Roser Cabanes

Combined use of high‐sensitivity ST2 and NTproBNP to improve the prediction of death in heart failure

To address the incremental usefulness of biomarkers from different disease pathways for predicting risk of death in heart failure (HF).

Mortalidad y causas de muerte en pacientes con insuficiencia cardiaca: experiencia de una unidad especializada multidisciplinaria

Introduccion y objetivos La mortalidad de la insuficiencia cardiaca es similar o incluso superior a la de muchos canceres. Suele ocurrir por progresion de la enfermedad, aunque la muerte subita se ha descrito como una causa frecuente. El objetivo es evaluar la mortalidad y sus causas en una poblacion ambulatoria de pacientes con insuficiencia cardiaca de etiologia diversa tratados en una unidad especializada multidisciplinaria y analizar los factores asociados con ellas. Metodos Estudio de seguimiento de cohorte (mediana, 36 meses) de 960 pacientes (el 70,9% varones; mediana de edad, 69 anos; mayoritariamente de etiologia isquemica, con fraccion de eyeccion del 31% y en clase funcional fundamentalmente II y III). Resultados Se registraron 351 fallecimientos (36,5%): 230 de causa cardiovascular (65,5%), fundamentalmente por insuficiencia cardiaca (33,2%) y muerte subita (16%), 94 de causa no cardiovascular (26,8%), fundamentalmente neoplasias (10,5%) y procesos septicos (6,8%), y 27 (7,7%) de causa desconocida. Mostraron relacion independiente con la mortalidad: edad, sexo, clase funcional, fraccion de eyeccion, tiempo de evolucion, etiologia isquemica, diabetes mellitus, aclaramiento de creatinina, vasculopatia periferica, fragilidad y ausencia de tratamiento con inhibidores de la enzima de conversion de angiotensina o antagonistas de los receptores de la angiotensina II, bloqueadores beta, estatinas y antiagregantes. El factor principal asociado a muerte cardiovascular fue la etiologia isquemica. No hallamos ningun factor predictor claramente determinante de muerte subita. Conclusiones Aunque la mortalidad de los pacientes atendidos en una unidad especializada de insuficiencia cardiaca no fue baja, una cuarta parte fallecio de causa no cardiovascular. El principal factor asociado a muerte cardiovascular fue la etiologia isquemica. La muerte subita afecto solo al 5,8% de la poblacion.

Depression, antidepressants, and long-term mortality in heart failure

BACKGROUND This study was designed to assess whether depression and the use of antidepressants were related to long-term mortality in heart failure. METHODS Heart failure outpatients (n=1017) from a specialized tertiary unit in Spain were prospectively studied for a median follow-up of 5.4 years (IQR 3.1-8.1). Depressive symptoms were assessed using an abbreviated version of the geriatric depression scale. Survival rates during the study period (August 2001 until December 2010) and hazard ratios (HR) for mortality were adjusted by several demographic and clinical variables. RESULTS Depressive symptoms were detected in 302 patients (29.7%) at baseline and 222 (21.8%) de novo during follow-up; 304 patients (29.9%) received at least one prescription of antidepressants, mainly selective serotonin reuptake inhibitors (92.8%); 441 patients (43.4%) died. In a multivariate Cox proportional hazard model, depression was associated with an increased all-cause (HR, 1.39; 95% CI, 1.15-1.68), but not cardiovascular, mortality risk after adjustment for several demographic and clinical confounders. The use of any antidepressant was not independently associated with mortality (HR, 0.89; 95% CI, 0.71-1.13), but benzodiazepines showed a protective role (HR, 0.70; 95% CI, 0.57-0.87). On the contrary, fluoxetine prescriptions, but not duration of fluoxetine treatment, were associated with increased mortality (HR, 1.66; 95% CI, 1.13-2.44). CONCLUSIONS Depressive symptoms are associated with long-term mortality, but the use of antidepressants and benzodiazepines is safe regarding survival in HF patients, although further research is needed considering individual antidepressants separately.

