Evaluation of urinary density as a biomarker for the diagnosis of acute heart failure

Background

Heart failure (HF) has become a public healthcare concern with significant costs to countries because of the aging world population. Acute heart failure (AHF) is a common condition faced frequently in emergency departments, and patients often present to hospitals with complaints of breathlessness. The patient must be evaluated with anamnesis, physical examination, blood, and imaging results to diagnose AHF. Brain natriuretic peptide (BNP) is a widely accepted biomarker for the diagnosis of HF.

Methods

The files of the patients who applied to the emergency department with complaints of breathlessness were scanned, and BNP and urinary density (UD) levels were evaluated for the diagnosis of HF in patients.

Results

The results support that BNP is an effective biomarker in AHF, as is widely accepted. When the correlation between BNP and UD measurements was examined in the present study, a negative correlation was detected between the parameters. The results also suggested that low UD values may help diagnose AHF.

Conclusion

If similar results are obtained in prospective multicenter studies with the participation of more patients, UD value can be used as a biomarker for the diagnosis of AHF.

The effect of caregivers' health literacy levels on the quality of life and self-care of patients with heart failure

BACKGROUND

The aim of this study is to examine the effects of health literacy levels of caregivers on the self-care behaviors and quality of life of patients aged 65 years and older with heart failure.

METHODS

The study was conducted in a university hospital in Erzincan, Türkiye between November 4, 2023, and February 12, 2024, on patients hospitalized in internal medicine, cardiology, and cardiovascular surgery wards and their caregivers (n = 206 pairs).

RESULTS

As a result of the multivariate regression analysis, it was determined that the access, appraisal, and application sub-dimensions of the health literacy of the caregivers positively affected the self-care behaviors and quality of life levels of the patients.

CONCLUSIONS

These results reveal the significant effect of the health literacy levels of the caregivers in the management process of heart failure disease. Healthcare providers -especially nurses- can improve patient outcomes of patients with heart failure by considering the health literacy level of their caregivers and using innovative educational methods that can improve the health knowledge and skills of caregivers.

Death Anxiety and Religious Coping in Heart Failure Patients

This study was conducted to determine death anxiety and religious coping in heart failure patients. It was determined that 64% of the patients were male, the mean death anxiety score was 7.78 ± 3.91, 38% had ≤6 points and 62% had ≥7 points. Positive religious coping score was 20.54 ± 6.58 and negative religious coping score was 6.86 ± 3.18. Patients with a diagnosis of heart failure ≥3 years had higher death anxiety levels. There was a weak positive correlation between death anxiety and positive and negative religious coping scores. Death anxiety and the number of days hospitalized were determined to predict positive religious coping in regression analysis. The model explained 7.6% of the total variance in positive religious coping. Heart failure patients were detected to have high death anxiety. Patients were observed to have high positive religious coping scores. As death anxiety increases, patients exhibit positive religious coping behavior.

Trends in heart failure between 2016 and 2022 in Türkiye (TRends-HF): a nationwide retrospective cohort study of 85 million individuals across entire population of all ages

Background

Data on the burden of heart failure (HF) outside western countries are limited, but available data suggest it may present differently in other countries. The aim of this study was to examine the incidence, prevalence, and survival rates of HF in Türkiye, with a specific focus on how these rates vary according to age, sex, comorbidities, and socioeconomic status (SES).

Methods

We harnessed the extensive National Electronic Database of the Turkish Ministry of Health, covering Turkey's entire population from January 1, 2016, to December 31, 2022, to identify 2,722,151 cases of HF and their associated comorbidities using ICD-10 codes. Analyzing the primary endpoint of all-cause mortality, our study utilized anonymized data to examine patient demographics, comorbidities, socioeconomic status, and survival patterns, employing statistical techniques to delve into relationships and trends. The data were segmented by gender, socioeconomic status, and age, involving cross-tabulations and statistical metrics to explore connections, odds ratios, and survival rates.

Findings

The estimated prevalence of HF was 2.114% in Türkiye at the end of 2022, with an annual incidence ranging between 3.00 and 6.06 per 1000 person years. Females were older than males (69.8 ± 13.9 years vs. 66.8 ± 13.9 years, respectively). The most common comorbidities were congenital heart diseases and anemia under the age of 20, and hypertension and atherosclerotic cardiovascular disease in the adult population. Only 23.6% (643,159/2,722,151) of patients were treated with any triple guideline-directed medical therapy (GDMT) and 3.6% (96,751/2,722,151) of patients were on quadruple GDMT. The survival rates for patients with HF at 1, 5, and 7 years were 83.3% (95% CI: 83.2-83.3), 61.5% (95% CI: 61.4-61.6), and 57.7% (95% CI: 57.6-57.8) among females, and 82.1% (95% CI: 82.0-82.2), 58.2% (95% CI: 58.1-58.3), and 54.2% (95% CI: 54.0-54.3) among males. Despite a tendency for an increase from the highest to the lowest SES, the prevalence of HF and mortality were paradoxically lowest in the lowest SES region.

Interpretation

The prevalence, incidence, and survival rates of HF in Türkiye were comparable to western countries, despite the notable difference of HF onset occurring 8-10 years earlier in the Turkish population. Drug usage statistics indicate there is a need for effective strategies to improve treatment with GDMT.

Funding

None.

Turkish Validity and Reliability of the Self-care of Hypertension Inventory (SC-HI) among Older Adults

PURPOSE

To assess the psychometric properties of the Turkish version of the Self-care of Hypertension Inventory (SC-HI) among older adults with hypertension.

DESIGN

This was a methodological study.

METHODS

The study sample enrolled 176 older adults. The study carried out preliminary psychometric analyses.

FINDINGS

Item-level content validity index ranged between 0.87 to 1.0, and the index of content validity was 0.98. The Cronbach's α for the total scale was 0.84.

CONCLUSION

The cross-cultural adaptation of SC-HI has been realized successfully in Turkish.

CLINICAL EVIDENCE

Health care providers may utilize the scale to evaluate "older individuals" hypertension self-care abilities.

