Heart failure and the aging population: an increasing burden in the 21st century?

Numerosity comparison, cognitive strategies, and general cognitive functioning in older people

Introduction

Studies have shown age-related differences in numerical cognition, for example, in the level of numerosity comparison ability. Moreover, some studies point out individual differences in the cognitive strategies employed during the performance of numerosity comparison tasks and reveal that they are related to the aging process. One probable cause of these differences is the level of cognitive functioning. The aim of our study was to determine the relationships among numerosity comparison ability, the cognitive strategies utilized in the performance of numerosity comparison tasks and the general cognitive functioning in older people.

Methods

Forty-seven elderly people participated in the study. The participants were examined using overall cognitive functioning scales and computerized numerosity comparison task.

Results

The results showed many correlations between the participants' level of cognitive functioning and the percent of correct responses (PCR) and response time (RT) during numerosity comparison, as well as with the cognitive strategies applied by the participants. Task correctness was positively related to the level of performance in the attention and executive function tasks. In contrast, the long-term memory resources index and visuospatial skills level were negatively correlated with RT regarding numerosity comparison task performance. The level of long-term memory resources was also positively associated with the frequency of use of more complex cognitive strategies. Series of regression analyses showed that both the level of general cognitive functioning and the cognitive strategies employed by participants in numerosity comparison can explain 9-21 percent of the variance in the obtained results.

Discussion

In summary, these results showed significant relationships between the level of cognitive functioning and proficiency in numerosity comparison measured in older people. Moreover, it has been shown that cognitive resources level is related to the strategies utilized by older people, which indicates the potential application for cognitive strategy examinations in the development of new diagnostic tools.

Chronic care for heart failure patients: Who to refer back to the general practitioner?-Experiences of the Dutch integrated heart failure care model

OBJECTIVE

The number of patients with heart failure (HF) and corresponding burden of the healthcare system will increase significantly. The Dutch integrated model, 'Transmural care of HF Patients' was based on the European Society of Cardiology (ESC) guidelines and initiated to manage the increasing prevalence of HF patients in primary and secondary care and stimulate integrated care. It is unknown how many HF patients are eligible for back-referral to general practitioners (GPs), which is important information for the management of chronic HF care. This study aims to evaluate clinical practice of patients for whom chronic HF care can be referred from the cardiologist to the GP based on the aforementioned chronic HF care model.

DESIGN AND METHODS

A retrospective case record-based study was conducted, which included all chronic HF patients registered in the cardiology information systems of two different hospitals. Subsequently, 200 patients were randomly selected for evaluation. The following patients were considered eligible for referral to the GP: 1/Stable HF patients with reduced left ventricular ejection fraction (LVEF), 2/Stable HF patients with a recovered LVEF and 3/Stable HF patients with a preserved LVEF, 4/HF, palliative setting.

RESULTS

Of the 200 patients, 17% was considered eligible for referral to the GP. This group consisted of 5% patients with a reduced LVEF, 10.5% patients with recovered LVEF and 1.5% patients with a preserved LVEF. Main indicators for HF care by cardiologists were active cardiac disease other than HF (39.5%), recent admission for HF (29.5%) or a recent adjustment in HF medication (7.5%).

CONCLUSION

Applying the chronic HF care model of the 'Transmural care of HF patients' and the ESC-guidelines, results in an important opportunity to further optimise HF integrated care and to deal with the increasing number of HF patients referred to the hospital.

Progress in the study of aging marker criteria in human populations

The use of human aging markers, which are physiological, biochemical and molecular indicators of structural or functional degeneration associated with aging, is the fundamental basis of individualized aging assessments. Identifying methods for selecting markers has become a primary and vital aspect of aging research. However, there is no clear consensus or uniform principle on the criteria for screening aging markers. Therefore, we combine previous research from our center and summarize the criteria for screening aging markers in previous population studies, which are discussed in three aspects: functional perspective, operational implementation perspective and methodological perspective. Finally, an evaluation framework has been established, and the criteria are categorized into three levels based on their importance, which can help assess the extent to which a candidate biomarker may be feasible, valid, and useful for a specific use context.

Exploring Regional Disparities in Heart Failure Epidemiology and Outcomes: A Comprehensive Study Across Geographical Regions in Türkiye

Background

Heart failure (HF) is a common condition that affects 1-3% of the general population. Its prevalence exhibits notable international and intranational disparities, partly explained by socioeconomic status, religion, ethnic diversity, and geographic factors. A comprehensive understanding of the epidemiological symptoms of HF in different regions of Türkiye has yet to be revealed.

Aims

To examine epidemiological data from 2016 to 2022, focusing on crucial patient characteristics and geographical regions, to determine the incidence and prevalence of HF in Türkiye across seven diverse geographical regions.

Study Design

A nationwide population-based retrospective cohort study.

Methods

The comprehensive National Electronic Database of the Turkish Ministry of Health was used in this study to obtain data that covers the whole Turkish population from January 1, 2016, to December 31, 2022. The International Classification of Diseases-10 (ICD-10) codes were used to identify adults with HF (n = 2,701,099) and associated comorbidities. Türkiye is divided into seven geographically distinct regions. Epidemiological characteristics and survival data of these regions were analyzed separately. All-cause mortality was set as the primary outcome.

Results

In , the total estimated prevalence of adult patients with HF is 2.939%, ranging from 2.442% in Southeastern Anatolia to 4.382% in the Black Sea Region. Except for the Eastern Anatolia Region, the three most often reported comorbidities were hypertension, dyslipidemia, and anxiety disorders. The rates of prescribing guideline-directed medical therapy (GDMT) for HF and other medications varied significantly. GDMT prescription rates were lowest in the Eastern Anatolia Region (82.6% for beta-blockers, 48.7% for RASi, 31.8% for mineralocorticoid receptor antagonists, and 9.4% for SGLT2i). The Mediterranean and Aegean regions had the highest median N-terminal brain natriuretic peptide (NT-proBNP) levels of 1,990,0 pg/ml (518.0-6,636,0) and 1,441,0 pg/ml (363.0-5,000,0), respectively. From 2016 to 2022, 915,897 (33.9%) of 2,701,099 patients died. The Eastern Anatolia Region had the lowest all-cause mortality rate of 26.5%, whereas the Black Sea Region had the highest all-cause mortality rate of 35.3%.

Conclusion

Our real-world analysis revealed geographic disparities in HF characteristics, such as decreased mortality in socioeconomically challenged regions. Higher stress susceptibility in developed regions may increase the likelihood of adverse outcomes.

A Critical Evaluation of Patient Pathways and Missed Opportunities in Treatment for Heart Failure

BACKGROUND

Heart failure (HF) is a global problem responsible for significant morbidity and mortality.

METHODS

This review describes the patient pathways and missed opportunities related to treatment for patients with HF.

RESULTS

The contemporary management strategies in HF, including medical therapies, device therapy, transplant, and palliative care. Despite the strong evidence base for therapies that improve prognosis and symptoms, there remains a large number of patients that are not optimally managed. The treatment of patients with HF is highly influenced by those who are caring for them and varies widely across geographical regions. HF patients can be broadly classified into two key groups: those who have known HF, and those who are incidentally found to have reduced left ventricular systolic dysfunction or other cardiac abnormality when an echocardiogram is performed. While all patients are under the care of a general practitioner or family doctor, in other instances, non-cardiologist physicians, cardiologists, and specialist HF nurses-each will have varying levels of expertise in managing HF-are part of the broader team involved in the specialist management of patients with HF.

CONCLUSIONS

There are many potential missed opportunities in HF treatment, which include general opportunities, medications, etiology-specific therapy, device therapy, therapies when initial treatments fail, and palliative care.

