This article updates the Heart Failure Association of the European Society of Cardiology (ESC) 2007 classification of advanced heart failure and describes new diagnostic and treatment options for ...these patients. Recognizing the patient with advanced heart failure is critical to facilitate timely referral to advanced heart failure centres. Unplanned visits for heart failure decompensation, malignant arrhythmias, co‐morbidities, and the 2016 ESC guidelines criteria for the diagnosis of heart failure with preserved ejection fraction are included in this updated definition. Standard treatment is, by definition, insufficient in these patients. Inotropic therapy may be used as a bridge strategy, but it is only a palliative measure when used on its own, because of the lack of outcomes data. Major progress has occurred with short‐term mechanical circulatory support devices for immediate management of cardiogenic shock and long‐term mechanical circulatory support for either a bridge to transplantation or as destination therapy. Heart transplantation remains the treatment of choice for patients without contraindications. Some patients will not be candidates for advanced heart failure therapies. For these patients, who are often elderly with multiple co‐morbidities, management of advanced heart failure to reduce symptoms and improve quality of life should be emphasized. Robust evidence from prospective studies is lacking for most therapies for advanced heart failure. There is an urgent need to develop evidence‐based treatment algorithms to prolong life when possible and in accordance with patient preferences, increase life quality, and reduce the burden of hospitalization in this vulnerable patient population.
In patients with acute heart failure, early intervention with an intravenous vasodilator has been proposed as a therapeutic goal to reduce cardiac-wall stress and, potentially, myocardial injury, ...thereby favorably affecting patients' long-term prognosis.
In this double-blind trial, we randomly assigned 2157 patients with acute heart failure to receive a continuous intravenous infusion of either ularitide at a dose of 15 ng per kilogram of body weight per minute or matching placebo for 48 hours, in addition to accepted therapy. Treatment was initiated a median of 6 hours after the initial clinical evaluation. The coprimary outcomes were death from cardiovascular causes during a median follow-up of 15 months and a hierarchical composite end point that evaluated the initial 48-hour clinical course.
Death from cardiovascular causes occurred in 236 patients in the ularitide group and 225 patients in the placebo group (21.7% vs. 21.0%; hazard ratio, 1.03; 96% confidence interval, 0.85 to 1.25; P=0.75). In the intention-to-treat analysis, there was no significant between-group difference with respect to the hierarchical composite outcome. The ularitide group had greater reductions in systolic blood pressure and in levels of N-terminal pro-brain natriuretic peptide than the placebo group. However, changes in cardiac troponin T levels during the infusion did not differ between the two groups in the 55% of patients with paired data.
In patients with acute heart failure, ularitide exerted favorable physiological effects (without affecting cardiac troponin levels), but short-term treatment did not affect a clinical composite end point or reduce long-term cardiovascular mortality. (Funded by Cardiorentis; TRUE-AHF ClinicalTrials.gov number, NCT01661634 .).
Death certification represents an excellent source for mortality statistics and appropriate public health surveillance. Errors in reporting the cause of death impede the development of national ...health policies and, accordingly, allocation of resources. The aim of this study was to determine the frequency of errors in the cause of death and to identify factors that may be associated with inaccuracies in death certificates.
A cross-sectional study of all natural death certifications in a defined Greek region was conducted over the period 2006-2010. Specific criteria for major and minor errors were adopted for the evaluation of death certificates.
A total of 5,828 death certificates due to natural causes were identified. Major errors were found in 64.6 % of them with almost every death certificate having a minor error. Major error rate did not differ per year (p =0.65). Most commonly encountered major errors were a non-acceptable cause of death (31.2 %) and an incorrect sequencing (16.8 %). Factors affecting their frequency were the age of the deceased (older than 80 years, p =0.025), the area of certificate completion (rural and semi-urban, p <0.001) and doctor's grade (consultant, p <0.026).
High rate of recording errors at death certification influences the accuracy of the cause of death in a defined region in Southern Greece. Due to their impact on mortality statistics and health policies, standard practices of death certification should be established. Coordinated educational interventions are expected to play a significant role on this. Hippokratia 2016, 20(1): 19-25.
Abstract
Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the ‘HFA–PEFF diagnostic ...algorithm’. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for HF symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e′), left ventricular (LV) filling pressure estimated using E/e′, left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2–4 points) implies diagnostic uncertainty, in which case Step 3 (F1: Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2: Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.
