Theresa A. McDonagh

UK guidelines for referral and assessment of adults for heart transplantation

Patients with advanced heart failure have a dismal prognosis and poor quality of life. Heart transplantation provides an effective treatment for a subset of these patients. This article provides cardiologists with up-to-date information about referral for transplantation, the role of left ventricular assist devices prior to transplant, patient selection, waiting-list management and donor heart availability. Timing is of central importance; patients should be referred before complications (eg, cardiorenal syndrome or secondary pulmonary hypertension) have developed that will increase the risk of, or potentially contraindicate, transplantation. Issues related to heart failure aetiology, comorbidity and adherence to medical treatment are reviewed. Finally, the positive role that cardiologists can play in promoting and facilitating organ donation is discussed.

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.

Utility of overnight pulse oximetry and heart rate variability analysis to screen for sleep-disordered breathing in chronic heart failure

Background Sleep-disordered breathing (SDB) is under diagnosed in chronic heart failure (CHF). Screening with simple monitors may increase detection of SDB in a cardiology setting. This study aimed to evaluate the accuracy of heart rate variability analysis and overnight pulse oximetry for diagnosis of SDB in patients with CHF. Methods 180 patients with CHF underwent simultaneous polysomnography, ambulatory electrocardiography and wrist-worn overnight pulse oximetry. SDB was defined as an apnoea-hypopnoea index ≥15/h. To identify SDB from the screening tests, the per cent very low frequency increment (%VLFI) component of heart rate variability was measured with a pre-specified cutoff ≥2.23%, and the 3% oxygen desaturation index was measured with a pre-specified cutoff >7.5 desaturations/h. Results 173 patients with CHF had adequate sleep study data; SDB occurred in 77 (45%) patients. Heart rate variability was measurable in 78 (45%) patients with area under the %VLFI receiver operating characteristic curve of 0.50. At the ≥2.23% cutoff, %VLFI sensitivity was 58% and specificity was 48%. The 3% oxygen desaturation index was measurable in 171 (99%) patients with area under the curve of 0.92. At the pre-specified cutoff of >7.5 desaturations/h, the 3% oxygen desaturation index had a sensitivity of 97%, specificity of 32%, negative likelihood ratio of 0.08 and positive likelihood ratio of 1.42. Diagnostic accuracy was increased using a cutoff of 12.5 desaturations/h, with sensitivity of 93% and specificity of 73%. Conclusions The high sensitivity and low negative likelihood ratio of the 3% oxygen desaturation index indicates that pulse oximetry would be of use as a simple screening test to rule out SDB in patients with CHF in a cardiology setting. The %VLFI component of heart rate variability is not suitable for detection of SDB in CHF.

The effect of respiratory scoring on the diagnosis and classification of sleep disordered breathing in chronic heart failure.

STUDY OBJECTIVES To evaluate the effect of respiratory scoring criteria on diagnosis and classification of sleep disordered breathing (SDB) in chronic heart failure (CHF). DESIGN Cross-sectional observational study. SETTING Heart failure and general cardiology clinics at two London hospitals. PATIENTS OR PARTICIPANTS One hundred eighty stable patients with CHF and a median age of 69.6 y, 86% male. INTERVENTIONS SDB was diagnosed by polysomnography. The apnea-hypopnea index (AHI) was initially scored using a conservative hypopnea definition of a ≥ 50% decrease in nasal airflow with a ≥ 4% oxygen desaturation. The AHI was rescored with hypopnea defined according to the American Academy of Sleep Medicine (AASM) alternative scoring rule, requiring an associated ≥ 3% oxygen desaturation or arousal. SDB was defined as AHI ≥ 15/h. Diagnosis and classification of SDB as obstructive sleep apnea (OSA) or central sleep apnea (CSA) with each rule were compared. The effect of mixed apneas on classification of SDB as CSA or OSA was also investigated. MEASUREMENTS AND RESULTS Median AHI increased from 9.3/h to 13.8/h (median difference 4.6/h) when the AASM alternative rule was used to score hypopneas. SDB prevalence increased from 29% to 46% with the alternative scoring rule (P < 0.001). Classification of SDB as OSA or CSA was not significantly altered by hypopnea scoring rules or the categorization of mixed apneas. CONCLUSION Hypopnea scoring rules can significantly influence the apnea-hypopnea index and diagnosis of sleep disordered breathing in chronic heart failure but do not alter the classification as obstructive sleep apnea or central sleep apnea. Standardization of hypopnea scoring rules is important to ensure consistency in diagnosis of sleep disordered breathing in chronic heart failure patients.