Depression, anxiety, stress levels, and coping styles of caregivers of patients with left ventricular assist device

PURPOSE

To determine the depression, anxiety, stress (DAS) levels, and coping styles of caregivers of patients with left ventricular assist device (LVAD).

DESIGN AND METHODS

The sample of the study consisted of 74 caregivers of patients with LVAD. Data were collected using Individual Data Form, DASS 21, and Coping Styles Scale.

FINDINGS

Depression was found in 67.6%, anxiety in 45.9%, and stress in 50% of the caregivers of patients with LVAD. A significant relationship was found between the sociodemographic characteristics of caregivers, some variables related to the patient and the care process, and coping styles with stress, and DAS levels of caregivers.

PRACTICE IMPLICATIONS

Considering the variables that may affect the DAS levels of the LVAD caregivers will improve the expected results from the LVAD.

Cost-of-disease of Heart Failure in Turkey: A Delphi Panel-based Analysis of Direct and Indirect Costs

Background:

Heart failure (HF) is considered a significant public health issue with a substantial and growing epidemiologic and economic burden in relation to longer life expectancy and aging global population.

Aims:

To determine cost-of-disease of heart failure (HF) in Turkey from the payer perspective.

Study Design:

Cross-sectional cost of disease study.

Methods:

In this cost-of-disease study, annual direct and indirect costs of management of HF were determined based on epidemiological, clinical and lost productivity inputs provided by a Delphi panel consisted of 11 experts in HF with respect to ejection fraction (EF) status (HF patients with reduced EF (HFrEF), mid-range EF (HFmrEF) and preserved EF (HFpEF)) and New York Heart Association (NYHA) classification. Direct medical costs included cost items on outpatient management, inpatient management, medications, and non-pharmaceutical treatments. Indirect cost was calculated based on the lost productivity due to absenteeism and presenteeism.

Results:

51.4%, 19.5%, and 29.1% of the patients were estimated to be HFrEF, HFmrEF, and HFpEF patients, respectively. The total annual direct medical cost per patient was $887 and non-pharmaceutical treatments ($373, 42.1%) were the major direct cost driver. Since an estimated nationwide number of HF patients is 1,128,000 in 2021, the total annual national economic burden of HF is estimated to be $1 billion in 2021. The direct medical cost was higher in patients with HFrEF than in those with HFmrEF or HFpEF ($1,147 vs. $555 and $649, respectively). Average indirect cost per patient was calculated to be $3,386 and was similar across HFrEF, HFmrEF and HFpEF groups, but increased with advanced NYHA stage.

Conclusion:

Our findings confirm the substantial economic burden of HF in terms of both direct and indirect costs and indicate that the non-pharmaceutical cost is the major direct medical cost driver in HF management, regardless of the EF status of HF patients.

Current Prevalence, Incidence, and Outcomes of Heart Failure with Preserved Ejection Fraction

The current trends of prevalence, incidence, and mortality in heart failure with preserved ejection fraction are summarized. We describe the differences in the definitions of heart failure with preserved ejection fraction used in community-based studies, heart failure registries, and clinical trials. The worldwide prevalence of heart failure with preserved ejection fraction is approximately 2%; it is becoming the dominant form of heart failure owing to the aging population. The longitudinal trend of mortality in this disease is decreasing, and the risk of mortality is similar between heart failure with preserved ejection fraction and heart failure with reduced ejection fraction.

Adherence to guideline-directed medical and device Therapy in outpAtients with heart failure with reduced ejection fraction: The ATA study

Objective:

Despite recommendations from heart failure guidelines on the use of pharmacologic and device therapy in patients with heart failure with reduced ejection fraction (HFrEF), important inconsistencies in guideline adherence persist in practice. The aim of this study was to assess adherence to guideline-directed medical and device therapy for the treatment of patients with chronic HFrEF (left ventricular ejection fraction ≤40%).

Methods:

The Adherence to guideline-directed medical and device Therapy in outpAtients with HFrEF (ATA) study is a prospective, multicenter, observational study conducted in 24 centers from January 2019 to June 2019.

Results:

The study included 1462 outpatients (male: 70.1%, mean age: 67±11 years, mean LVEF: 30%±6%) with chronic HFrEF. Renin–angiotensin system (RAS) inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and ivabradin were used in 78.2%, 90.2%, 55.4%, and 12.1% of patients, respectively. The proportion of patients receiving target doses of medical treatments was 24.6% for RAS inhibitors, 9.9% for beta-blockers, and 10.5% for MRAs. Among patients who met the criteria for implantable cardioverter–defibrillator (ICD) and cardiac resynchronization therapy (CRT), only 16.9% of patients received an ICD (167 of 983) and 34% (95 of 279) of patients underwent CRT (95 of 279).

Conclusion:

The ATA study shows that most HFrEF outpatients receive RAS inhibitors and beta-blockers but not MRAs or ivabradin when the medical reasons for nonuse, such as drug intolerance or contraindications, are taken into account. In addition, most eligible patients with HFrEF do not receive target doses of pharmacological treatments or guideline-recommended device therapy.

Current clinical practice of cardiac resynchronization therapy in Turkey: Reflections from Cardiac Resynchronization Therapy Survey-II

Objective:

Cardiac resynchronization therapy (CRT) has been shown to reduce mortality in selected patients with heart failure with reduced ejection fraction (HFrEF). CRT Survey-II was a snapshot survey to assess current clinical practice with regard to CRT. Herein, we aimed to compare Turkish data with other countries of European Society of Cardiology (ESC).

Methods:

The survey was conducted between October 2015 and December 2016 in 42 ESC member countries. All consecutive patients who underwent a de novo CRT implantation or a CRT upgrade were eligible.

Results:

A total of 288 centers included 11,088 patients. From Turkey, 16 centers recruited 424 patients representing 12.9% of all implantations. Compared to the entire cohort, Turkish patients were younger with a lower proportion of men and a higher proportion with ischemic etiology. Electrocardiography (ECG) showed sinus rhythm in 81.5%, a QRS duration of <130 ms in 10.1%, and ≥150 ms in 63.8% of patients. Left bundle branch block (LBBB) was more common. Median left ventricular ejection fraction (LVEF) was 25%, lower than in the overall ESC cohort, but NYHA class was more often II. Most common indication for CRT implantation was HF with a wide QRS (70.8%). Almost 98.3% of devices implanted were CRT-D, in contrast to the overall cohort. Fluoroscopy time was longer, but duration of overall procedure was shorter. LV lead implantation was unsuccessful in 2.6% patients. Periprocedural complication rate was 6.3%. The most common complication was bleeding. Remote monitoring was less utilized.