Association between focused cardiac ultrasound and time to furosemide administration in acute heart failure

BACKGROUND

Heart failure (HF) is a global health burden, and its management in the emergency department (ED) is important. This study aimed to evaluate the association between focused cardiac ultrasound (FoCUS) and early administration of diuretics in patients with acute HF admitted to the ED.

METHODS

This retrospective observational study was conducted at a tertiary academic hospital. Patients with acute HF patients who were admitted to the ED and receiving intravenous medication between January 2018 and December 2019 were enrolled. The main exposure was a FoCUS examination performed within 2 h of ED triage. The primary outcome was the time to furosemide administration.

RESULTS

Of 1154 patients with acute HF, 787 were included in the study, with 116 of them having undergone FoCUS. The time to furosemide was significantly shorter in the FoCUS group (median time (q1-q3), 112 min; range, 65-163 min) compared to the non-FoCUS group (median time, 131 min; range, 71-229 min). In the multivariable logistic regression analysis adjusting for age, sex, chief complaint, mode of arrival, triage level, shock status, and desaturation at triage, early administration of furosemide within 2 h from triage was significantly higher in the FoCUS group (adjusted odds ratio, 1.63; 95% confidence intervals, 1.04-2.55) than in the non-FoCUS group.

CONCLUSIONS

Early administration of intravenous furosemide was associated with FoCUS examination in patients with acute HF admitted to the ED. An early screening protocol could be useful for improving levels in clinical practice at EDs.

The relationship between choroidal blood flow and glaucoma progression in a Japanese study population

PURPOSE

To determine whether choroidal blood flow (BF) is related to visual field (VF) defect severity and progression in eyes with open-angle glaucoma (OAG).

STUDY DESIGN

Retrospective and longitudinal.

METHODS

This study comprised 443 eyes of 285 OAG patients who underwent laser speckle flowgraphy (LSFG), optical coherence tomography, and visual-field (VF) testing at baseline. The patients were then observed for at least 2 years and at least 5 reliable VF tests were performed. In the LSFG images, we set regions of interest at the optic nerve head (ONH) and the parapapillary choroid to obtain ONH-tissue mean blur rate (MBR) and choroidal MBR, respectively. We used univariable and multivariable linear mixed-effects models to determine clinical factors associated with choroidal MBR at baseline. We also used a linear mixed-effects model to determine the contribution of ONH-tissue MBR and choroidal MBR to baseline mean deviation (MD) and to MD slope during follow-up, adjusting for potential confounding factors, including circumpapillary retinal nerve fiber layer thickness.

RESULTS

Choroidal MBR was associated with age, MD slope, and ONH-tissue MBR (β = -0.181, P = 0.001; β = 0.134, P = 0.002; β = 0.096, P = 0.049, respectively). ONH-tissue MBR was associated with both MD and MD slope (β = 0.146, P = 0.004; β = 0.152, P = 0.009, respectively), whereas choroidal MBR was associated only with MD slope (β = 0.147, P = 0.005).

CONCLUSION

LSFG-derived choroidal MBR might be a useful biomarker to predict VF defect progression in a Japanese population.

Retinal photograph-based deep learning predicts biological age, and stratifies morbidity and mortality risk

BACKGROUND

ageing is an important risk factor for a variety of human pathologies. Biological age (BA) may better capture ageing-related physiological changes compared with chronological age (CA).

OBJECTIVE

we developed a deep learning (DL) algorithm to predict BA based on retinal photographs and evaluated the performance of our new ageing marker in the risk stratification of mortality and major morbidity in general populations.

METHODS

we first trained a DL algorithm using 129,236 retinal photographs from 40,480 participants in the Korean Health Screening study to predict the probability of age being ≥65 years ('RetiAGE') and then evaluated the ability of RetiAGE to stratify the risk of mortality and major morbidity among 56,301 participants in the UK Biobank. Cox proportional hazards model was used to estimate the hazard ratios (HRs).

RESULTS

in the UK Biobank, over a 10-year follow up, 2,236 (4.0%) died; of them, 636 (28.4%) were due to cardiovascular diseases (CVDs) and 1,276 (57.1%) due to cancers. Compared with the participants in the RetiAGE first quartile, those in the RetiAGE fourth quartile had a 67% higher risk of 10-year all-cause mortality (HR = 1.67 [1.42-1.95]), a 142% higher risk of CVD mortality (HR = 2.42 [1.69-3.48]) and a 60% higher risk of cancer mortality (HR = 1.60 [1.31-1.96]), independent of CA and established ageing phenotypic biomarkers. Likewise, compared with the first quartile group, the risk of CVD and cancer events in the fourth quartile group increased by 39% (HR = 1.39 [1.14-1.69]) and 18% (HR = 1.18 [1.10-1.26]), respectively. The best discrimination ability for RetiAGE alone was found for CVD mortality (c-index = 0.70, sensitivity = 0.76, specificity = 0.55). Furthermore, adding RetiAGE increased the discrimination ability of the model beyond CA and phenotypic biomarkers (increment in c-index between 1 and 2%).

CONCLUSIONS

the DL-derived RetiAGE provides a novel, alternative approach to measure ageing.

Uncovering the treatable burden of severe aortic stenosis in the UK

OBJECTIVE

To estimate the population prevalence and treatable burden of severe aortic stenosis (AS) in the UK.

METHODS

We adapted a contemporary model of the population profile of symptomatic and asymptomatic severe AS in Europe and North America to estimate the number of people aged ≥55 years in the UK who might benefit from surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI).

RESULTS

With a point prevalence of 1.48%, we estimate that 291 448 men and women aged ≥55 years in the UK had severe AS in 2019. Of these, 68.3% (199 059, 95% CI 1 77 201 to 221 355 people) would have been symptomatic and, therefore, more readily treated according to their surgical risk profile; the remaining 31.7% of cases (92 389, 95% CI 70 093 to 144 247) being asymptomatic. Based on historical patterns of intervention, 58.4% (116 251, 95% CI 106 895 to 1 25 606) of the 199 059 symptomatic cases would qualify for SAVR, with 7208 (95% CI 7091 to 7234) being assessed as being in a high, preoperative surgical risk category. Among the remaining 41.6% (82 809, 95% CI 73 453 to 92 164) of cases potentially unsuitable for SAVR, an estimated 61.7% (51 093, 95% CI 34 780 to 67 655) might be suitable for TAVI. We estimate that 172 859 out of 291 448 prevalent cases of severe AS (59.3%) will subsequently die within 5 years without proactive management.

CONCLUSIONS

These data suggest a high burden of severe AS in the UK requiring surgical or transcatheter intervention that challenges the ongoing capacity of the National Health Service to meet the needs of those affected.

The cost-effectiveness of B-type natriuretic peptide-guided care in compared to standard clinical assessment in outpatients with heart failure in Tehran, Iran

BACKGROUND

B-type natriuretic peptide (BNP) is commonly used as a diagnostic method for patients with heart failure. This study was designed to evaluate the cost-effectiveness of BNP compared to standard clinical assessment in outpatients with heart failure with reduced ejection fraction (HFrEF) in Tehran, Iran.

METHODS

This study was a cost-effectiveness analysis carried on 400 HFrEF outpatients > 45 years who were admitted to Rasoul Akram General Hospital of Tehran, Iran. A Markov model with a lifetime horizon was developed to evaluate economic and clinical outcomes for BNP and standard clinical assessment. Quality-adjusted life-years (QALYs), direct, and indirect costs collected from the patients.

RESULTS

The results of this study indicated that mean QALYs and cost were estimated to be 2.18 QALYs and $1835 for BNP and 2.07 and $2376 for standard clinical assessment, respectively. In terms of reducing costs and increasing QALYs, BNP was dominant compared to standard clinical assessment. Also, BNP had an 85% probability of being cost-effective versus standard clinical assessment if the willingness to pay threshold is higher than $20,800/QALY gained.

