Suzanna M C Hardman

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaborati

Authors/Task Force Members: John J.V. McMurray (Chairperson) (UK)*, Stamatis Adamopoulos (Greece), Stefan D. Anker (Germany), Angelo Auricchio (Switzerland), Michael Bohm (Germany), Kenneth Dickstein (Norway), Volkmar Falk (Switzerland), Gerasimos Filippatos (Greece), Cândida Fonseca (Portugal), Miguel Angel Gomez-Sanchez (Spain), Tiny Jaarsma (Sweden), Lars Kober (Denmark), Gregory Y.H. Lip (UK), Aldo Pietro Maggioni (Italy), Alexander Parkhomenko (Ukraine), Burkert M. Pieske (Austria), Bogdan A. Popescu (Romania), Per K. Ronnevik (Norway), Frans H. Rutten (The Netherlands), Juerg Schwitter (Switzerland), Petar Seferovic (Serbia), Janina Stepinska (Poland), Pedro T. Trindade (Switzerland), Adriaan A. Voors (The Netherlands), Faiez Zannad (France), Andreas Zeiher (Germany).

Mode of death in patients with newly diagnosed heart failure in the general population.

Early prognosis for incident (new) heart failure (HF) patients in the general population is poor. Clinical trials suggest approximately half of chronic HF patients die suddenly but mode of death for incident HF cases in the general population has not been evaluated.

The diagnostic accuracy of plasma BNP and NTproBNP in patients referred from primary care with suspected heart failure: Results of the UK natriuretic peptide study

To determine the diagnostic accuracy of the measurement of plasma B‐type natriuretic peptide (BNP) and N‐terminal pro‐BNP (NTproBNP) in patients referred by their general practitioners (GPs) with symptoms suggestive of heart failure. Additionally, to compare the diagnostic accuracy of the resting 12‐lead electrocardiogram (ECG) with that of the peptides.

Improving survival in the 6 months after diagnosis of heart failure in the past decade: population-based data from the UK.

Objective: To investigate the secular trend in survival after a new diagnosis of heart failure in the UK population. Design and Setting: Comparison of all-cause mortality in the 6 months after diagnosis of heart failure in population-based studies in the south east of England in 2004–5 (Hillingdon–Hastings Study) and 1995–7 (Hillingdon–Bromley Studies). Participants: 396 patients in the 2004–5 cohort and 552 patients in the 1995–7 cohort with incident (new) heart failure. Main Outcome Measures: All-cause mortality. Results: All-cause mortality rates were 6% (95% CI 3% to 8%) at 1 month, 11% (8% to 14%) at 3 months and 14% (11% to 18%) at 6 months in the 2004–5 cohort compared with 16% (13% to 20%), 22% (19% to 25%) and 26% (22% to 29%), respectively, in the 1995–7 cohort (difference between the two cohorts, p<0.001). The difference in survival was not explained by any difference in the demographics or severity of heart failure at presentation. There was a difference at baseline and thereafter in the use of neurohormonal antagonists (β-blockers and angiotensin-converting enzyme inhibitors). Conclusions: Although early mortality remains high among patients with newly diagnosed heart failure in the UK general population, there is strong evidence of a marked improvement in survival from 1995–7 to 2004–5, perhaps partly explained by an increased usage of neurohormonal antagonists.

Quantifying the added value of BNP in suspected heart failure in general practice: an individual patient data meta-analysis

Background Diagnosing early stages of heart failure with mild symptoms is difficult. B-type natriuretic peptide (BNP) has promising biochemical test characteristics, but its diagnostic yield on top of readily available diagnostic knowledge has not been sufficiently quantified in early stages of heart failure. Objectives To quantify the added diagnostic value of BNP for the diagnosis of heart failure in a population relevant to GPs and validate the findings in an independent primary care patient population. Design Individual patient data meta-analysis followed by external validation. The additional diagnostic yield of BNP above standard clinical information was compared with ECG and chest x-ray results. Patients and methods Derivation was performed on two existing datasets from Hillingdon (n=127) and Rotterdam (n=149) while the UK Natriuretic Peptide Study (n=306) served as validation dataset. Included were patients with suspected heart failure referred to a rapid-access diagnostic outpatient clinic. Case definition was according to the ESC guideline. Logistic regression was used to assess discrimination (with the c-statistic) and calibration. Results Of the 276 patients in the derivation set, 30.8% had heart failure. The clinical model (encompassing age, gender, known coronary artery disease, diabetes, orthopnoea, elevated jugular venous pressure, crackles, pitting oedema and S3 gallop) had a c-statistic of 0.79. Adding, respectively, chest x-ray results, ECG results or BNP to the clinical model increased the c-statistic to 0.84, 0.85 and 0.92. Neither ECG nor chest x-ray added significantly to the ‘clinical plus BNP’ model. All models had adequate calibration. The ‘clinical plus BNP’ diagnostic model performed well in an independent cohort with comparable inclusion criteria (c-statistic=0.91 and adequate calibration). Using separate cut-off values for ‘ruling in’ (typically implying referral for echocardiography) and for ‘ruling out’ heart failure—creating a grey zone—resulted in insufficient proportions of patients with a correct diagnosis. Conclusion BNP has considerable diagnostic value in addition to signs and symptoms in patients suspected of heart failure in primary care. However, using BNP alone with the currently recommended cut-off levels is not sufficient to make a reliable diagnosis of heart failure.