Conclusion:

These are the first observational data reflecting the current CRT practice in Turkey and comparing it with other countries of Europe. Findings of this study may help detect gaps and provide insights for improvement. (Anatol J Cardiol 2020; 24: 382-96)

External validation of the ACUTE HF score in patients hospitalized for acute decompensated heart failure

OBJECTIVE

Recently, the ACUTE HF score has been developed as a new tool for predicting short and long term mortality in patients with acute heart failure (AHF). However, this. score has not yet been validated externally. The present study aimed to investigate the prognostic value of ACUTE HF score in a different patient cohort.

METHODS

We retrospectively enrolled all consecutive adult patients hospitalized due to AHF between January 2016 and January 2019. The ACUTE HF score is calculated by 7 different variables including age, creatinine, non-invasive ventilation, history of stroke or transient ischemic attack, left ventricular systolic function, mitral regurgitation and history of hospitalization.The primary endpoint of the study was in-hospital mortality.

RESULTS

A total of 418 AHF patients (mean age 70.2 ± 11.3 years, 52% male) were included, and 26 (6.2%) patients died during the in-hospital course. Patients in the study were divided into three groups according to ACUTE HF score: low-risk (<1.5, n = 210), intermediate-risk (1.5-3, n = 50), and high-risk groups (>3, n = 158). The multivariate analysis showed that the ACUTE HF score was an independent predictor of in-hospital mortality(OR: 2.15; 95% CI, 0.94-4.34; p < 0.001).

CONCLUSION

The ACUTE HF score was a useful prognostic score for the prediction of in-hospital mortality in patients with AHF. Further validation studies in different regions of the world and with different AHF populations are needed to determine its generalisability.

Snapshot evaluation of acute and chronic heart failure in real-life in Turkey: A follow-up data for mortality

Objective:

Heart failure (HF) is a progressive clinical syndrome. SELFIE-TR is a registry illustrating the overall HF patient profile of Turkey. Herein, all-cause mortality (ACM) data during follow-up were provided.

Methods:

This is a prospective outcome analysis of SELFIE-TR. Patients were classified as acute HF (AHF) versus chronic HF (CHF) and HF with reduced ejection fraction (HFrEF), HF with mid-range ejection fraction, and HF with preserved ejection fraction and were followed up for ACM.

Results:

There were 1054 patients with a mean age of 63.3±13.3 years and with a median follow-up period of 16 (7–17) months. Survival data within 1 year were available in 1022 patients. Crude ACM was 19.9% for 1 year in the whole group. ACM within 1 year was 13.7% versus 32.6% in patients with CHF and AHF, respectively (p<0.001). Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta blocker, and mineralocorticoid receptor antagonist were present in 70.6%, 88.2%, and 50.7%, respectively. In the whole cohort, survival curves were graded according to guideline-directed medical therapy (GDMT) scores ≤1 versus 2 versus 3 as 28% versus 20.2% versus 12.2%, respectively (p<0.001). Multivariate analysis of the whole cohort yielded age (p=0.009) and AHF (p=0.028) as independent predictors of mortality in 1 year.

Conclusion:

One-year mortality is high in Turkish patients with HF compared with contemporary cohorts with AHF and CHF. Of note, GDMT score is influential on 1-year mortality being the most striking one on chronic HFrEF. On the other hand, in the whole cohort, age and AHF were the only independent predictors of death in 1 year. (Anatol J Cardiol 2020; 23: 160-8)

Comparison of high-flow oxygen treatment and standard oxygen treatment in patients with hypertensive pulmonary edema

Objective:

The aim compares the blood gases, vital signs, mechanical ventilation requirement, and length of hospitalization in patients with hypertensive pulmonary edema treated with standard oxygen therapy (SOT) and high-flow oxygen therapy (HFOT).

Methods:

This prospective observational study was conducted in patients with tachypneic, hypoxemic, hypertensive pulmonary edema. The patients’ 0^th, 1^st, and 2^nd hour blood gas results; 0^th, 1^st, and 2^nd hour vital signs; requirement of endotracheal intubation, length of hospitalization, and the prognosis were recorded on the study form.

Results:

A total of 112 patients were included in this study, of whom 50 underwent SOT and 62 received HFOT. The initial blood gas analysis revealed significantly lower levels of pH, PaO₂, and SpO₂ and significantly higher levels of PaCO₂ in the HFOT group. Patients in the HFOT group had significantly higher respiratory rate and pulse rate and significantly lower SpO₂ values. The recovery of vital signs was significantly better in the HFOT group (p<0.05). Similarly, follow-up results of arterial blood gas analysis were better in the HFOT group (p<0.05). Both length of stay in the emergency department (p<0.05) and length of intensive care unit hospitalization s significantly shorter in the HFOT group (p<0.05).

Conclusion:

HFOT can be much more effective in patients with hypertensive pulmonary edema than SOT as it shortens the length of stay both in the emergency service and in the intensive care unit. HFOT also provides better results in terms of blood gas analysis, heart rate, and respiratory rate in the follow-up period.

Successful Liver And Kidney Transplantations From A Donor With Left Ventricular Assist Device

Organ transplant from donors with ventricular assist devices is not common. Here, we report organ retrieval from a donor with a left ventricular assist device who had been on the heart transplant wait list before a brain death diagnosis. The organ donor was diagnosed with dilated cardiomyopathy and underwent left ventricular assist device surgery for bridging to heart transplant in 2016. Brain death occurred 22 months after implantation of the device at the age of 39 years due to widespread intraparenchymal and subarachnoid hemorrhage. Brain death diagnosis was confirmed with brain perfusion single-photon emission computed tomography. In accordance with the donor's will, the relatives approved organ donation. The donor's organ reserve was assessed to be suitable for liver and kidney transplants, and proper donor care was given. During recovery of organs, the organ transplant team was accompanied by cardiovascular surgeons to control flow of the left ventricular assist device and to ensure optimum organ perfusion. After a successful operation, the liver was transplanted to a patient with primary sclerosing cholangitis who had been on the wait list for liver transplant for 13 years. The kidneys were transplanted to patients awaiting kidney transplant for 31 and 14 years with diagnoses of nephrolithiasis and polycystic kidney disease, respectively. No complications occurred among the liver and kidney transplant recipients. There are few reports of donors with assist devices. This is the first case of an organ donor with an assist device waiting for an organ transplant who became an actual donor in our country.