Quality of life monitoring in ambulatory heart failure patients: temporal changes and prognostic value

Heart failure (HF) is a chronic condition that typically affects a patients quality of life (QoL). Little is known about long‐term QoL monitoring in HF. This study aimed to evaluate the temporal changes and prognostic value of QoL assessment in a real‐life cohort of HF patients.

Mortality and Cause of Death in Patients With Heart Failure: Findings at a Specialist Multidisciplinary Heart Failure Unit

INTRODUCTION AND OBJECTIVES Heart failure mortality is similar to or even higher than that due to various cancers. It is usually associated with disease progression, though sudden death has also been reported as a frequent cause of mortality. The objectives of this study were to investigate mortality and its causes in outpatients with heart failure of different etiologies who were treated in a specialist multidisciplinary unit, and to identify associated factors. METHODS The follow-up cohort study (median duration 36 months) involved 960 patients (70.9% male; median age 69 years; ejection fraction 31%; and the majority had an ischemic etiology and were in functional class II or III). RESULTS Overall, 351 deaths (36.5%) occurred: 230 due to cardiovascular causes (65.5%), mainly heart failure (33.2%) and sudden death (16%); 94 due to non-cardiovascular causes (26.8%), mainly malignancies (10.5%) and septic processes (6.8%); and 27 (7.7%) due to unknown causes. Mortality was independently associated with age, sex, functional class, ejection fraction, time since symptom onset, ischemic etiology, diabetes, creatinine clearance rate, peripheral vascular disease, fragility, and the absence of treatment with an angiotensin-converting enzyme inhibitor or angiotensin-II receptor blocker, beta-blockers, statins or antiplatelet agents. The principal factor associated with cardiovascular death was an ischemic etiology. No factor studied clearly predicted sudden death. CONCLUSIONS Even though mortality in patients treated at a specialist heart failure unit was not low, a quarter died from non-cardiovascular causes. The principal factor associated with cardiovascular death was an ischemic etiology. Only 5.8% of the study population experienced sudden death.

Fragility is a key determinant of survival in heart failure patients

BACKGROUND Heart failure (HF) is a chronic condition with poor prognosis, and has a high prevalence among older adults. Due to older age, fragility is often present among HF patients. However, even young HF patients show a high degree of fragility. The effect of fragility on long-term prognosis in HF patients, irrespective of age, remains unexplored. The aim of this study was to assess the influence of fragility on long-term prognosis in outpatients with HF. METHODS AND RESULTS At least one abnormal evaluation among four standardized geriatric scales was used to identify fragility. Predefined criteria for such scales were: Barthel Index, <90; OARS scale, <10 in women and <6 in men; Pfeiffer Test, >3 (± 1, depending on educational grade); and ≥ 1 positive response for depression on the abbreviated Geriatric Depression Scale (GDS). We assessed 1314 consecutive HF outpatients (27.8% women, mean age years 66.7 ± 12.4 years with different etiologies. Fragility was detected in 581 (44.2%) patients. 626 deaths occurred during follow-up; the median follow-up was 3.6 years [P25-P75: 1.8-6.7] for the total cohort, and 4.9 years [P25-P75: 2.5-8.4] for living patients. Fragility and its components were significantly associated with decreased survival by univariate analysis. In a comprehensive multivariable Cox regression analysis, fragility remained independently associated with survival in the entire cohort, and in age and left ventricular ejection fraction subgroups. CONCLUSION Fragility is a key determinant of survival in ambulatory patients with HF across all age strata.

Educational level and self-care behaviour in patients with heart failure before and after nurse educational intervention