Abstract Introduction This study was designed to determine the variability of the electric pulp response threshold in premolars and the relationship between the response threshold and age. Methods ...Ninety-seven volunteers were recruited, ranging from 20–72 years old. The volunteers were categorized into 6 age groups: group 1, 20–29 years; group 2, 30–39 years; group 3, 40–49 years; group 4, 50–59 years; group 5, 60-69 years; and group 6, 70–79 years. All intact premolars present in each dental arch were tested. Three sites (the tip of the buccal cusp, the center of the middle, and cervical third of the buccal surface) on each tooth crown were tested. Results In total, 1965 measurements were done. A progressive increase of mean threshold value was observed from groups 1 to 6. The response threshold value showed significant differences among the 6 age groups. The effect of age was more intense in mandibular premolars. In first and second mandibular premolars the cusp tip required the lowest current to evoke a response. In maxillary premolars no significant differences among the sites were found. Also, the mean threshold value of the mandibular premolars was lower than that of the maxillary premolars in subjects of the same age, and the mean threshold value of the first premolars was lower than that of the second premolars. The buccal cusp tip of the first mandibular premolars responded more quickly than any other tested site. Conclusions Age is related with higher response threshold values. The optimum site for testing the lower premolars is the buccal cusp tip.
Summary Nutritional support is becoming a mainstay of the comprehensive therapeutic approach to patients with chronic diseases. Chronic heart failure (CHF) and chronic obstructive pulmonary disease ...(COPD) are frequently associated with the progressive development of malnutrition, due to reduced energy intake, increased energy expenditure and impaired anabolism. Malnutrition and eventually cachexia have been shown to have a negative influence on the clinical course of CHF and COPD, and to impinge on patients' quality of life. Nutritional support in these patients should be therefore considered, particularly to prevent progressive weight loss, since restoration of lean and fat body mass may not be achievable. In CHF and COPD patients, the gastrointestinal tract is normally accessible and functioning. Although recent reports suggest that heart failure is associated with modifications of intestinal morphology, permeability and absorption, the clinical relevance of these are still not clear. Oral supplementation and enteral nutrition should represent the first choices when cardiopulmonary patients need nutritional support, particularly given the potential complications and economic burden of parenteral nutrition. This appropriately preferential enteral approach partly explains the lack of robust clinical trials of the role of parenteral nutrition in CHF and COPD patients. Based on the available evidence collected via PubMed, Medline, and SCOPUS searches, it is recommended that parenteral nutrition is reserved for those patients in whom malabsorption has been documented and in those in whom enteral nutrition has failed. Summary of statements: Parenteral Nutrition in Cardiology Subject Recommendations Grade Number Background The prevalence of cardiac cachexia, defined from weight loss of at least 6% in 6 months, has been estimated at about 12–15% in patients in New York Heart Association (NYHA) classes II–IV. The incidence of weight loss >6% in CHF patients with NYHA class III/IV is approximately 10% per year. CHF affects nutritional state, energy and substrate metabolism. B 1.1 The mortality in CHF patients with cardiac cachexia is 2–3 times higher than in non-cachectic CHF patients. B 1.2 Although there is limited evidence that gut function is impaired in CHF, decreased cardiac function can reduce bowel perfusion and lead to bowel wall oedema, resulting in malabsorption. B 1.3 Indications Although there is no evidence available from well-designed studies, PN is recommended to stop or reverse weight loss in patients with evidence of malabsorption, on the basis that it improves outcome in other similar conditions and there is a plausible physiological argument for it. C 1.4 Currently there is no indication for PN in the prophylaxis of cardiac cachexia. Further studies are needed to assess the impact of the parenteral administration of specific substrates on cardiac function. C 1.5 Contra-indications There are no specific contraindications to PN in CHF patients. However, considering that cardiac function is decreased and water retention is frequently found in CHF patients, it is recommended that PN should be avoided, other than in patients with evidence of malabsorption in whom enteral nutrition has been shown, or is strongly expected, to be ineffective. B 1.6 Implementation When feeding CHF patients, either enterally or parenterally, fluid overload must be avoided. C 1.6 Summary of statements: Parenteral Nutrition in Respiratory Medicine Subject Recommendations Grade Number Background Between 25% and 40% of patients with advanced COPD are malnourished. B 2.1 Being underweight and having low fat-free mass are independently associated with a poor prognosis in patients with chronic respiratory insufficiency, especially in COPD. B 2.2 Indications There is no evidence showing that gut function is impaired in COPD patients. Therefore, considering that enteral nutrition is less expensive and associated with fewer and less severe complications than parenteral nutrition, enteral nutrition should represent the first approach to patients with COPD in need of nutritional support. B 2.3 There is limited evidence that COPD patients intolerant of EN profit from PN. Small studies do however suggest that, in combination with exercise and anabolic pharmacotherapy, PN has the potential to improve nutritional status and function. C 2.4 Effect of PN Loss of body weight is correlated with increased morbidity and mortality. However, due to the lack of studies of its effects, it is not possible to be sure if prognosis is influenced by the provision of PN. B 2.5 Regimen selection In patients with stable COPD, glucose-based PN causes an increase in the respiratory CO2 load. PN composition should accordingly be orientated towards lipids as the energy source. There is not sufficient evidence to recommend specific lipid substrates. B 2.6
The aim of this study was to evaluate the benefits and safety of long-term i.v. iron therapy in iron-deficient patients with heart failure (HF).