The effect of cardiac resynchronization therapy on arterial stiffness and central hemodynamic parameters

INTRODUCTION

Cardiac resynchronization therapy (CRT) is a device-based method of treatment which decreases morbidity and mortality in heart failure with reduced ejection fraction (HFrEF). This study was aimed to investigate the effects of CRT on hemodynamic and arterial stiffness parameters evaluated by noninvasive method, and determine whether there is a correlation between the changes after CRT in these parameters and the clinical response to CRT or not.

METHODS

The study included 46 patients with HFrEF who were planned to undergo CRT implantation. Before the CRT implantation, clinical and demographic data were recorded from all patients. Hemodynamic and arterial stiffness parameters were measured oscillometrically by an arteriograph before CRT implantation. The patients were re-evaluated minimum three months after CRT; the above-mentioned parameters were measured again and compared to the pre-CRT period.

RESULTS

Compared to the period before CRT, mean systolic blood pressure (SBP) (116.8 ± 19.1 mm Hg vs 127.7 ± 20.9 mm Hg, P = .005), central SBP (cSBP) (106.2 ± 17.3 mm Hg vs 116.8 ± 18.7 mm Hg, P = .015), cardiac output (CO) (4.6 ± 0.8 lt/min vs 5.1 ± 0.8 lt/min, P = .002), stroke volume (65.6 ± 16.3 mL vs 72.0 ± 14.9 mL), and pulse wave velocity (PWV) (10 ± 1.6 m/sec vs 10.4 ± 1.8 m/sec, P = .004) increased significantly in post-CRT period. In addition, the same parameters were significantly increased post-CRT period in patients with clinical response. However, there was not any similar increase in nonresponder patients.

CONCLUSION

This study demonstrated that SBP, CO, and PWV increased significantly after CRT. The modest increases in these parameters were observed to be associated with positive clinical outcomes.

Epidemiology of heart failure

The heart failure syndrome has first been described as an emerging epidemic about 25 years ago. Today, because of a growing and ageing population, the total number of heart failure patients still continues to rise. However, the case mix of heart failure seems to be evolving. Incidence has stabilized and may even be decreasing in some populations, but alarming opposite trends have been observed in the relatively young, possibly related to an increase in obesity. In addition, a clear transition towards heart failure with a preserved ejection fraction has occurred. Although this transition is partially artificial, due to improved recognition of heart failure as a disorder affecting the entire left ventricular ejection fraction spectrum, links can be made with the growing burden of obesity‐related diseases and with the ageing of the population. Similarly, evidence suggests that the number of patients with heart failure may be on the rise in low‐income countries struggling under the double burden of communicable diseases and conditions associated with a Western‐type lifestyle. These findings, together with the observation that the mortality rate of heart failure is declining less rapidly than previously, indicate we have not reached the end of the epidemic yet. In this review, the evolving epidemiology of heart failure is put into perspective, to discern major trends and project future directions.

Indirect costs of adult pneumococcal disease and the productivity-based rate of return to the 13-valent pneumococcal conjugate vaccine for adults in Turkey

Productivity benefits of health technologies are ignored in typical economic evaluations from a health payer’s perspective, risking undervaluation. We conduct a productivity-based cost-benefit analysis from a societal perspective and estimate indirect costs of adult pneumococcal disease, vaccination benefits from the adult 13-valent pneumococcal conjugate vaccine (PCV13 Adult), and rates of return to PCV13 Adult for a range of hypothetical vaccination costs. Our context is Turkey’s funding PCV13 for the elderly and for non-elderly adults with select comorbidities within the Ministry of Health’s National Immunization Program. We use a Markov model with one-year cycles. Indirect costs from death or disability equal the expected present discounted value of lifetime losses in the infected individual’s paid and unpaid work and in caregivers’ paid work. Vaccination benefits comprise averted indirect costs. Rates of return equal vaccination benefits divided by vaccination costs, minus one. Input parameters are from public data sources. We model comorbidities’ effects by scalar multiplication of the parameters of the general population. Indirect costs per treatment episode of inpatient community-acquired pneumonia (CAP), bacteremia, and meningitis – but not for outpatient CAP – approach or exceed Turkish per capita gross domestic product. Vaccination benefits equal $207.02 per vaccination in 2017 US dollars. The rate of return is positive for all hypothetical costs below this. Results are sensitive to herd effects from pediatric vaccination and vaccine efficacy rates. For a wide range of hypothetical vaccination costs, the rate of return compares favorably with those of other global development interventions with well-established strong investment cases.

Geographical Variations in Patients with Heart Failure and Preserved Ejection Fraction: A Sub-Group Analysis of the APOLLON Registry

BACKGROUND

Clinical characteristics of patients with heart failure may vary geographically. However, limited data are available regarding the geographical differences of patients with heart failure and preserved ejection fraction.

AIMS

The present subgroup analysis aims to investigate the geographical differences in clinical characteristics, management, and primary etiology of patients with heart failure and preserved ejection fraction in Turkey.

STUDY DESIGN

A cross-sectional study.

METHODS

A comPrehensive, ObservationaL registry of heart faiLure with mid-range and preserved ejection fractiON (APOLLON) is a multicenter and observational study conducted in seven regions of Turkey (NCT03026114). The present study is a post-hoc analysis of the APOLLON registry. In this substudy, we compared the clinical characteristics of 819 consecutive patients with heart failure and preserved ejection fraction (mean age, 67 years; 57.8% women) admitted to cardiology outpatient units in different geographical regions.