Background: Self-care is important for heart failure (HF) management and may be influenced by the patient’s educational level. Aim: We assessed the relationship of educational level with baseline self-care behaviour and changes one year after a nursing intervention in HF outpatients attending a HF unit. Patients and method: Three hundred and thirty-five HF patients were studied, with a median age of 67 years (P25–75 57–75) and a median HF duration of six months (P25–75 1–36). HF aetiology was mainly ischaemic heart disease (53.4%). Median ejection fraction was 30% (P25–75 24–37%). The functional class was mainly II (66.3%) and III (25.7%). Educational levels were: very low 17.3%; low 62.1%; medium–high 20.6%. Patients were evaluated at the first visit (baseline) and one year after the educational intervention with the nine-item European Heart Failure Self-care Behaviour Scale. Results: Median patient scores differed in the baseline (19 (P25–75 15–26) vs. 16 (P25–75 13–21) vs. 15 (P25–75 12.5–15.5)) and the one-year evaluation (15 (P25–75 13–17) vs. 13 (P25–75 11–15) vs. 12 (P25–75 10–14)) for the three educational levels, respectively, with statistically significant differences between levels (p=0.007 to p<0.001) except between low and medium-high education at one year (p=0.057). In the one-year evaluation, self-care behaviour significantly improved in the three educational groups (p<0.001), with a similar, albeit not statistically significant, magnitude of improvement in all groups. Conclusions: Self-care behaviour at baseline and one year after a nursing intervention was better in patients with a higher education, although the improvement with the intervention was similar irrespective of the educational level.

Brilliant violet fluorochromes in simultaneous multicolor flow cytometry–fluorescence in situ hybridization measurement of monocyte subsets and telomere length in heart failure

Conventional analytical methods to determine telomere length (TL) have been replaced by more precise and reproducible procedures, such as fluorescence in situ hybridization coupled with flow cytometry (flow–FISH). However, simultaneous measurement of TL and cell phenotype remains difficult. Relatively expensive and time-consuming cell-sorting purification is needed to counteract the loss, due to stringent FISH conditions, of prehybridization fluorescence by the organic fluorochromes conventionally used in the phenotyping step. Here, we sought to assess whether the newly developed Brilliant Violet (BV) dyes are valuable to specifically and simultaneously assess the distribution and telomere attrition of monocyte subsets circulating in the blood of a cohort of patients with heart failure. We performed flow–FISH on blood samples from 28 patients with heart failure. To differentiate among monocyte subsets, we used BV and conventional fluorochromes conjugated to antibodies against CD86, CD14, CD16, and CD15. We simultaneously assessed the TLs of the monocyte subsets with a telomere-specific peptide nucleic acid probe labeled with fluorescein isothiocyanate. The BV dyes completely tolerated the harsh conditions required for adequate DNA denaturation and simultaneously provided accurate identification of monocyte subpopulations and respective TLs. The presented protocol may be faster and less expensive than those used currently for purposes such as establishing associations among patient categories, disease progression, monocyte heterogeneity, and aging in the context of heart failure.

Analysis of Telephone Calls to a Heart Failure Unit: Reasons for the Call and Resource Use