An examination of the self‐regulation model in atrial fibrillation

Objectives. To examine the role of the presence of symptoms on illness representations. To examine the success of the Self-Regulation Model in explaining psychosocial adjustment in patients with atrial fibrillation (AF). Design. A cross-sectional study of 62 AF patients attending either specialized AF or cardiac out-patient clinics. Method. Individuals were classified as symptomatic or asymptomatic and completed the Illness Perception Questionnaire (IPQ), COPE, and Psychosocial Adjustment to Illness Scale (PAIS). Comparisons between groups and explanation of psychosocial adjustment were examined. Results. Symptomatic and asymptomatic participants did not differ on subscales of the IPQ, with the exception of identity. Both symptom status and IPQ subscales explained independent and significant amounts of variance in PAIS domains. In contrast the COPE accounted for minimal amounts of variance in all PAIS domains. Conclusions. The presence of symptoms is not directly influential in the elaboration of the illness representation. Both symptoms and illness representations should be targeted in interventions to improve adjustment to AF.

Cerebral microembolism detected by transcranial Doppler during cardiac procedures.

Background and Purpose Cerebral embolism with clinical sequelae may rarely complicate cardioversion and cardiac catheterization. Transcranial Doppler sonography has recently been introduced to monitor microemboli entering the middle cerebral artery in cardiac and carotid surgery. We therefore used this technique to evaluate the risk of asymptomatic embolism during common cardiac procedures. Methods Patients were monitored by transcranial Doppler while undergoing direct current cardioversion (n=15) and cardiac catheterization (n=17). Results Microemboli were detected in all patients having cardiac catheterization but in only 1 patient after cardioversion. Conclusions Microembolism occurred frequently during cardiac catheterization and rarely during cardioversion. It is not yet known whether this has clinical relevance.

Fortnightly review: anticoagulation in heart disease.

Thromboembolism is a common complication of heart disease. The decision to prescribe an anticoagulant to prevent thromboemboli should be based on a particular patients risk without treatment and the likely benefit and side effects of the proposed treatment. In this article we will discuss the use of warfarin and heparin in patients with heart disease. #### Summary points This review article is based on our chapter in Current Issues in Cardiology , which was subject to formal peer review and published in 1997.1 We undertook a full Medline search in each of the relevant subjects. We also sought references from recent papers, editorials, and review articles. When a choice was available we chose large well conducted double blind randomised trials, but we included observational series when they were the only available evidence. Atrial fibrillation is not benign and is the commonest cause of cardiogenic stroke (fig 1).2 Within the general population the best available estimates suggest a prevalence of 0.5% for those …

Ivabradine in heart failure: NICE guidance

In the normal heart the sinus node determines the heart rate.1 Sino-atrial myocytes are characterised by a poorly developed contractile system and self-generating repetitive action potentials, a feature not found in the myocytes of cardiac muscle. At the end of the action potential, depolarisation of the membrane voltage continues, during phase four, until this triggers another action potential. While sino-atrial myocytes are heavily innervated by both sympathetic and vagal nerves, the spontaneous activity is independent of innervation. The mechanisms controlling, or modifying, these spontaneous diastolic depolarisations are central to interventions that might be employed to modify heart rate. Early thinking attributed pacemaker activity to the decay of an outward K+ current, but in the late 1970s Brown et al identified, to their surprise, a new likely inward current accordingly described as a ‘funny current or I f ’.2 Although many questions remain unanswered,3 I f is now recognised as an Na/K inward current activated by hyperpolarisation and modulated by the autonomic nervous system. Adrenaline induced rate acceleration in sino-atrial myocytes is almost entirely due to shortening of the diastolic duration with minimal effect on action potential shape and duration2 in contrast to adrenalin-mediated influences on cardiac action potentials elsewhere. Vagal influences are similarly associated with slowing of phase four of the sino-atrial myocytes rather than influencing the morphology elsewhere. There appears to be upregulation of the I f channel in cardiac hypertrophy and heart failure (HF).4 ,5 While there is extensive evidence that a slower heart rate is associated with better outcomes, be that as a marker of overall fitness in the general population,6 ,7 in people with a range of cardiovascular conditions,8–10 in HF specifically,11 ,12 or to the diverse therapeutic effects of β-blockers in HF,13 , …

Variation in hospital performance for heart failure management in the National Heart Failure Audit for England and Wales

Objective Investigation of variations in provider performance and its determinants may help inform strategies for improving patient outcomes. Methods We used the National Heart Failure Audit comprising 68 772 patients with heart failure with reduced left ventricular ejection fraction (HFREF), admitted to 185 hospitals in England and Wales (2007–2013). We investigated hospital adherence to three recommended key performance measures (KPMs) for inhospital care (ACE inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) on discharge, β-blockers on discharge and referral to specialist follow-up) individually and as a composite performance score. Hierarchical regression models were used to investigate hospital-level variation. Results Hospital-level variation in adherence to composite KPM ranged from 50% to 97% (median 79%), but after adjustments for patient characteristics and year of admission, only 8% (95% CI 7% to 10%) of this variation was attributable to variations in hospital features. Similarly, hospital prescription rates for ACE-I/ARB and β-blocker showed low adjusted hospital-attributable variations (7% CI 6% to 9% and 6% CI 5% to 8%, for ACE-I/ARB and β-blocker, respectively). Referral to specialist follow-up, however, showed larger variations (median 81%; range; 20%, 100%) with 26% of this being attributable to hospital-level differences (CI 22% to 31%). Conclusion Only a small proportion of hospital variation in medication prescription after discharge was attributable to hospital-level features. This suggests that differences in hospital practices are not a major determinant of observed variations in prescription of investigated medications and outcomes. Future healthcare delivery efforts should consider evaluation and improvement of more ambitious KPMs.