CONCLUSION

Based on the results of the present study, measuring BNP levels represents good value for money, decreasing costs and increasing QALYs compared to standard clinical assessment. It is suggested that the costs of the BNP test be covered by insurance in Iran. The result of the current study has important implications for policymakers in developing clinical guidelines for the diagnosis of heart failure.

Evaluating the usability and acceptability of a geographical information system (GIS) prototype to visualise socio-economic and public health data

BACKGROUND

Understanding the impact of socio-economic inequality on health outcomes is arguably more relevant than ever before given the global repercussions of Covid-19. With limited resources, innovative methods to track disease, population needs, and current health and social service provision are essential. To best make use of currently available data, there is an increasing reliance on technology. One approach of interest is the implementation and integration of mapping software. This research aimed to determine the usability and acceptability of a methodology for mapping public health data using GIS technology.

METHODS

Prototype multi-layered interactive maps were created demonstrating relationships between socio-economic and health data (vaccination and admission rates). A semi-structured interview schedule was developed, including a validated tool known as the System Usability Scale (SUS), which assessed the usability of the mapping model with five stakeholder (SH) groups. Fifteen interviews were conducted across the 5 SH and analysed using content analysis. A Kruskal-Wallis H test was performed to determine any statistically significant difference for the SUS scores across SH. The acceptability of the model was not affected by the individual use of smart technology among SHs.

RESULTS

The mean score from the SUS for the prototype mapping models was 83.17 out of 100, indicating good usability. There was no statistically significant difference in the usability of the maps among SH (p = 0.094). Three major themes emerged with respective sub-themes from the interviews including: (1) Barriers to current use of data (2) Design strengths and improvements (3) Multiple benefits and usability of the mapping model.

CONCLUSION

Irrespective of variations in demographics or use of smart technology amongst interviewees, there was no significant difference in the usability of the model across the stakeholder groups. The average SUS score for a new system is 68. A score of 83.17 was calculated, indicative of a "good" system, as falling within the top 10% of scores. This study has provided a potential digital model for mapping public health data. Furthermore, it demonstrated the need for such a digital solution, as well as its usability and future utilisation avenues among SH.

Models for Heart Failure Admissions and Admission Rates, 2016 through 2018

BACKGROUND

Approximately 6.5 to 6.9 million individuals in the United States have heart failure, and the disease costs approximately $43.6 billion in 2020. This research provides geographical incidence and cost models of this disease in the U.S. and explanatory models to account for hospitals' number of heart failure DRGs using technical, workload, financial, geographical, and time-related variables.

METHODS

The number of diagnoses is forecast using regression (constrained and unconstrained) and ensemble (random forests, extra trees regressor, gradient boosting, and bagging) techniques at the hospital unit of analysis. Descriptive maps of heart failure diagnostic-related groups (DRGs) depict areas of high incidence. State- and county-level spatial and non-spatial regression models of heart failure admission rates are performed. Expenditure forecasts are estimated.

RESULTS

The incidence of heart failure has increased over time with the highest intensities in the East and center of the country; however, several Northern states have seen large increases since 2016. The best predictive model for the number of diagnoses (hospital unit of analysis) was an extremely randomized tree ensemble (predictive R² = 0.86). The important variables in this model included workload metrics and hospital type. State-level spatial lag models using first-order Queen criteria were best at estimating heart failure admission rates (R² = 0.816). At the county level, OLS was preferred over any GIS model based on Moran's I and resultant R²; however, none of the traditional models performed well (R² = 0.169 for the OLS). Gradient-boosted tree models predicted 36% of the total sum of squares; the most important factors were facility workload, mean cash on hand of the hospitals in the county, and mean equity of those hospitals. Online interactive maps at the state and county levels are provided.

CONCLUSIONS

Heart failure and associated expenditures are increasing. Costs of DRGs in the study increased $61 billion from 2016 through 2018. The increase in the more expensive DRG 291 outpaced others with an associated increase of $92 billion. With the increase in demand and steady-state supply of cardiologists, the costs are likely to balloon over the next decade. Models such as the ones presented here are needed to inform healthcare leaders.

Investigation of Relationship between Occupational Stress and Cardiovascular Risk Factors among Nurses

Background:

One of the major causes of various work-related health problems among nurses is occupational stress. Hence, the main purpose of the present research was to find association between occupational stress of nurses and risk factors of cardiovascular disease.

Methods:

In this cross-sectional study, the Osipow job stress questionnaire was employed to assess the occupational stress among the 250 nurses in Emam Khomeini hospital of Tehran in 2018. Based on stress score for participants, subjects divided into two groups: Scoring of group one was 60–179 (mild and average stress) and group two between 180 and 300 (average to acute and acute stress). Systolic and diastolic blood pressures were recorded for subjects after 10hrs fasting. Then the blood samples were collected to measure cholesterol, triglyceride and glucose levels. For determining the association between education level, job experience and study groups, the Chi-square test and for comparing job stress between two groups of study the Mann–Whitney U test was used.

Results:

Subjects with job stress in group one was 70(28%) and group two was 180(72%). The association between level of education and two study groups was not significant (P=0.129) while between job experience and two study groups was significant (P=0.004). Mean of Blood glucose levels for group I (98.0± 37.5), was higher than group II (82.5±12.0) and statistically significant (P=0.001). No significant difference was found between two groups of study for other parameters.

Conclusion:

High level of work-related stress among subjects affected the values related to blood glucose level, but no significant relationship was found between other risk factors of cardiovascular diseases and occupational stress among nurses.

A direct comparison of natural and acoustic-radiation-force-induced cardiac mechanical waves

Natural and active shear wave elastography (SWE) are potential ultrasound-based techniques to non-invasively assess myocardial stiffness, which could improve current diagnosis of heart failure. This study aims to bridge the knowledge gap between both techniques and discuss their respective impacts on cardiac stiffness evaluation. We recorded the mechanical waves occurring after aortic and mitral valve closure (AVC, MVC) and those induced by acoustic radiation force throughout the cardiac cycle in four pigs after sternotomy. Natural SWE showed a higher feasibility than active SWE, which is an advantage for clinical application. Median propagation speeds of 2.5-4.0 m/s and 1.6-4.0 m/s were obtained after AVC and MVC, whereas ARF-based median speeds of 0.9-1.2 m/s and 2.1-3.8 m/s were reported for diastole and systole, respectively. The different wave characteristics in both methods, such as the frequency content, complicate the direct comparison of waves. Nevertheless, a good match was found in propagation speeds between natural and active SWE at the moment of valve closure, and the natural waves showed higher propagation speeds than in diastole. Furthermore, the results demonstrated that the natural waves occur in between diastole and systole identified with active SWE, and thus represent a myocardial stiffness in between relaxation and contraction.

Time-Course Changes in Optic Nerve Head Blood Flow and Retinal Nerve Fiber Layer Thickness in Eyes with Open-angle Glaucoma

PURPOSE

To determine whether decreased optic nerve head (ONH) blood flow (BF) precedes or follows decreased circumpapillary retinal nerve fiber layer thickness (cpRNFLT) in eyes with open-angle glaucoma (OAG).

DESIGN

Retrospective, longitudinal study.

PARTICIPANTS

This study followed up 350 eyes of 225 OAG patients for at least 2 years and collected data from each patient from at least 5 examinations obtained with laser speckle flowgraphy (LSFG) and OCT.

METHODS

In the superior, temporal, and inferior ONH quadrants, tissue area mean blur rate (MT), representing ONH tissue BF, was measured with LSFG, whereas cpRNFLT was measured with OCT. A multivariate linear mixed-effects model was used to identify potential predictors of faster MT decrease, adjusting for possible confounding factors. Based on these results, each quadrant of each patient was assigned a risk point if the quadrant was the superior or temporal, if patient age was older than the median (61 years), and if patient pulse rate was higher than median (74 beats per minute). The quadrants were then compared with a mixed-effects Cox model for MT and cpRNFLT changes, defined as a difference between the baseline value and the values from the latest 2 consecutive follow-up visits of more than 1.96 × the corresponding coefficient of variation.