CONFIRM-HF was a multi-centre, double-blind, ...placebo-controlled trial that enrolled 304 ambulatory symptomatic HF patients with left ventricular ejection fraction ≤45%, elevated natriuretic peptides, and iron deficiency (ferritin <100 ng/mL or 100-300 ng/mL if transferrin saturation <20%). Patients were randomized 1 : 1 to treatment with i.v. iron, as ferric carboxymaltose (FCM, n = 152) or placebo (saline, n = 152) for 52 weeks. The primary end-point was the change in 6-min-walk-test (6MWT) distance from baseline to Week 24. Secondary end-points included changes in New York Heart Association (NYHA) class, Patient Global Assessment (PGA), 6MWT distance, health-related quality of life (QoL), Fatigue Score at Weeks 6, 12, 24, 36, and 52 and the effect of FCM on the rate of hospitalization for worsening HF. Treatment with FCM significantly prolonged 6MWT distance at Week 24 (difference FCM vs. placebo: 33 ± 11 m, P = 0.002). The treatment effect of FCM was consistent in all subgroups and was sustained to Week 52 (difference FCM vs. placebo: 36 ± 11 m, P < 0.001). Throughout the study, an improvement in NYHA class, PGA, QoL, and Fatigue Score in patients treated with FCM was detected with statistical significance observed from Week 24 onwards. Treatment with FCM was associated with a significant reduction in the risk of hospitalizations for worsening HF hazard ratio (95% confidence interval): 0.39 (0.19-0.82), P = 0.009. The number of deaths (FCM: 12, placebo: 14 deaths) and the incidence of adverse events were comparable between both groups.
Treatment of symptomatic, iron-deficient HF patients with FCM over a 1-year period resulted in sustainable improvement in functional capacity, symptoms, and QoL and may be associated with risk reduction of hospitalization for worsening HF (ClinicalTrials.gov number NCT01453608).
Aims
The objectives of the present study were to describe epidemiology and outcomes in ambulatory heart failure (HF) patients stratified by left ventricular ejection fraction (LVEF) and to identify ...predictors for mortality at 1 year in each group.
Methods and results
The European Society of Cardiology Heart Failure Long‐Term Registry is a prospective, observational study collecting epidemiological information and 1‐year follow‐up data in 9134 HF patients. Patients were classified according to baseline LVEF into HF with reduced EF EF <40% (HFrEF), mid‐range EF EF 40–50% (HFmrEF) and preserved EF EF >50% (HFpEF). In comparison with HFpEF subjects, patients with HFrEF were younger (64 years vs. 69 years), more commonly male (78% vs. 52%), more likely to have an ischaemic aetiology (49% vs. 24%) and left bundle branch block (24% vs. 9%), but less likely to have hypertension (56% vs. 67%) or atrial fibrillation (18% vs. 32%). The HFmrEF group resembled the HFrEF group in some features, including age, gender and ischaemic aetiology, but had less left ventricular and atrial dilation. Mortality at 1 year differed significantly between HFrEF and HFpEF (8.8% vs. 6.3%); HFmrEF patients experienced intermediate rates (7.6%). Age, New York Heart Association (NYHA) class III/IV status and chronic kidney disease predicted mortality in all LVEF groups. Low systolic blood pressure and high heart rate were predictors for mortality in HFrEF and HFmrEF. A lower body mass index was independently associated with mortality in HFrEF and HFpEF patients. Atrial fibrillation predicted mortality in HFpEF patients.
Conclusions
Heart failure patients stratified according to different categories of LVEF represent diverse phenotypes of demography, clinical presentation, aetiology and outcomes at 1 year. Differences in predictors for mortality might improve risk stratification and management goals.
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