Guidelines are more accessible than ever and represent an important tool in clinical practice. The National Institute for Health and Care Excellence (NICE) has developed recommendations for heart ...failure diagnosis and management based not only on morbidity and mortality trial outcome data but also in-depth economic analysis, with a focus on generalisability to UK National Health Service clinical practice. There is broad consistency in structure and content between NICE guidelines and those produced by major cardiovascular organisations such as the American College of Cardiology/American Heart Association and the European Society of Cardiology. However, important differences do exist-largely attributable to publication timing-a factor that is enhanced by the rapid pace of heart failure research. This article reviews the most recent iteration of NICE chronic heart failure guidelines and compares them with major guidelines on an international scale. Variations in recommendations will be explored including implications for NICE guideline updates in the future.
Aims
In recent years there has been an increase in the number of biomarkers in heart failure (HF). The clinical role for these novel biomarkers in combination is not clear.
Methods and results
The ...following novel biomarkers were measured from 628 patients recently hospitalized with decompensated HF; mid‐regional pro‐adrenomedullin (MR‐proADM), mid‐regional pro‐atrial natriuretic peptide (MR‐proANP), copeptin, high‐sensitivity cardiac troponin T (hs‐cTnT), ST2, galectin‐3, cystatin C, combined free light chains (cFLC) and high sensitivity C‐reactive protein (hsCRP). The incremental prognostic value of these novel biomarkers was evaluated within an extensive model containing established predictors of mortality. During a mean (SD) follow‐up of 3.2 (1.5) years, 290 (46%) patients died. Elevated concentrations of all novel biomarkers were associated with an increased unadjusted risk of mortality but only two‐thirds were independent predictors following multivariable analysis. Using dichotomized cut‐points from receiver operating characteristic analysis, MR‐proADM, hs‐cTnT, cFLC, hsCRP, and ST2 remained independent predictors of mortality. Further dichotomization into low (0–2 elevated biomarkers) or high (at least three of the five biomarkers elevated) risk groups provided greatest incremental prognostic value (hazard ratio 2.20, 95% confidence interval 1.37–3.54; P = 0.001) and improved the performance of the model (C‐statistic 0.730 from 0.721, net reclassification index 32.5%).
Conclusion
The novel biomarkers included in this study added little, if any, incremental prognostic value on their own to a model containing established predictors of mortality. However, following dichotomization, five of the novel biomarkers provided incremental prognostic value. There was a clear gradient in the risk of death with increasing numbers of elevated novel biomarkers, with the presence of at least three identifying patients at greatest risk of mortality.
Document Reviewers: Rudolf A. de Boer (CPG Review Co-ordinator) (Netherlands), P. Christian Schulze (CPG Review Co-ordinator) (Germany), Elena Arbelo (Spain), Jozef Bartunek (Belgium), Johann ...Bauersachs (Germany), Michael A. Borger (Germany), Sergio Buccheri (Sweden), Elisabetta Cerbai (Italy), Erwan Donal (France), Frank Edelmann (Germany), Gloria Färber (Germany), Bettina Heidecker (Germany), Borja Ibanez (Spain), Stefan James (Sweden), Lars Køber (Denmark), Konstantinos C. Koskinas (Switzerland), Josep Masip (Spain), John William McEvoy (Ireland), Robert Mentz (United States of America), Borislava Mihaylova (United Kingdom), Jacob Eifer Møller (Denmark), Wilfried Mullens (Belgium), Lis Neubeck (United Kingdom), Jens Cosedis Nielsen (Denmark), Agnes A. Pasquet (Belgium), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Bianca Rocca (Italy), Xavier Rossello (Spain), Leyla Elif Sade (United States of America/Türkiye), Hannah Schaubroeck (Belgium), Elena Tessitore (Switzerland), Mariya Tokmakova (Bulgaria), Peter van der Meer (Netherlands), Isabelle C. Van Gelder (Netherlands), Mattias Van Heetvelde (Belgium), Christiaan Vrints (Belgium), Matthias Wilhelm (Switzerland), Adam Witkowski (Poland), and Katja Zeppenfeld (Netherlands) All experts involved in the development of this Focused Update have submitted declarations of interest. These have been compiled in a report and simultaneously published in a supplementary document to the Focused Update. The report is also available on the ESC website www.escardio.org/guidelines See the European Heart Journal online for supplementary documents that include evidence tables.