MAIN OUTCOME MEASURES

Ophthalmic and systemic variables and MT and cpRNFLT in the superior, temporal, and inferior quadrants.

RESULTS

The multivariate model showed that MT decrease was faster in older patients with higher pulse rate and slower in inferior quadrants (P < 0.05). Quadrants with 0 risk points showed primary cpRNFLT decrease (P = 0.048), 1-risk point quadrants showed simultaneous cpRNFLT and MT decrease (P = 0.260), and 2-risk point and 3-risk point quadrants showed primary MT decrease (P < 0.001).

CONCLUSIONS

Older patients with higher pulse rate are at greater risk of a primary reduction in ONH tissue BF, that is, preceding cpRNFLT decrease, in the superior and temporal quadrants.

The role of sacubitril/valsartan in the treatment of chronic heart failure with reduced ejection fraction in hypertensive patients with comorbidities: From clinical trials to real-world settings

Background:

Sacubitril/valsartan, the first agent to be approved in a new class of drugs called angiotensin receptor neprilysin inhibitors (ARNIs), has been shown to reduce cardiovascular mortality and morbidity compared to enalapril in outpatient subjects with chronic heart failure (HF) and reduced left ventricular ejection fraction (HFrEF). However, there is little real-world evidence about the efficacy of ARNIs in elderly hypertensive patients with HFrEF and comorbidities.

Methods:

In this prospective open-label study, 108 subjects, 54 of them (mean age 78.6 ± 8.2 years, 75.0 % male), with HFrEF (29.8 ± 4.3 %) and New York Heart Association (NYHA) class II-III symptoms were assigned to receive ARNIs twice daily, according to the recommended dosage of 24/26, 49/51, 97/103 mg. Patients were gender- and age-matched with a control arm of patients with HFrEF receiving the optimal standard therapy for HF. The clinic blood pressure (BP), N-terminal pro-B-type natriuretic peptide (NT-proBNP), estimated glomerular filtration rate (eGFR), blood glucose and glycated hemoglobin (HbA1c), uric acid (UA), left ventricular ejection fraction (LVEF) and NYHA class were evaluated at a mean follow-up of 12 months. During the follow-up, the clinical outcomes, including mortality and re-hospitalization for HF, were collected.

Results:

NYHA class significantly improved in the ARNI arm compared to the control (24.9 vs. 6.4 %, shifting from class III to II, and 55.4 vs. 25.2 %, from class II to I, p < 0.05 for all). A significant improvement in LVEF and eGFR levels was found in the ARNI arm compared to controls (42.4 vs. 34.2 %, 73.8 vs. 61.2 mL/min, respectively; p < 0.001 for all). NT-proBNP, clinic systolic and diastolic BP, blood glucose, HbA1c and UA values were reduced in both treatment arms, but they were lower in the ARNI arm compared controls (3107 vs. 4552 pg/mL, 112.2 vs. 120.4 and 68.8 vs. 75.6 mmHg, 108.4 vs. 112.6 mg/dL, 5.4 vs. 5.9 % and 5.9 vs. 6.4 mg/dL, respectively, p < 0.05). Mortality and re-hospitalization for HF was lower in the ARNI arm than controls (20.1 vs. 33.6 % and 27.7 vs. 46.3 % respectively; p < 0.05 for all). Gender differences were not found in either arm. No patients refused to continue the study, and no side effects to the ARNI treatment were observed.

Conclusions:

In elderly patients with HFrEF and comorbidities, ARNI treatment seems effective and safe. The improvement in LVEF and cardiac remodeling, BP, eGFR, serum glucose, UA and HbA1c could be the mechanisms by which ARNIs play their beneficial role on clinical outcomes. However, these results need to be confirmed in studies involving a greater number of subjects, and with a longer follow-up.

Effect of nitrate treatment on functional capacity and exercise time in patients with heart failure: a systematic review and meta-analysis

Objectives

Heart failure (HF) is a common and potentially fatal condition. In 2015, HF affected approximately 40 million people globally. Evidence showing that the use of nitrates can improve clinical outcomes in patients with HF is limited. This study aimed to assess the effect of nitrates on functional capacity and exercise time in patients with HF.

Methods

PubMed, Cochrane Library, and Embase databases were reviewed for articles on the use of nitrates and other treatments for patients with HF. The primary endpoints were the 6-minute walk test distance, exercise time, and quality of life. Secondary endpoints were all-cause mortality, arrhythmia, hospitalization, and worsening HF. The weighted mean difference, risk ratio, and 95% confidence interval were calculated.

Results

A total of 14 related studies that comprised 26,321 patients were included. No significant differences were found in the 6-minute walk test distance, exercise time, and quality of life between the nitrate and control treatment groups. There were also no differences in all-cause mortality, the incidence of arrhythmia, hospitalization, and worsening HF between these two groups.

Conclusion

Patients with HF who receive nitrate treatment do not have better quality of life or exercise capacity compared with controls.

Application of Transition-Metal Catalysis, Biocatalysis, and Flow Chemistry as State-of-the-Art Technologies in the Synthesis of LCZ696

LCZ696 is a novel treatment for patients suffering from heart failure that combines the two active pharmaceutical ingredients sacubitril and valsartan in a single chemical compound. While valsartan is an established drug substance, a new manufacturing process suitable for large-scale commercial production had to be developed for sacubitril. The use of chemocatalysis, biocatalysis, and flow chemistry as state-of-the-art technologies allowed to efficiently build up the structure of sacubitril and achieve the defined performance targets.

Macrophage Activities in Myocardial Infarction and Heart Failure

Heart diseases remain the major cause of death worldwide. Advances in pharmacological and biomedical management have resulted in an increasing proportion of patients surviving acute heart failure (HF). However, many survivors of HF in the early stages end up increasing the disease to chronic HF (CHF). HF is an established frequent complication of myocardial infarction (MI), and numerous influences including persistent myocardial ischemia, shocked myocardium, ventricular remodeling, infarct size, and mechanical impairments, as well as hibernating myocardium trigger the development of left ventricular systolic dysfunction following MI. Macrophage population is active in inflammatory process, yet the clear understanding of the causative roles for these macrophage cells in HF development and progression is actually incomplete. Long ago, it was thought that macrophages are of importance in the heart after MI. Also, though inflammation is as a result of adverse HF in patients, but despite the fact that broad immunosuppression therapeutic target has been used in various clinical trials, no positive results have showed up, but rather, the focus on proinflammatory cytokines has proved more benefits in patients with HF. Therefore, in this review, we discuss the recent findings and new development about macrophage activations in HF, its role in the healthy heart, and some therapeutic targets for myocardial repair. We have a strong believe that there is a need to give maximum attention to cardiac resident macrophages due to the fact that they perform various tasks in wound healing, self-renewal of the heart, and tissue remodeling. Currently, it has been discovered that the study of macrophages goes far beyond its phagocytotic roles. If researchers in future confirm that macrophages play a vital role in the heart, they can be therapeutically targeted for cardiac healing.

Spatial patterns and social-economic influential factors of population aging: A global assessment from 1990 to 2010

The world's population is aging rapidly. In this paper, three population aging indicators were collected to represent the elderly population, the oldest-old population, and centenarians. The spatial patterns of three population aging indicators and the influencing social-economic factors and their spatial spillover effects in the world from 1990 to 2010 were investigated. The empirical strategy was based on application of spatial autocorrelation methods and spatial error modeling. The results revealed the significant positive spatial autocorrelation as well as the obvious spatial disparities and clusters of the aging indicators in the world. Furthermore, spatial spillover effects of population aging indicators were detected with positive influence of several social-economic factors (e.g., per capita GNI, urbanization rate, and life expectancy) not only of population aging in a country itself, but in its neighboring counties. In sum, these findings indicated that population aging are a spatio-temporal process, and the spatial spillover effects from neighbors also vary among these indicators, which should be considered into the differentiated policies in response to the challenge of an aging society.

