockers, particularly specific evidencebased agents, as a quality metric. Yet, also from OptimizeHF, prescription of a b-blocker at discharge was strongly associated with reduced morbidity and mortality. It seems as if there are a number of possible explanations for why the quality chasm continues, but 2 seem especially pertinent, in my mind. One revolves around the issue of education and knowledge. As we all know, not all education becomes knowledge. If that were true, there would be no need for spell check on computers. The application of information into practice remains clinically challenging, despite the availability of and accessibility to established tools, order sets, clinical pathways, etc. targeting enhanced adherence to performance measures. In reality, we are all creatures of habit and do many things rotely. While change is difficult, in health care it is necessary, and failure to practice contemporarily is unacceptable. The consequences are far greater and affect quality of life, longevity, and other important outcomes for patients, for families, and for society. We must continue to do our part in raising the bar for quality in heart failure—both for what the guidelines recommend and for what quality measures mandate. The other big issue focuses on awareness. To date, no celebrity has shared their diagnosis of heart failure with the public. This is very unlike other diseases or conditions in which celebrities heighten awareness through disclosure of personal information. Think of breast cancer, and many individuals come to mind: Melissa Etheridge, Edie Falco, Olivia Newton John. The list goes on and on. Think of heart failure, and many individuals come to mind, but only after they have died: George Carlin, Don Ho, Yolanda King. The impact factor is markedly reduced when awareness comes after death. It adds to the common misperception that heart failure is a terminal diagnosis. We must continue to spread the word about heart failure: the risks for developing it and how to reduce those risks, the early signs and symptoms of heart failure, treatment options using drugs, devices, or both, and that many individuals can and do lead a high-quality life for many years. Raising the bar in heart failure care requires acceptance that ‘‘we’ve always done it this way’’ attitudes are longer tolerable and that higher standards are necessary to achieve the objective of excellence and improved outcomes for our patients. Much hard work, stamina, and perseverance are required, as only those individuals and institutions with these traits will be successful. As nurses, our duty to public welfare is paramount, and we accept responsibility every day through our judgments and decisions made about the care given to patients. But this care is not just our own individual actions or inactions. Rather, it includes the judgments and decisions made by our physician colleagues and other members of the health

Heart Failure: A Call to Action

A recent survey commissioned by The American Association of Heart Failure Nurses, The Preventive Cardiovascular Nurses Association, and The Society for Chest Pain Centers found that respondents had a striking lack of awareness and knowledge about heart failure. This article reviews the confusion and misperceptions surrounding heart failure, discusses implications of the survey findings, and offers suggestions for patients at risk for heart failure as well as professionals who work with these patients-including clinicians, researchers, and those in larger groups such as institutions and government bodies.