RESULTS

Based on the geographical distribution of the entire Turkish population, the highest number of patients enrolled were from Marmara (271 patients, 33.1%). All demographical characteristics, clinical and laboratory findings, comorbidities, primary etiology, and medications prescribed were significantly different between the regions. Furthermore, inter-regional gender differences were identified. Comparatively, the Aegean and Mediterranean regions had older patients with heart failure and preserved ejection fraction (p<0.001), and the Black Sea, Southeast, and East Anatolia regions had predominantly male patients (51.2, 54.5, and 56.9%, respectively; p=0.002). Notably, the Mediterranean and Southeast Anatolia had more symptomatic patients, and history of hospitalization for heart failure was more prevalent in Southeast Anatolia (33.3%, p<0.001). Prevalence of atrial fibrillation was higher in the Mediterranean and Southeast Anatolia regions (51 and 48.5%, p<0.001), and patients with heart failure and preserved ejection fraction had a higher prevalence of hypertension in the Mediterranean, Southeast Anatolia, and Black Sea regions (p=0.002). Angiotensin-converting enzyme inhibitors were more frequently prescribed in East Anatolia (52.3%, p=0.001), and the prevalence of patients with heart failure and preserved ejection fraction using loop diuretics (48.8%, p=0.003) was higher in the Black Sea region.

CONCLUSION

This study was the first to show geographical differences in clinical characteristics of patients with heart failure and preserved ejection fraction in Turkey. Determination of the clinical characteristics of the heart failure and preserved ejection fraction population based on the geographical region may enables physicians to adopt a region-specific clinical approach toward heart failure and preserved ejection fraction.

Demographics of patients with heart failure who were over 80 years old and were admitted to the cardiology clinics in Turkey

OBJECTIVE

Heart failure (HF) has a high prevalence and mortality rate in elderly patients; however, there are few studies that have focused on patients older than 80 years. The aim of this study is to describe and compare the age-specific demographics and clinical features of Turkish elderly patients with HF who were admitted to cardiology clinics.

METHODS

The Epidemiology of Cardiovascular Disease in Elderly Turkish population (ELDER-TURK) study was conducted in 73 centers in Turkey, and it recruited a total of 5694 patients aged 65 years or older. In this study, the clinical profile of the patients who were aged 80 years or older and those between 65 and 79 years with HF were described and compared based on the ejection fraction (EF)-related classification: HFrEF and HFpEF (is considered as EF: ≥50%).

RESULTS

A total of 1098 patients (male, 47.5%; mean age, 83.5+-3.1 years) aged ≥80 years and 4596 patients (male, 50.2 %; mean age, 71.1+-4.31 years) aged 65-79 years were enrolled in this study. The prevalence of HF was 39.8% for patients who were ≥80 years and 27.1% for patients 65-79 years old. For patients aged ≥80 years with HF, the prevalence rate was 67% for hypertension (HT), 25.6% for diabetes mellitus (DM), 54.3% for coronary artery disease (CAD), and 42.3% for atrial fibrilation. Female proportion was lower in the HFrEF group (p=0.019). The prevalence of HT and DM was higher in the HFpEF group (p<0.01), whereas CAD had a higher prevalence in the HFrEF group (p=0.02). Among patients aged 65-79 years, 43.9% (548) had HFpEF, and 56.1% (700) had HFrEF. In this group of patients aged 65-79 years with HFrEF, the prevalence of DM was significantly higher than in patients aged ≥80 years with HFrEF (p<0.01).

CONCLUSION

HF is common in elderly Turkish population, and its frequency increases significantly with age. Females, diabetics, and hypertensives are more likely to have HFpEF, whereas CAD patients are more likely to have HFrEF.

Cost of heart failure management in Turkey: results of a Delphi Panel

Objective:

To analyze health-related cost of heart failure (HF) and to evaluate health-related source utilization aiming to provide data on the economic burden of HF in actual clinical practice in Turkey.

Methods:

The study used the Delphi process of seeking expert consensus of opinion including 11 cardiologists who are experienced in HF. The standardized questionnaire comprised items to reflect the opinion of the expert panelists on the distribution of the HF patients in terms of demographic and clinical characteristics and background disease states. Costs related to out-patient follow-up, in-patient follow-up, medications, and other therapies were also evaluated.

Results:

34.1% of the HF patients were in the age range of 60–69 years, and 62.3% were males. Coronary heart disease was the leading cause of HF (59.6%); 63.6% of the HF patients had reduced ejection fraction (rEF) and 42.3% were in New York Heart Association (NYHA)-II class. Approximately 75 % of the patients were followed up by a cardiology unit. The total annual visit number was estimated as 3.41. Approximately 32% of HF patients were hospitalized 1.64 times a year, for an average of 6.77 days each time. The total annual costs of all HF patients and HF-rEF patients were estimated as 1.537 TL and as 2.141 TL, respectively.

Conclusion:

The analysis demonstrating the magnitude of the economic impact of HF management on Turkey’s healthcare system may help facilitate health and social policy interventions to improve the prevention and treatment of HF. (Anatol J Cardiol 2016; 16: 554-62)

NT-proBNP levels and mortality in a general population-based cohort from Turkey: a long-term follow-up study

AIM

We investigated the relationship between NT-ProBNP and mortality in a general population-based cohort.

METHODS & RESULTS

A total of 2021 out of 4650 participants from previously published HAPPY study were included. Mean follow-up was 84.5 ± 10.4 months. After adjusting for risk factors, high levels of LogNT-proBNP predicted all-cause death (HR: 3.23; 95% CI: 2.20-4.75; p < 0.001) and cardiovascular death (HR: 3.85; 95% CI: 2.37-6.26; p < 0.001). Regression analysis revealed that LogNT-proBNP was an independent predictor of all-cause death (HR: 2.85; 95% CI: 1.91-4.24; p < 0.001) and cardiovascular death (HR: 3.02; 95% CI: 1.84-4.95; p < 0.001). Conclusıon: Our study showed that in long term follow-up, NT-proBNP is associated with increased all-cause and cardiovascular mortality.