Abstract The apelin-APJ system is a novel neurohormonal pathway, with studies to date suggesting that it may be of pathophysiologic relevance in heart failure and may indeed be a viable therapeutic ...target in this syndrome. This interest is driven primarily by the demonstration of its vasodilator, inotropic, and aquaretic actions as well as its apparent antagonistic relationship with the renin-angiotensin system. However, its promise is heightened further by the observation that, unlike other and more established cardioprotective pathways, it appears to be down-regulated in heart failure, suggesting that augmentation of this axis may have a powerful effect on the heart failure syndrome. We review the literature regarding the apelin-APJ system in heart failure and suggest areas requiring further research.
We conducted a meta-analysis of randomised controlled trials (RCTs) of implantable haemodynamic monitoring (IHM)-guided care.
PubMed and Ovid MEDLINE were searched for RCTs of IHM in patients with ...heart failure (HF). Outcomes were examined in total (first and recurrent) event analyses.
Five trials comparing IHM-guided care with standard care alone were identified and included 2710 patients across ejection fraction (EF) ranges. Data were available for 628 patients (23.2%) with heart failure with preserved ejection fraction (HFpEF) (EF ≥50%) and 2023 patients (74.6%) with heart failure with a reduced ejection fraction (HFrEF) (EF <50%). Chronicle, CardioMEMS and HeartPOD IHMs were used. In all patients, regardless of EF, IHM-guided care reduced total HF hospitalisations (HR 0.74, 95% CI 0.66 to 0.82) and total worsening HF events (HR 0.74, 95% CI 0.66 to 0.84). In patients with HFrEF, IHM-guided care reduced total worsening HF events (HR 0.75, 95% CI 0.66 to 0.86). The effect of IHM-guided care on total worsening HF events in patients with HFpEF was uncertain (fixed-effect model: HR 0.72, 95% CI 0.59 to 0.88; random-effects model: HR 0.60, 95% CI 0.32 to 1.14). IHM-guided care did not reduce mortality (HR 0.92, 95% CI 0.71 to 1.20). IHM-guided care reduced all-cause mortality and total worsening HF events (HR 0.80, 95% CI 0.72 to 0.88).
In patients with HF across all EFs, IHM-guided care reduced total HF hospitalisations and worsening HF events. This benefit was consistent in patients with HFrEF but not consistent in HFpEF. Further trials with pre-specified analyses of patients with an EF of ≥50% are required.
CRD42021253905.
Exposure to endocrine disrupting chemicals such as bisphenol A (BPA) is primarily from the diet through canned foods. Characterizing dietary exposures can be conducted through biomonitoring and ...dietary surveys; however, these methods can be time-consuming and challenging to implement.
We developed a novel dietary exposure risk questionnaire to evaluate BPA exposure and compared these results to 24-hr dietary recall data from participants (n = 404) of the Diet Intervention Examining The Factors Interacting with Treatment Success (DIETFITS) study, a dietary clinical trial, to validate questionnaire responses. High BPA exposure foods were identified from the dietary recalls and used to estimate BPA exposure. Linear regression models estimated the association between exposure to BPA and questionnaire responses. A composite risk score was developed to summarize questionnaire responses.
In questionnaire data, 65% of participants ate canned food every week. A composite exposure score validated that the dietary exposure risk questionnaire captured increasing BPA exposure. In the linear regression models, utilizing questionnaire responses vs. 24-hr dietary recall data, participants eating canned foods 1-2 times/week (vs. never) consumed 0.78 more servings (p < 0.001) of high BPA exposure foods, and those eating canned foods 3+ times/week (vs. never) consumed 0.89 more servings (p = 0.013) of high BPA exposure foods. Participants eating 3+ packaged items/day (vs. never) consumed 62.65 more total grams of high BPA exposure food (p = 0.036).
Dietary exposure risk questionnaires may provide an efficient alternative approach to 24-hour dietary recalls to quantify dietary BPA exposure with low participant burden.
The trial was prospectively registered at clinicaltrials.gov as NCT01826591 on April 8, 2013.
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