Salivary Protein Panel to Diagnose Systolic Heart Failure

Screening for systolic heart failure (SHF) has been problematic. Heart failure management guidelines suggest screening for structural heart disease and SHF prevention strategies should be a top priority. We developed a multi-protein biomarker panel using saliva as a diagnostic medium to discriminate SHF patients and healthy controls. We collected saliva samples from healthy controls (n = 88) and from SHF patients (n = 100). We developed enzyme linked immunosorbent assays to quantify three specific proteins/peptide (Kallikrein-1, Protein S100-A7, and Cathelicidin antimicrobial peptide) in saliva samples. The analytical and clinical performances and predictive value of the proteins were evaluated. The analytical performances of the immunoassays were all within acceptable analytical ranges. The multi-protein panel was able to significantly (p < 0.001) discriminate saliva samples collected from patients with SHF from controls. The multi-protein panel demonstrated good performance with an overall diagnostic accuracy of 81.6% (sensitivity of 79.2% and specificity of 85.7%) when distinguishing SHF patients from healthy individuals. In conclusion, we have developed immunoassays to measure the salivary concentrations of three proteins combined as a panel to accurately distinguish SHF patients from healthy controls. While this requires confirmation in larger cohorts, our findings suggest that this three-protein panel has the potential to be used as a biomarker for early detection of SHF.

Cost-effectiveness of B-type natriuretic peptide-guided care in patients with heart failure: a systematic review

Measuring the level of B-type natriuretic peptide (BNP), as a guide to pharmacotherapy, can increase the survival of patients with heart failure. This study is aimed at systematically reviewing the studies conducted on the cost-effectiveness of BNP-guided care in patients with heart failure. Using the systematic review method, we reviewed the published studies on the cost-effectiveness of BNP-guided care in patients with heart failure during the years 2004 to 2017. The results showed that all studies clearly stated the time horizon of the study and included direct medical costs in their analysis. In addition, most of the studies used the Markov model. The quality-adjusted life years (QALYs) were the main outcome used for measuring the effectiveness. The studies reported various ranges of the incremental cost-effectiveness ratio (ICER); accordingly, the highest ratio was observed in the USA ($32,748) and the lowest ratio was observed in Canada ($6251). Although the results of the studies were different in terms of a number of aspects, such as the viewpoint of the study, the study horizons, and the costs of expenditure items, they reached similar results. Based on the results of the present study, it seems that the use of BNP or N-terminal pro-BNP (NT-pro-BNP) in patients with heart failure may reduce cost compared to the symptom-based clinical care and increase QALY. In this regard, these studies were designed and conducted in high-income countries; thus, the application of these results in low- and middle-income countries will be limited.

Usefulness of Left Atrial Volume as an Independent Predictor of Development of Heart Failure in Patients With Atrial Fibrillation

Left atrial (LA) volume is known as a robust predictor of heart failure (HF) development in patients with sinus rhythm. However, among patients with atrial fibrillation (AF), the utility of LA volume for prediction of HF development has not been determined. The objective of this study was to investigate the utility of LA volume for prediction of HF development in patients with AF. Among adult patients who were referred for transthoracic echocardiography, those with AF at the baseline echocardiography were included and prospectively followed up to new-onset HF events. Patients who had significant valvular heart disease, congenital heart disease, or reduced left ventricular (LV) ejection fraction were excluded. Cox-proportional hazards models were used to assess the risk of HF development. Of a total of 562 patients, 422 (mean age 69.6 ± 9.7 years, 66.1% men) met study criteria, and 52 (12.3%) developed HF during a mean follow-up of 55 ± 43 months. Patients with HF events had larger indexed LA volume, compared with those without HF events (69 ± 46 vs 50 ± 23 ml/m², p <0.0001). In a multivariable analysis adjusted for other co-morbidities, LA volume was a significant predictor for HF development [per 10 ml/m²; hazard ratio (HR) 1.14, 95% confidence interval (CI) 1.06 to 1.22, p <0.001], independently of age (per 10 years; HR 1.71, 95% CI 1.16 to 2.52, p <0.01), LV ejection fraction (per 10%; HR 0.67, 95% CI 0.52 to 0.86, p <0.01), and indexed LV mass (per 10 g/m²; HR 1.13, 95% CI 1.03 to 1.24, p <0.05). Also, LA volume had an incremental effect for prediction of HF development to these conventional risk factors (p <0.0001). In conclusion, LA volume provides prognostic information for the prediction of future HF events in patients with AF.

Have Traditional Heart Failure Management Programs Reached Their "Use by" Date? Time to Apply More Nuanced Care

PURPOSE OF REVIEW

To determine the current evidence supporting the otherwise proven heart failure management programs (HFMPs) in the setting of an increasingly older and more complex patient population.

RECENT FINDINGS

Attempts to replace proven face-to-face, multidisciplinary management of HF with remote management techniques (including telemedicine and implantable remote monitoring devices) have yielded mixed results. This may well reflect the clinical cascade effect of greater surveillance paradoxically leading to worse health outcomes as well as a narrow focus on HF alone in patients with clinically significant multimorbidity. Concurrently, there is preliminary evidence that the increasing phenomenon of HF and multimorbidity in older patients is undermining the otherwise positive impact of "traditional" HFMPs. A more nuanced approach to determining who would benefit from what form of HF management, including the integration of remote surveillance techniques, is required.

Benefits of Intensive Blood Pressure Treatment in Patients With Type 2 Diabetes Mellitus Receiving Standard but Not Intensive Glycemic Control

This study aimed to assess whether intensive blood pressure (BP) treatment has benefits in preventing cardiovascular events, including heart failure in patients with type 2 diabetes mellitus. Using the ACCORD BP trial (Action to Control Cardiovascular Risk in Diabetes Blood Pressure) data, hazard ratios for cardiovascular events with 95% confidence intervals were calculated using the Cox proportional hazard models to compare the time to the first cardiovascular event in patients receiving standard (n=2362) or intensive glycemic control (n=2371). The overall mean follow-up period was 4.5 years, and cardiovascular events were confirmed in 528 patients. The cardiovascular event risk in patients receiving standard glycemic control was significantly lower in the intensive BP treatment group than in the standard BP treatment group (hazard ratio, 0.71; 95% confidence interval, 0.56-0.90; P=0.005), whereas that in patients receiving intensive glycemic control did not differ significantly between the groups (hazard ratio, 1.06; 95% confidence interval, 0.83-1.36; P=0.61). There was a significant interaction between the BP treatment strategy and glycemic control (P=0.02). The stroke risk in patients receiving standard glycemic control was significantly lower in the intensive BP treatment group, but not in patients receiving intensive glycemic control. Although not significant, all-cause mortality in patients receiving intensive glycemic control was higher in patients receiving intensive BP treatment than in those receiving standard BP treatment (hazard ratio, 1.38; 95% confidence interval, 0.99-1.92; P=0.05). Benefits of intensive BP treatment were observed only in ACCORD BP participants receiving standard glycemic control without additional risk factors.

Patients with heart failure and their partners with chronic illness: interdependence in multiple dimensions of time

Background

Informal caregivers play a vital role in supporting patients with heart failure (HF). However, when both the HF patient and their long-term partner suffer from chronic illness, they may equally suffer from diminished quality of life and poor health outcomes. With the focus on this specific couple group as a dimension of the HF health care team, we explored this neglected component of supportive care.

Materials and methods

From a large-scale Canadian multisite study, we analyzed the interview data of 13 HF patient-partner couples (26 participants). The sample consisted of patients with advanced HF and their long-term, live-in partners who also suffer from chronic illness.