Rationale, Design, and Methodology of the APOLLON trial: A comPrehensive, ObservationaL registry of heart faiLure with midrange and preserved ejectiON fraction

OBJECTIVE

Although almost half of chronic heart failure (HF) patients have mid-range (HFmrEF) and preserved left-ventricular ejection fraction (HFpEF), no studies have been carried out with these patients in our country. This study aims to determine the demographic characteristics and current status of the clinical background of HFmrEF and HFpEF patients in a multicenter trial.

METHODS

A comPrehensive, ObservationaL registry of heart faiLure with mid range and preserved ejectiON fraction (APOLLON) trial will be an observational, multicenter, and noninterventional study conducted in Turkey. The study population will include 1065 patients from 12 sites in Turkey. All data will be collected at one point in time and the current clinical practice will be evaluated (ClinicalTrials.gov number NCT03026114).

RESULTS

We will enroll all consecutive patients admitted to the cardiology clinics who were at least 18 years of age and had New York Heart Association class II, III, or IV HF, elevated brain natriuretic peptide levels within the last 30 days, and an left ventricular ejection fraction (LVEF) of at least 40%. Patients fulfilling the exclusion criteria will not be included in the study. Patients will be stratified into two categories according to LVEF: mid-range EF (HFmrEF, LVEF 40%-49%) and preserved EF (HFpEF, LVEF ≥50%). Regional quota sampling will be performed to ensure that the sample was representative of the Turkish population. Demographic, lifestyle, medical, and therapeutic data will be collected by this specific survey.

CONCLUSION

The APOLLON trial will be the largest and most comprehensive study in Turkey evaluating HF patients with a LVEF ≥40% and will also be the first study to specifically analyze the recently designated HFmrEF category.

Reliability and validity of Family Caregiver Quality of Life Scale in heart failure

Background

In this study, the Family Caregiver Quality of Life scale developed specifically for family caregivers of heart failure patients was translated into the Turkish language, and its reliability and validity was performed.

Methods

The scale was first translated into Turkish and back-translated, adapting it to the Turkish culture. The Turkish questionnaire of the scale was applied to 200 family caregivers. To evaluate the reliability of the scale and all subscales, test-retest was applied, and the Cronbach's alpha reliability coefficients were calculated. The structural validity of the scale was examined through the factor analysis.

Results

The internal consistency reliability (a=0.82) of the Turkish Questionnaire of the scale was proved. Two-week test-retest reliability was supported by an intraclass correlation coefficient of 0.91. The questionnaire's factor structure demonstrated acceptable fit, indicating that it could be applied to the Turkish population. The item loads found by the factor analysis ranged from 0.32 to 0.99, explaining %63 of the variance (eigenvalue=2.61-4.06). Criterion-related validity was supported by correlations with the Short Form-36 General (r=0.473, p<0.01) and Mental (r=0.406; p<0.01) Health subscales.

Conclusion

The Turkish version of this scale can measure the quality of life of family caregivers of heart failure patients with adequate reliability and validity.

The effect on patient outcomes of a nursing care and follow-up program for patients with heart failure: A randomized controlled trial

BACKGROUND

Heart failure is associated with exacerbated symptoms such as dyspnea and edema and results in frequent hospitalization and a poor quality of life. With the adoption of a comprehensive nursing care and follow-up program, patients with heart failure may exhibit improvements in their self-care capabilities and their hospitalizations may be reduced.

OBJECTIVE

The purpose of this study was to examine the effect of a nursing care and follow-up program for patients with heart failure on self-care, quality of life, and rehospitalization.

DESIGN AND SETTING

This research was conducted as a single-center, single-blind, randomized controlled study at the heart failure outpatient clinic of a university hospital in Turkey.

PARTICIPANTS

A total of 90 patients with heart failure were randomly assigned into either the specialized nursing care group (n=45) or the control group (n=45).

METHODS

The nursing care and follow-up program applied in the intervention group was based on the Theory of Heart Failure Self-care. Data were collected at the beginning of the trial, and at three and six months after the study commenced. Self-care of the patients was assessed by the Self-Care of Heart Failure Index. Quality of life was assessed with the "Left Ventricular Dysfunction Scale". Rehospitalization was evaluated based on information provided by the patients or by hospital records.

RESULTS

A statistically significant difference was found between the intervention and control group with respect to the self-care and quality of life scores at both three and six months. While the intervention group experienced fewer rehospitalizations at three months, no significant differences were found at six months.

CONCLUSION

The results obtained in this study show that the nursing care and follow-up program implemented for patients with heart failure improved self-care and quality of life. Although there were no significant differences between the groups at six months, fewer rehospitalizations in the intervention group was considered to be an important result.

Post-discharge heart failure monitoring program in Turkey: Hit-PoinT

Objective:

The aim of this study was to assess the efficacy and feasibility of an enhanced heart failure (HF) education with a 6-month telephone follow- up program in post-discharge ambulatory HF patients.

Methods:

The Hit-Point trial was a multicenter, randomized, controlled trial of enhanced HF education with a 6-month telephone follow-up program (EHFP) vs routine care (RC) in patients with HF and reduced ejection fraction. A total of 248 patients from 10 centers in various geographical areas were randomized: 125 to EHFP and 123 to RC. Education included information on adherence to treatment, symptom recognition, diet and fluid intake, weight monitoring, activity and exercise training. Patients were contacted by telephone after 1, 3, and 6 months. The primary study endpoint was cardiovascular death.

Results:

Although all-cause mortality didn’t differ between the EHFP and RC groups (p=NS), the percentage of cardiovascular deaths in the EHFP group was significantly lower than in the RC group at the 6-month follow up (5.6% vs. 8.9%, p=0.04). The median number of emergency room visits was one and the median number of all cause hospitalizations and heart failure hospitalizations were zero. Twenty-tree percent of the EHFP group and 35% of the RC group had more than a median number of emergency room visits (p=0.05). There was no significant difference regarding the median number of all–cause or heart failure hospitalizations. At baseline, 60% of patients in EHFP and 61% in RC were in NYHA Class III or IV, while at the 6-month follow up only 12% in EHFP and 32% in RC were in NYHA Class III or IV (p=0.001).