Pulmonary hypertension in left heart disease: A review

Pulmonary hypertension (PH) occurs commonly in patients with left heart disease, and is associated with increased morbidity and mortality. The pathophysiologic mechanisms of PH in left heart disease are complex, and are thought to be a composite of both passive and active components. PH that is disproportionate to the underlying left heart disease may be attributable to reactive pulmonary vascular remodelling. Management of these patients is focused upon treatment of the underlying left heart disease and its associated comorbidities. There is no supporting evidence for the routine use of specific PH therapies in these patients at present. However, there is some suggestion that PDE-5 inhibitors may be useful, but their safety and efficacy needs to be formally evaluated in controlled trials before further recommendations are made.

РЕКОМЕНДАЦИИ ESC/ERS ПО ДИАГНОСТИКЕ И ЛЕЧЕНИЮ ЛЕГОЧНОЙ ГИПЕРТЕНЗИИ 2015

The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS) Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT)

S16 Detection of sleep-disordered breathing in chronic heart failure patients: utility of heart rate variability versus pulse oximetry?

Introduction and Objectives Sleep-disordered breathing (SDB) is a frequent comorbidity in chronic heart failure (CHF). Patients are often asymptomatic and sleep studies may be required for SDB diagnosis. Our department has previously reported that %VLFI component of Heart Rate Variability (HRV) is correlated with apnoea-hypopnoea index (AHI) in CHF (r=0.52). Thus, we tested the hypotheses that %VLFI component of HRV, or pulse oximetry, can be used to rule out SDB in patients with CHF. Methods Stable CHF patients attending cardiology clinics were enrolled, irrespective of cause or severity of CHF. Patients were studied using polysomnography, simultaneous ambulatory electrocardiography and pulse oximetry. SDB was defined as AHI ≥15.0/h, measured by polysomnogram. Fourier analysis of the electrocardiogram was used to measure %VLFI component of HRV, with a cutoff ≥2.23% to indicate SDB. The oxygen desaturation index (ODI) ≥3% was measured by pulse oximeter, with a cutoff >7.5 desaturations/h to indicate SDB. Diagnostic performance of %VLFI and ODI≥3% were calculated, with the polysomnogram as reference standard for SDB diagnosis. Results 180 CHF patients were studied, seven were excluded due to insufficient sleep (<200 min). In 173 CHF patients (mean (SD) age 66.9 (13.0) years; 86% male; Epworth Sleepiness Scale 7.6 (4.3); NYHA 2.1 (0.6); median (IQR) BNP 118 (55–239) pg/ml), SDB was present in 77 (45%) patients with mean AHI 32.4 (18.2)/h. %VLFI was measured in 77 (45%) patients: in CHF patients with SDB (n=36), mean %VLFI was 3.13% (2.4) compared to 3.25% (2.6) in patients without SDB (n=41). Cardiac pacing, atrial fibrillation and frequent ectopy prevented %VLFI measurement in the remainder. ODI ≥3% was measured in 171 patients: in CHF patients with SDB (n=76), mean ODI ≥3% was 29.2 (17.2)/h compared to 10.2 (6.4)/h in patients without SDB (n=95). Conclusion The %VLFI component of HRV has no utility to screen for SDB in patients with CHF. Moreover, it could not be measured in more than half of this cohort of patients. In contrast, the high sensitivity and negative predictive value of the ODI ≥3% suggest pulse oximetry is a valuable tool to rule out SDB in CHF patients.Abstract S16 Table 1 Diagnostic performance of %VLFI and ODI >3% for detection of SDB in CHF patients %VLFI ODI>3% Sensitivity 0.53 0.97 Specificity 0.44 0.32 Positive predictive value 0.45 0.53 Negative predictive value 0.51 0.94 Positive likelihood ratio 0.94 1.42 Negative likelihood ratio 1.08 0.08 Area under receiver operating characteristic curve 0.49 0.92