Results

The analysis highlighted the profound enmeshment of the couples. The couples' interdependence was exemplified in the ways they synchronized their experience in shared dimensions of time and adapted their day-to-day routines to accommodate each other's changing health status. Particularly significant was when both individuals were too ill to perform caregiving tasks, which resulted in the couples being in a highly fragile state.

Conclusion

We conclude that the salience of this couple group's oscillating health needs and their severe vulnerabilities need to be appreciated when designing and delivering HF team-based care.

The effect of nurse-led education on hospitalisation, readmission, quality of life and cost in adults with heart failure. A systematic review

OBJECTIVE

The purpose of this systematic review was to highlight the effect of nurse-led 1:1 patient education sessions on Quality of Life (QoL), readmission rates and healthcare costs for adults with heart failure (HF) living independently in the community.

METHOD

A systematic review of randomised control trials was undertaken. Using the search terms nurse, education, heart failure, hospitalisation, readmission, rehospitalisation, economic burden, cost, expenditure and quality of life in PubMed, CINAHL and Google Scholar databases were searched. Papers pertaining to nurse-led 1:1 HF disease management of education of adults in the community with a history of HF were reviewed.

RESULT

The results of this review identified nurse-led education sessions for adults with HF contribute to reduction in hospital readmissions, reduction in hospitalisation and a cost benefit. Additionally, higher functioning and improved QoL were also identified.

CONCLUSION

These results suggest that nurse-led patient education for adults with HF improves QoL and reduces hospital admissions and readmissions.

PRACTICE IMPLICATIONS

Nurse-led education can be delivered utilising diverse methods and impact to reduce readmission as well as hospitalisation.

Cognitive decline in heart failure

Cognitive impairment (CI) is common in older adults with heart failure (HF). The prevalence of CI is higher among patients with HF than in those without. The spectrum of CI in HF is similar to that observed in the general population and may range from delirium to isolated memory or non-memory-related deficits to dementia. Both HF with reduced ejection fraction and HF with preserved ejection fraction have been associated with defects in different domains of cognition. Numerous risk factors have been shown to contribute to CI in HF. Additionally, various pathophysiological mechanisms related to HF can contribute to cognitive decline. These conditions are not routinely screened for in clinical practice settings with HF populations, and guidelines on optimal assessment strategies are lacking. Validated tools and criteria should be used to differentiate acute cognitive decline (delirium) from chronic cognitive decline such as mild cognitive impairment and dementia. CI in HF has been associated with higher rates of disability and impairment in self-care activities that may in turn increase healthcare cost, hospital readmission and mortality. Early detection of CI may improve clinical outcomes in older adults with HF. Appropriate HF management strategies may also help to reduce CI in patients with HF, and future research is needed to develop and test newer and more effective interventions to improve outcomes in patients with HF and CI.

Feasibility of optimizing pharmacotherapy in heart failure patients admitted to an acute geriatric ward: role of the clinical pharmacist

PURPOSE

Heart failure is associated with high mortality and (re)hospitalization rates. Multidisciplinary teams involving pharmacists are effective in preventing disease-related adverse outcomes such as heart-failure-related hospitalizations. We aimed to investigate the impact of integrating clinical pharmacists into a multidisciplinary care team on drug therapies in geriatric heart failure patients. Additionally, we wished to standardize the clinical pharmacy intervention by developing a comprehensive algorithm.

METHODS

A prospective feasibility study was conducted in which systematic pharmaceutical recommendations in a geriatric heart failure population were given. Inclusion criteria were admission to the acute geriatric ward, a minimum age of 75 years and a diagnosis of heart failure. The number of pharmaceutical recommendations, the acceptance rate by the treating physician and the patients' clinical tolerability of the recommendations were registered. Six months after discharge, the general practitioner was contacted to determine drug therapy and heart-failure-related clinical outcomes. We developed a comprehensive algorithm to provide a structured, step-by-step approach for the pharmacotherapeutic evaluation of older heart failure patients.

RESULTS

Thirty patients were included over a 5-month period; one patient dropped out. Sixty-one pharmaceutical recommendations were formulated for the treating physicians of which 43 were accepted. Five recommendations were not tolerated by the patients. The majority of the recommendations regarded diuretic therapy. The final algorithm was considered to contain the basic items needed to provide a comprehensive pharmacotherapeutic evaluation.

CONCLUSIONS

A clinical pharmacist can play an important role in the optimization of therapy for HF patients in a geriatric ward.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02149940.

Comprehensive transcriptional landscape of porcine cardiac and skeletal muscles reveals differences of aging

Aging significantly affects the cardiac muscle (CM) and skeletal muscles (SM). Since the aging process of CM and SM may be different, high throughput RNA sequencing was performed using CM and SM in different age conditions to evaluate the expression profiles of messenger RNA (mRNA), long non-coding RNA (lncRNA), micro RNA (miRNA), and circular (circRNA). Several mRNAs, lncRNAs, and miRNAs were highly expressed and consistently appeared in both ages in one of the two muscle tissues. Gene ontology (GO) annotation described that these genes were required for maintaining normal biological functions of CM and SM tissues. Furthermore, 26 mRNAs, 4 lncRNAs, 22 miRNAs, and 26 circRNAs were differentially expressed during cardiac muscle aging. Moreover, 81 mRNAs, 5 lncRNAs, 79 miRNAs, and 62 circRNAs were differentially expressed during aging of skeletal muscle. When comparing the expression profiles of CM and SM during aging, the senescence process in CM and SM was found to be fundamentally different. In addition, we assessed multi-group cooperative control relationships and constructed circRNA-miRNA-mRNA co-expression networks in muscular aging. In conclusion, our findings will contribute to the understanding of muscular aging and provide a foundation for future studies on the molecular mechanisms underlying muscular aging.

Acute inhibition of PMCA4, but not global ablation, reduces blood pressure and arterial contractility via a nNOS-dependent mechanism

Cardiovascular disease is the world's leading cause of morbidity and mortality, with high blood pressure (BP) contributing to increased severity and number of adverse outcomes. Plasma membrane calcium ATPase 4 (PMCA4) has been previously shown to modulate systemic BP. However, published data are conflicting, with both overexpression and inhibition of PMCA4 in vivo shown to increase arterial contractility. Hence, our objective was to determine the role of PMCA4 in the regulation of BP and to further understand how PMCA4 functionally regulates BP using a novel specific inhibitor to PMCA4, aurintricarboxylic acid (ATA). Our approach assessed conscious BP and contractility of resistance arteries from PMCA4 global knockout (PMCA4KO) mice compared to wild‐type animals. Global ablation of PMCA4 had no significant effect on BP, arterial structure or isolated arterial contractility. ATA treatment significantly reduced BP and arterial contractility in wild‐type mice but had no significant effect in PMCA4KO mice. The effect of ATAin vivo and ex vivo was abolished by the neuronal nitric oxide synthase (nNOS) inhibitor Vinyl‐l‐NIO. Thus, this highlights differences in the effects of PMCA4 ablation and acute inhibition on the vasculature. Importantly, for doses here used, we show the vascular effects of ATA to be specific for PMCA4 and that ATA may be a further experimental tool for elucidating the role of PMCA4.