Among other aims, multidisciplinary heart failure (HF) management programs are designed to reduce admissions and improve survival rates. The nursing team plays a crucial role in the achievement of these aims. Activities conducted by nursing staff when patients visit a HF unit include encouraging self-help, providing health care advice, and assessing the patient’s biopsychosocial situation. In addition, an increasingly important aspect of these programs is telephone assistance, which the nursing staff provide alongside patient visits. However, few publications discuss the reasons why patients use this telephone service and how dealing with them affects the professionals working at a specialist unit. We therefore decided to analyze telephone calls received between February and November 2012 by a multidisciplinary HF unit at a tertiary care hospital offering outpatient services. Our aim was to assess the most common reasons for the calls and the response given or action taken following the call. During the study period, 716 telephone calls were received from 310 patients; therefore, 39.2% of the 789 patients treated during this period used the service (Table). A total of 56% of the calls were made by the patient and the remaining 44% by primary care, usually a family member. There was no difference between the patients who called the unit and those who did not in age, sex, marital status, level of education or time registered with the unit. Of the patients who called, those who had been under the care of the unit for less than 1 year when the study began (median =2 years) made more calls (P=.006) than those who had been under its care for more than 1 year (median =1 year). The reasons for the calls are shown in the Figure. There was no difference in reason based on who made the call (P=.18), level of education (P=.15), or marital status (P=.49), but differences were found based on the time registered with the unit (P<.001), since patients who had been with the unit for more than 1 year called more to ask questions about nonheart-related treatment (23.3%), and the more recently registered tended to ask questions about treatment for their HF (27.7%). Only 73 calls (10.2%) were due to worsening symptoms; the most common reasons were fatigue or tiredness (32 calls [43.8%]) and edema (28 calls [38.3%]), ahead of dyspnea (18 calls [24.6%]) and sudden weight gain (12 calls [16.4%]); some patients described more than 1 symptom. Of the calls made in relation to HF treatment, 48% were due to symptomatic hypotension, possibly triggered by the HF treatment itself and with time of year as an added causative trigger, such that these calls significantly increased (P=.004) from June to September compared with the rest of the study period. The most common action taken by the nursing staff (52%) was to give telephone advice (sometimes including advice to visit the patient’s family physician), while the patient’s HF treatment was changed in only 3.5% of cases. There were no differences in the actions taken by the nursing staff based on who made the call (P=.14), but, as expected, there were differences based on the reason for the call (P<.001). Of all the calls prompted by clinical worsening, 42 (58%) led to an unscheduled visit to the unit, 5 (7%) resulted in a visit to the emergency department and 5 (7%) required a change in medication. Of calls made in relation to HF treatment, 22 (14%) resulted in the caller being referred to a on a study of telephone nursing advice, in which the most common reason for calls by the patient or carer was a worsening of the HF symptoms (50% of patients), although we are unable to draw comparisons due to the differences between the 2 studies and the type of unit. Contrary to our expectations, we found that the main reason for telephone calls to the HF unit was to request advice on treatment not directly related to HF rather than to request advice on worsening of HF symptoms; we believe this finding reflects the large extent to which patients depend on the staff of the unit rather than any mistrust of their physicians. A not inconsiderable proportion of calls were related to bureaucratic issues that could have been dealt with by administrative staff, although it is not unusual for nurses to handle these tasks in units such as ours, a consideration that could affect the planning of future HF units. Just over 10% of calls resulted in an extra visit to the unit more or less immediately, due to the ease with which patients are able to access our care, a feature that sets this type of unit apart. Finally, the nurses only redirected one-tenth of calls to the unit’s medical staff, confirming their ability to deal

Long-term mortality risk stratification in heart failure using classification and regression trees with a combination of biomarkers

Background: Mortality remains high in heart failure (HF). Several statistical models can be used in order to evaluate the additive usefulness of the combination of biomarkers reflecting different pathophysiological pathways. Objectives: To assess the performance of SPSS Classification and Regression trees (CART) for risk of death stratification using serum biomarkers. Patients and methods: We analyzed 876 consecutive outpatients (72% men, median age 70.4 years, main etiology of HF ischemic heart disease (52.7%), median LVEF 34%). A combination of biomarkers reflecting myocyte injury (hs-cTnT), myocardial stretch (NT-proBNP) and ventricular fibrosis and remodelling (ST2) was used. Results: During a median follow-up of 4 years, 370 patients died. Using semi-automatic CART (only selecting the minimum cases for parental (80) and filial (40) nodes), 12 nodes were obtained. At first step, hs-cTnT (cutoff point 16 ng/L) yielded 2 nodes with mortality rates of 18.4% (node 1) and 57.1% (node 2). At second step, ST2 (cut points 45 ng/L for low hs-cTnT and 91.6 ng/L for high hs-cTnT) yielded nodes with mortality rates of 13.9% (node 3), 35.7% (node 4), 54.2% (node 5), and 87.5% (node 6). At third step, hs-cTnT emerged again significant to further split node 3, and node 5 was divided by NTproBNP levels (cutoff point 1846.5 ng/L). The last step used again ST2 to split node 9. The mortality in the terminal branch nodes ranged from 3.3% (node 7) to 87.2% (node 6). Agreement between predicted and observed death was 70%. ![Figure][1] CART for total mortality Conclusions: Using a simple CART decision tree with the biomarkers hs-cTnT, ST2 and NTproBNP good stratification of risk of death was easily achieved in chronic HF outpatients. [1]: pending:yes