Conclusion:

These results demonstrate the potential clinical benefits of an enhanced HF education and follow up program led by a cardiologist in reducing cardiovascular deaths and number of emergency room visits with an improvement in functional capacity at 6 months in post-discharge ambulatory HF patients.

Influence of influenza vaccination on recurrent hospitalization in patients with heart failure

BACKGROUND

The current study aimed to evaluate the influence of regular annual influenza vaccinations on cardiovascular (CV) death and heart failure-related hospitalizations (HFrH) in stable outpatients with heart failure with reduced ejection fraction.

METHODS

The Turkish research team-HF (TREAT-HF) is a network undertaking multicenter, observational cohort studies in HF. This study is a subgroup analysis of TREAT-HF outpatient cohorts who completed a questionnaire on influenza vaccination status and for whom follow-up data were available. A total of 656 patients with available follow-up data for CV death and HFrH including recurrent hospitalization were included in the study. Patients were classified into two groups: those who received regular influenza vaccination (40 %) and those who did not receive vaccination.

RESULTS

During a mean follow-up of 15 ±6 months, 113 (18 %) patients had CV death and 471 (72 %) patients had at least one HFrH. The CV death rate was similar in both groups of patients (16 vs. 19 %, p = 0.37), whereas, HFrH and recurrent HFrH were significantly less frequently encountered in patients who received regular influenza vaccination than in those who did not receive vaccination (43 vs. 92 % and 16 vs. 66 %, p < 0.001, respectively). In a multivariate Cox proportional hazards model - in addition to a few clinical factors - vaccination status (HR = 0.30, 95 % CI = 0.17-0.51, p < 0.001) and graduation from university (HR = 0.35, 95 % CI = 0.17-0.72, p = 0.004) remained independently associated with the risk of recurrent HFrH.

CONCLUSION

Regular influenza vaccination does not influence CV deaths; however, it decreases HFrH including recurrent episodes of HFrH in outpatients with heart failure with reduced ejection fraction.

Spectrum of epidemiological and clinical findings in patients with heart failure with preserved ejection fraction stratified by study design: a systematic review

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) represents a major global and economic burden, but its epidemiological, clinical, and outcome data have varied according to study design.

METHODS AND RESULTS

We conducted a systematic review of published HFpEF clinical trials and observational studies (community-based studies and registries) from August 1998 to July 2013 using PubMed and EMBASE databases. Two independent investigators manually screened and extracted relevant data. We included 62 articles (19 describing clinical trials, 12 describing community-based observational studies, and 31 describing registries). The ejection fraction (EF) cut-off values ranged widely for HFpEF from >40% to >55%. However, differences in EF cut-offs were not clearly associated with incidence and prevalence data across studies. Of all patients with heart failure in community studies, 33-84% had HFpEF, which tended to be higher than reported in registries. The HFpEF patients in included studies were primarily older, white (>70%) patients with hypertension (∼50-90%) and coronary artery disease (up to 60%). All-cause mortality and all-cause hospitalizations ranged from 13% to 23% (26-50 months follow-up) and 55% to 67% (37-50 months follow-up), respectively, in clinical trials; cardiovascular causes accounted for 70% of both outcomes. All-cause mortality tended to be higher in registries than in clinical trials and community-based observational studies up to 5 years into follow-up.

CONCLUSIONS

Important differences in EF thresholds, epidemiological indices, clinical profiles, treatment patterns, and outcomes exist across contemporary HFpEF clinical trials, observational studies, and registries. Precision in definition and inclusion of more uniform populations may facilitate improved profiling of HFpEF patients.

Diagnosis and management of acute heart failure

Acute heart failure (AHF) is a life threatening clinical syndrome with a progressively increasing incidence in general population. Turkey is a country with a high cardiovascular mortality and recent national statistics show that the population structure has turned to an 'aged' population.As a consequence, AHF has become one of the main reasons of admission to cardiology clinics. This consensus report summarizes clinical and prognostic classification of AHF, its worldwide and national epidemiology, diagnostic work-up, principles of approach in emergency department,intensive care unit and ward, treatment in different clinical scenarios and approach in special conditions and how to plan hospital discharge.

Prevalence and outcomes of comorbid illnesses in elderly patients with respiratory diseases

AIM

The aim of the present study was to determine the prevalence of comorbidities in very elderly patients hospitalized as a result of acute respiratory diseases and to analyze sex-specific differences, and to examine the effects of these comorbidities on their treatment outcomes.

METHODS

A total of 3316 patients were admitted to our pulmonary inpatient clinic between 2009 and 2011, and 243 of them (aged over 80 years) with acute respiratory disease were included in our study. Data were retrospectively collected, and included demographic features, comorbidities, laboratory findings, length of hospital stay and in-hospital mortality.

RESULTS

In total of 243, 144 patients (59.3%) were men and 99 patients (40.7%) were women. The mean age was 84 ± 3 years. The prevalence of comorbidity was 75.7% (n = 184). The most common comorbid disease in patients with chronic obstructive pulmonary disease was congestive heart failure (32.9%), and it was chronic obstructive pulmonary disease (49.4%) in patients with pneumonia. The rate of having one comorbidity was 58.2% (n = 107) and 35.3% (n = 65) had two. Approximately half (52.6%) of the in-hospital deaths occurred within the first 48 hours of hospitalization. The number of comorbidities was higher in the deceased patients compared with the living patients (P = 0.01).

CONCLUSIONS

The present study showed that the majority of our patients had at least one comorbidity. The first 48 hours of hospitalization was very important, especially for the patients with comorbidities, to determine the need for intensive care unit and prognosis. The coexistence of comorbidities can increase the risk of mortality in the elderly. Geriatr Gerontol Int 2016; 16: 791-796.

Image-guided left ventricular lead placement in cardiac resynchronization therapy for patients with heart failure: a meta-analysis

Background

Heart failure (HF) is a debilitating condition that affects millions of people worldwide. One means of treating HF is cardiac resynchronization therapy (CRT). Recently, several studies have examined the use of echocardiography (ECHO) in the optimization of left ventricular (LV) lead placement to increase the response to CRT. The objective of this study was to synthesize the available data on the comparative efficacy of image-guided and standard CRT.