Effects of cognitive behavioural therapy for depression in heart failure patients: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to evaluate the effects of cognitive behavioural therapy (CBT) on depression, quality of life, hospitalisations and mortality in heart failure patients. The search strategy was developed for Ovid MEDLINE and modified accordingly to search the following bibliographic databases: PubMed, EMBASE, PsycINFO, CENTRAL and CINAHL. Databases were searched from inception to 6 March 2016 for randomised controlled trials (RCTs) or observational studies that used CBT in heart failure patients with depression or depressive symptoms. Six studies were identified: 5 RCTs and 1 observational study, comprising 320 participants with predominantly NYHA classes II-III, who were mostly male, with mean age ranging from 55 to 66 years. Compared to usual care, CBT was associated with a greater improvement in depression scores both initially after CBT sessions (standardised mean difference -0.34, 95% CI -0.60 to -0.08, p = 0.01) and at 3 months follow-up (standardised mean difference -0.32, 95% CI -0.59 to -0.04, p = 0.03). Greater improvement in quality of life scores was evident for the CBT group initially after CBT sessions, but with no difference at 3 months. Hospital admissions and mortality were similar, regardless of treatment group. CBT may be more effective than usual care at improving depression scores and quality of life for heart failure patients initially following CBT and for depression at 3 months. Larger and more robust RCTs are needed to evaluate the long-term clinical effects of CBT in heart failure patients.

Unmet Needs in the Pathogenesis and Treatment of Cardiovascular Comorbidities in Chronic Inflammatory Diseases

The developments that have taken place in recent decades in the diagnosis and therapy of a number of diseases have led to improvements in prognosis and life expectancy. As a consequence, there has been an increase in the number of patients affected by chronic diseases and who can face new pathologies during their lifetime. The prevalence of chronic heart failure, for example, is approximately 1-2% of the adult population in developed countries, rising to ≥10% among people >70 years of age; in 2015, more than 85 million people in Europe were living with some sort of cardiovascular disease (CVD) (Lubrano and Balzan World J Exp Med 5:21-32, 5; Takahashi et al. Circ J 72:867-72, 8; Kaptoge et al. Lancet 375:132-40, 9). Chronic disease can become, in turn, a major risk factor for other diseases. Furthermore, several new drugs have entered clinical practice whose adverse effects on multiple organs are still to be evaluated. All this necessarily involves a multidisciplinary vision of medicine, where the physician must view the patient as a whole and where collaboration between the various specialists plays a key role. An example of what has been said so far is the relationship between CVD and chronic inflammatory diseases (CIDs). Patients with chronic CVD may develop a CID within their lifetime, and, vice versa, a CID can be a risk factor for the development of CVD. Moreover, drugs used for the treatment of CIDs may have side effects involving the cardiovascular system and thus may be contraindicated. The purpose of this paper is to investigate the close relationship between these two groups of diseases and to provide recommendations on the diagnostic approach and treatments in light of the most recent scientific data available.

Heart failure - what's new and what's changed?

Physicians responsible for the care of patients with heart failure due to left ventricular systolic dysfunction have access to a broad range of evidence-based treatments that prolong life and reduce symptoms. In spite of the significant progress made over the last four decades, there is an ongoing need for novel therapies to treat a condition that is associated with stubbornly high morbidity and mortality. In this article, we discuss the findings of SERVE-HF, a randomised controlled trial of adaptive servo-ventilation in patients with left ventricular systolic dysfunction, as well as EMPA-REG, a study of the effects of a novel diabetic agent that may be of greater interest to heart failure specialists than diabetologists. We also examine further analyses of the groundbreaking PARADIGM-HF trial, which attempt to answer some of the unresolved questions from the original study of the first combined angiotensin-receptor blocker and neprilysin inhibitor, sacubitril valsartan. The recently published National Institute for Health and Care Excellence guidelines for the management of acute heart failure and plans to introduce best practice tariffs bring into focus the need for well-organised, multidisciplinary care. We discuss the challenges involved in developing and delivering a specialist service that meets the needs of a growing population of patients living with heart failure.

Trends in mortality rates by subtypes of heart disease in Mississippi, 1980-2013

BACKGROUND

Heart disease (HD) is the leading cause of death among Mississippians. However, trends in mortality rates for HD subtypes in Mississippi have not been adequately described. This study examined trends in mortality rates for HD subtypes among adults in Mississippi from 1980 through 2013.

METHODS

We used Mississippi Vital Statistics data to calculate age-specific mortality rates for HD subtypes for Mississippians age 35 and older. Cases were identified via underlying cause of death codes from the International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10). We used Joinpoint software to calculate the average annual percent change (AAPC) in mortality rates for HD subtypes by race, sex, and age group.

RESULTS

Overall, the age-adjusted coronary heart disease (CHD) mortality rate among Mississippi adults decreased by 62.7% between 1980 and 2013, with an AAPC of -3.0% (95% CI -3.7 to -2.3), while the age-adjusted heart failure mortality rate increased by 66.7%, with an AAPC of 1.4% (95% CI 0.5 to 2.3). Trends varied across HD subtypes: Annual rates of hypertensive HD mortality increased significantly for men, for individuals age 35 to 54, and for individuals age 75 and older. CHD mortality experienced a significant annual decrease among all race, sex, and age subgroups, while heart failure increased significantly among women, whites, and individuals age 75 and older.

CONCLUSIONS

From 1980 to 2013, CHD mortality decreased significantly while heart failure mortality increased significantly among adult Mississippians. However, HD subtype trends differed by race, sex, and age group.

Role of Inflammation in Heart Failure

PURPOSE OF REVIEW

This paper aims to discuss the interactions between inflammatory cytokines, immune cells, and heart failure (HF). The association of heart failure with inflammation has led to multiple studies on anti-inflammatory agents in acute and chronic heart failure.

RECENT FINDINGS

Recent findings have implicated leukocytes subclasses and multiple inflammatory mediators in the progression of heart failure and cardiovascular disease. Studies have discovered further details on the interaction between immune cells-particularly macrophages and lymphocytes-and inflammation. There are both cell-mediated and cytokine-mediated pathways of inflammation, which are interconnected. Additionally, a number of markers have been used and studied in heart failure disease progression. In this review, we discuss inflammatory biomarkers and immune cell mediators involved in HF. We will focus on the correlations and role of these inflammatory mediators in the genesis of HF. We will also discuss the evidence on beneficial effects of anti-inflammatory agents in the setting of chronic HF.

Efficacy and Safety of Inter-Atrial Shunt Devices for Heart Failure With Reduced or Preserved Ejection Fraction: Early Experiences

BACKGROUND

Elevated left atrial (LA) pressure is thought to be the common final pathological way in decompensated heart failure (HF). We aimed to gather currently available clinical evidence to evaluate the feasibility of inter-atrial shunt devices in HF patients.

METHODS

We searched PubMed and Cochrane Library databases through 23rd April 23, 2016. Data were extracted by two investigators independently. We pooled outcomes of interest in Revman 5.2 (The Cochrane Collaboration, Oxford, United Kingdom).

RESULTS

A total of four records were identified in the final review, involving HF patients with reduced ejection fraction (EF) and those with preserved EF. Pooled analysis showed that pulmonary capillary wedge pressure significantly reduced after inter-atrial shunt devices implantation, with a mean difference (MD) of -3.54mmHg (95% confidence interval [CI]=-5.63 to -1.45mmHg) and low heterogeneity (I²=16%), 6-minute walk distance significantly increased, with a MD of 36.84m (95% CI=3.52 to 70.16m) and low heterogeneity (I²=0%), and Minnesota Living with Heart Failure score significantly improved (MD=-22.99 with 95% CI -44.45 to -1.52) following shunting. No evidence of worsening pulmonary hypertension was observed in these studies. No device-related deaths, thrombo-embolic or cardiac events were recorded during follow-up.

CONCLUSIONS

Current evidence suggests that inter-atrial shunting might be a potential and promising therapy for HF, regardless of the ejection fraction.

Comorbidity and polypharmacy in chronic heart failure: a large cross-sectional study in primary care

BACKGROUND

Comorbidity is common in heart failure, but previous prevalence estimates have been based on a limited number of conditions using mainly non-primary care data sources.

AIM

To compare prevalence rates of comorbidity and polypharmacy in those with and without chronic heart failure due to left ventricular systolic dysfunction (LVSD).

DESIGN AND SETTING

A cross-sectional study of 1.4 million patients in primary care in Scotland.

METHOD

Data on the presence of LVSD, 31 other physical, and seven mental health comorbidities, and prescriptions were extracted from a database of 1 424 378 adults. Comorbidity prevalence was compared in patients with and without LVSD, standardised by age, sex, and deprivation. Pharmacology data were also compared between the two groups.

RESULTS

There were 17 285 patients (1.2%) who had a diagnosis of LVSD. Compared with standardised controls, the LVSD group had greater comorbidity, with the biggest difference found for seven or more conditions (odds ratio [OR] 4.10; 95% confidence interval (CI] = 3.90 to 4.32). Twenty-five physical conditions and six mental health conditions were significantly more prevalent in those with LVSD relative to standardised controls. Polypharmacy was higher in the LVSD group compared with controls, with the biggest difference found for ≥11 repeat prescriptions (OR 4.81; 95% CI = 4.60 to 5.04). However, these differences in polypharmacy were attenuated after controlling for the number of morbidities, indicating that much of the additional prescribing was accounted for by multimorbidity rather than LVSD per se.

CONCLUSION

Extreme comorbidity and polypharmacy is significantly more common in patients with chronic heart failure due to LVSD. The efficient management of such complexity requires the integration of general and specialist expertise.

8-Hydroxy-2-deoxyguanosine levels and heart failure: A systematic review and meta-analysis of the literature

BACKGROUND AND AIMS

The generation of reactive oxygen species (ROS) plays an important role in the etiology of several pathological conditions. High levels of 8-hydroxy-2-deoxyguanosine (8-OHdG), a biomarker of oxidative damage of DNA, have been found in patients with heart failure (HF). We performed a meta-analysis of the literature to investigate the association between 8-OHdG levels and HF.

METHODS AND RESULTS

A systematic search was performed in the PubMed, Web of Science, Scopus, EMBASE databases and studies evaluating 8-OHdG levels in HF patients and controls were included. Differences between cases and controls were expressed as standard mean difference (SMD) or mean difference (MD) with pertinent 95% confidence intervals (95%CI). Impact of clinical and demographic features on effect size was assessed by meta-regression. Six studies (446 HF patients and 140 controls) were included in the analysis. We found that HF patients showed higher 8-OHdG levels than controls (SMD:0.89, 95%CI: 0.68, 1.10). The difference was confirmed both in studies in which 8-OHdG levels were assessed in urine (MD:6.28 ng/mg creatinine, 95%CI: 4.01, 8.56) and in blood samples (MD:0.36 ng/ml, 95%CI: 0.04, 0.69). Interestingly, 8-OHdG levels progressively increased for increasing New York Heart Association (NYHA) class. Meta-regression models showed that none of clinical and demographic variables impacted on the difference in 8-OHdG levels among HF patients and controls.

CONCLUSIONS

8-OHdG levels are higher in HF patients HF than in controls, with a progressive increase for increasing NYHA class. However, larger prospective studies are needed to test 8-OHdG as a biomarker of HF severity and progression.

Does improvement in self-management skills predict improvement in quality of life and depressive symptoms? A prospective study in patients with heart failure up to one year after self-management education

Background

Heart failure (HF) patient education aims to foster patients’ self-management skills. These are assumed to bring about, in turn, improvements in distal outcomes such as quality of life. The purpose of this study was to test the hypothesis that change in self-reported self-management skills observed after participation in self-management education predicts changes in physical and mental quality of life and depressive symptoms up to one year thereafter.

Methods

The sample comprised 342 patients with chronic heart failure, treated in inpatient rehabilitation clinics, who received a heart failure self-management education program. Latent change modelling was used to analyze relationships between both short-term (during inpatient rehabilitation) and intermediate-term (after six months) changes in self-reported self-management skills and both intermediate-term and long-term (after twelve months) changes in physical and mental quality of life and depressive symptoms.

Results

Short-term changes in self-reported self-management skills predicted intermediate-term changes in mental quality of life and long-term changes in physical quality of life. Intermediate-term changes in self-reported self-management skills predicted long-term changes in all outcomes.

Conclusions

These findings support the assumption that improvements in self-management skills may foster improvements in distal outcomes.

Left univentricular pacing for cardiac resynchronization therapy using rate-adaptive atrioventricular delay

OBJECTIVE

To evaluate left univentricular (LUV) pacing for cardiac resynchronization therapy (CRT) using a rate-adaptive atrioventricular delay (RAAVD) algorithm to track physiological atrioventricular delay (AVD).

METHODS

A total of 72 patients with congestive heart failure (CHF) were randomized to RAAVD LUV pacing versus standard biventricular (BiV) pacing in a 1: 1 ratio. Echocardiography was used to optimize AVD for both groups. The effects of sequential BiV pacing and LUV pacing with optimized A-V (right atrio-LV) delay using an RAAVD algorithm were compared. The standard deviation (SD) of the S/R ratio in lead V1 at five heart rate (HR) segments (R_S/R-SD5), defined as the "tracking index," was used to evaluate the accuracy of the RAAVD algorithm for tracking physiological AVD.

RESULTS

The QRS complex duration (132 ± 9.8 vs. 138 ± 10 ms, P < 0.05), the time required for optimization (21 ± 5 vs. 50 ± 8 min, P < 0.001), the mitral regurgitant area (1.9 ± 1.1 vs. 2.5 ± 1.3 cm², P < 0.05), the interventricular mechanical delay time (60.7 ± 13.3 ms vs. 68.3 ± 14.2 ms, P < 0.05), and the average annual cost (13,200 ± 1000 vs. 21,600 ± 2000 RMB, P < 0.001) in the RAAVD LUV pacing group were significantly less than those in the standard BiV pacing group. The aortic valve velocity-time integral in the RAAVD LUV pacing group was greater than that in the standard BiV pacing group (22.7 ± 2.2 vs. 21.4 ± 2.1 cm, P < 0.05). The R_S/R-SD5 was 4.08 ± 1.91 in the RAAVD LUV pacing group, and was significantly negatively correlated with improved left ventricular ejection fraction (LVEF) (ΔLVEF, Pearson's r = -0.427, P = 0.009), and positively correlated with New York Heart Association class (Spearman's r = 0.348, P = 0.037).

CONCLUSIONS

RAAVD LUV pacing is as effective as standard BiV pacing, can be more physiological than standard BiV pacing, and can decrease the average annual cost of CRT.

Depression and self-care maintenance in patients with heart failure: A moderated mediation model of self-care confidence and resilience

BACKGROUND

Despite the recognition of the negative effects of depressive symptoms on self-care confidence and self-care maintenance in patients with heart failure, little is known about the moderating role of resilience underlying these relations.

AIMS

To explore whether depressive symptoms affect self-care maintenance through self-care confidence and whether this mediating process was moderated by resilience.

METHODS

The sample comprised 201 community-dwelling and medically stable patients with echocardiographically documented heart failure. A moderated mediation model was conducted to test whether self-care confidence mediated the association between depressive symptoms and self-care maintenance, and whether resilience moderated the direct and indirect effects of depressive symptoms after adjustment for covariates.

RESULTS

Depressive symptoms reduced self-care maintenance indirectly by decreasing self-care confidence (indirect effect: -0.22, 95% confidence interval: -0.36, -0.11), and this pathway was only significant for patients with moderate and high levels and not with low levels of resilience. Resilience also moderated the direct effects of depressive symptoms on self-care maintenance such that the negative association between depressive symptoms and self-care maintenance was reversed by the existence of high resilience.

CONCLUSIONS

Resilience moderated the direct and indirect effects of depressive symptoms through self-care confidence on self-care maintenance in heart failure patients. Efforts to improve self-care maintenance by targeting depressive symptoms may be more effective when considering self-care confidence in patients with moderate to high levels of resilience.