Methods

We searched the PubMed, Cochrane, Embase, and ISI Web of Knowledge databases through April 2014 with the following combinations of search terms: left ventricular lead placement, cardiac resynchronization therapy, image-guided, and echocardiography-guided. Studies meeting all of the inclusion criteria and none of the exclusion criteria were eligible for inclusion. The primary outcome measures were CRT response rate, change in LV ejection fraction (LVEF), and change in LV end systolic volume (LVESV). Secondary outcomes included the rates of all-cause mortality and HF-related hospitalization.

Results

Our search identified 103 articles, 3 of which were included in the analysis. In total, 270 patients were randomized to the image-guided CRT and 241, to the standard CRT. The pooled estimates showed a significant benefit for image-guided CRT (CRT response: OR, 2.098, 95 % CI, 1.432–3.072; LVEF: difference in means, 3.457, 95 % CI, 1.910–5.005; LVESV: difference in means, −20.36, 95 % CI, −27.819 – −12.902).

Conclusions

Image-guided CRT produced significantly better clinical outcomes than the standard CRT. Additional trials are warranted to validate the use of imaging in the prospective optimization of CRT.

Heart failure care in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Heart failure places a significant burden on patients and health systems in high-income countries. However, information about its burden in low- and middle-income countries (LMICs) is scant. We thus set out to review both published and unpublished information on the presentation, causes, management, and outcomes of heart failure in LMICs.

METHODS AND FINDINGS

Medline, Embase, Global Health Database, and World Health Organization regional databases were searched for studies from LMICs published between 1 January 1995 and 30 March 2014. Additional unpublished data were requested from investigators and international heart failure experts. We identified 42 studies that provided relevant information on acute hospital care (25 LMICs; 232,550 patients) and 11 studies on the management of chronic heart failure in primary care or outpatient settings (14 LMICs; 5,358 patients). The mean age of patients studied ranged from 42 y in Cameroon and Ghana to 75 y in Argentina, and mean age in studies largely correlated with the human development index of the country in which they were conducted (r = 0.71, p<0.001). Overall, ischaemic heart disease was the main reported cause of heart failure in all regions except Africa and the Americas, where hypertension was predominant. Taking both those managed acutely in hospital and those in non-acute outpatient or community settings together, 57% (95% confidence interval [CI]: 49%-64%) of patients were treated with angiotensin-converting enzyme inhibitors, 34% (95% CI: 28%-41%) with beta-blockers, and 32% (95% CI: 25%-39%) with mineralocorticoid receptor antagonists. Mean inpatient stay was 10 d, ranging from 3 d in India to 23 d in China. Acute heart failure accounted for 2.2% (range: 0.3%-7.7%) of total hospital admissions, and mean in-hospital mortality was 8% (95% CI: 6%-10%). There was substantial variation between studies (p<0.001 across all variables), and most data were from urban tertiary referral centres. Only one population-based study assessing incidence and/or prevalence of heart failure was identified.

CONCLUSIONS

The presentation, underlying causes, management, and outcomes of heart failure vary substantially across LMICs. On average, the use of evidence-based medications tends to be suboptimal. Better strategies for heart failure surveillance and management in LMICs are needed. Please see later in the article for the Editors' Summary.

Determinants of inpatient costs of angina pectoris, myocardial infarction, and heart failure in a university hospital setting in Turkey

Objective:

This study aimed to determine the correlates of in-hospital costs for angina pectoris (AP), myocardial infarction (MI), and heart failure (HF) in a university hospital setting.

Methods:

This is a retrospective cost-of-illness study using data from the records of patients who were admitted with AP, MI, or HF to Dokuz Eylül University Hospital during 2008. Direct medical costs were calculated from the Social Security Institute perspective using a bottom-up approach. Socio-demographic and clinical information was abstracted from patient files. Costs were presented in Turkish lira (TL). A generalized linear model was used in the multivariate analysis.

Results:

We included 337 in-patients in total in the study. AP was present in 26.4% (n=89), MI was present in 55.8% (n=188), and HF was present in 17.8% (n=60) of patients. MI was the most costly disease (2760 TL), followed by HF (2350 TL) and AP (1881 TL). The largest proportion of the total cost was formed by medical interventions (27.5%), followed by surgery (22.2%). Presence of DM, smoking, diagnosis of MI, HF, need for intensive care, and resulting in death were strong predictors of treatment costs.

Conclusion:

Both preadmission characteristics of patients (diabetes mellitus, smoking, use of anti-aggregant before admission) and in-patient characteristics (diagnosis, coronary artery bypass grafting, intensive care need, death) predicted the hospital cost of cardiovascular diseases (CVDs) independently. Our results may be used as input for health-economic models and economic evaluations to support the decision-making of reimbursement and the cost-effectiveness of public health interventions in healthcare.

Association between left ventricular dysfunction, anemia, and chronic renal failure. Analysis of the Heart Failure Prevalence and Predictors in Turkey (HAPPY) cohort

BACKGROUND

Anemia and chronic renal failure (CRF) are frequent comorbidities in patients with heart failure (HF), and they have been reported to be associated with increased mortality and hospitalization rates. HF, anemia, and CRF have been reported to interact with each other forming a vicious cycle termed cardio-renal-anemia syndrome. The aim of the present study was to evaluate the association of HF, anemia, and CRF using data from the large-scale"Heart Failure Prevalence and Predictors in Turkey (HAPPY)" study.

PATIENTS AND METHODS

Among the HAPPY cohort, 3,369 subjects who had either left ventricular dysfunction (LVD) or normal left ventricular function on echocardiography or normal serum NT-proBNP levels were included in this analysis.

RESULTS

The prevalence of anemia and CRF was significantly higher in patients with LVD compared with subjects with normal ventricular function (20.7 % vs. 4.0 % and 19.0 % vs. 3.7 %, respectively; p < 0.001 for each). Binary logistic regression analyses for the presence of LVD, anemia, and CRF demonstrated that each one was an independent predictor for the presence of the others.

CONCLUSION

These findings point to the presence of cardio-renal-anemia syndrome and the necessity of treating these comorbidities in patients with HF.