PhD student, Monash University
Heart failure (HF) is a complex clinical syndrome where the heart fails to fill or pump blood adequately to meet the requirement of the whole body as a result of any structural or functional impairment of the heart. HF remains a major public health burden with over 38 million individuals worldwide, and rising. It is increasing in prevalence and associated with poor clinical outcomes and high healthcare costs.
Coronary artery disease (CAD) is the most common cause of HF in the developed world. The presence and extent of coronary artery disease may augment the progression of HF, leading to higher mortality among ischemic compared with non-ischemic HF patients.
Technological advances have led to an increasing number of patients with HF being referred for revascularisation. Revascularisation is advocated to improve ventricular function and prognosis for patients with ischemic cardiomyopathy, and there is an increasing number of patients with left ventricular dysfunction referred for revascularisation.
To date, limited data exist on temporal trends of HF patients undergoing percutaneous coronary intervention (PCI). Importantly, the impact of changing medical technology and contemporary therapeutic measures on this high risk subset of patients has not been described. To appropriately align efforts towards reducing long-term mortality and morbidity of HF patients who undergo PCI, it is crucial to understand temporal changes in this population.
To address this, we examined temporal changes in baseline characteristics and clinical outcomes among patients with HF undergoing PCI in a contemporaneous registry. We employed autoregressive integrated moving average (ARIMA) models, which characterize temporal changes in trend, cycles and seasons, and also allow for dynamic time series forecasting.
We learned that the overall rates of major clinical outcomes were relatively high but remained stable between 2005 and 2014. These observations occurred on a background of optimal pharmacological treatment for both HF and CAD. With the assumption that there are no major changes in procedural practices within the hospitals under study over the short to medium term, these trends are expected to continue.
Whether we are observing a ‘plateau’ in outcomes among patients with HF undergoing PCI remains unclear. These patients represent the most complicated and frail cohort, with poorer prognosis compared with the general population undergoing PCI.
Abstract: To characterize the presentation and outcome of patients with heart failure (HF) after myocardial infarction (MI) according to left ventricular ejection fraction (LVEF) and test the hypothesis that the outcome of HF did not change over time.Little is known about the presentation and outcome of HF post-MI and how these may have changed over time.Using the Rochester Epidemiology Project, all residents of Olmsted County, Minnesota who experienced an incident MI between 1979 and 1998 were identified; MI and HF were validated using standardized criteria. Subjects were followed through their community medical record.Between 1979 and 1998, 1915 patients with incident MI and no prior history of HF were identified. Of these, 791(41%) experienced new onset HF as defined by Framingham criteria during 6.6+/-5.0 years of follow-up. Forty-seven percent were men, mean age was 73+/-12 years. Forty-four percent had impaired LVEF, 18% preserved LVEF and 38% had no LVEF measurement within 60 days after the HF event. Median survival after HF onset was 4 years and at 5 years after HF onset, only 45% were alive. Older age, male sex, comorbidity, hypertension and no LVEF assessment were associated with increased risk of death, however, patients with impaired LVEF had the worst outcome. Over time, survival did not improve (HR for year: 1.00; 95% CI 0.99, 1.02; P=0.919) even after adjustment for baseline characteristics.In this geographically defined cohort of patients with MI, new onset HF after the MI was frequent. When measured, LVEF was most frequently reduced, consistent with systolic heart failure. Mortality was high and did not decline over time and death was independently associated with male sex, older age, hypertension and comorbidity. It also differed according to LVEF, which was inconsistently ascertained in this setting, potentially representing practice opportunities.
Pub.: 12 Jan '05, Pinned: 26 Aug '17
Abstract: Revascularization is frequently advocated to improve ventricular function and prognosis for patients with heart failure due to coronary artery disease, especially when there is evidence of extensive myocardial viability.Patients with heart failure, coronary artery disease, and a left ventricular (LV) ejection fraction < 35%, who had a substantial volume of viable myocardium with contractile dysfunction assessed by any standard imaging technique, were randomly assigned to a strategy of conservative management vs. angiography with the intent of percutaneous or surgical revascularization. Patients requiring revascularization for angina or too frail for surgery were excluded. Only 138 of the planned 800 patients were enrolled because of withdrawal of funding due to slow recruitment. Also, a larger trial (The Surgical Treatment for Ischemic Heart Failure Trial) addressing a similar question became available, which investigators were encouraged to join. Of 69 patients assigned to the invasive strategy, 6 refused angiography, 2 died as a result of the diagnostic procedure, 14 were considered unsuitable for revascularization, 2 refused surgery, and 45 had revascularization. After a median follow-up of 59 (inter-quartile range: 33-63) months, there were 51 (37%) deaths; 25 (37%) in those assigned to the conservative strategy, and 26 (38%) in those assigned to the invasive strategy, 13 (29%) of whom had been revascularized.A conservative management strategy may not be inferior to one of coronary arteriography with the intent to revascularize in patients with heart failure, LV systolic dysfunction, and extensive myocardial viability. However, this study was underpowered and, further, larger trials are required to settle this issue. Clinical trials Registration No: ISRCTN86284615.
Pub.: 16 Dec '10, Pinned: 26 Aug '17
Abstract: We investigated the prognostic weight of several risk factors for heart failure in patients undergoing CABG. We followed 351 consecutive patients for 18+/-12 months after surgery to assess clinical outcome, presence and degree of heart failure. The risk of developing heart failure >class 2 at 1 year was investigated by logistic regression on the following preoperative variables: sex, age, left ventricular EF, QRS duration, previous MI, history of heart failure, atrial fibrillation (AF), hypertension, hypercholesterolemia, diabetes, previous stroke. Age was 70+/-8 years and EF was 54+/-12% at the time of surgery. Heart failure >class 2 occurred in 95/351 patients (27%) at follow up. Logistic regression identified QRS duration (OR=1.02), a history of stroke (OR=3.94), and diabetes (OR=1.98) as predictors of CHF at follow up. All the other variables were not risk markers for heart failure at logistic regression. Thirty five patients (10%) had QRS> or =140 ms before surgery; 51% of them had CHF at follow up compared to 24% of patients with QRS<140 ms (p<0.05). In the current surgical era, candidates to CABG (50% of patients older than 70 years) have a relevant likelihood of heart failure at follow up, despite myocardial revascularization. Risk stratification may rely upon inexpensive variables as previous stroke, diabetes, and QRS duration. A minority of patients (5%) could benefit from LV-based pacing, which should be considered at the same surgical time via an epicardial implantation.
Pub.: 07 Oct '05, Pinned: 26 Aug '17
Abstract: With a prevalence of 5.8 million in the United States alone, heart failure (HF) is associated with high morbidity, mortality, and healthcare expenditures. Close to 1 million hospitalizations for heart failure (HHF) occur annually, accounting for over 6.5 million hospital days and a substantial portion of the estimated $37.2 billion that is spent each year on HF in the United States. Although some progress has been made in reducing mortality in patients hospitalized with HF, rates of rehospitalization continue to rise, and approach 30% within 60 to 90 days of discharge. Approximately half of HHF patients have preserved or relatively preserved ejection fraction (EF). Their post-discharge event rate is similar to those with reduced EF. HF readmission is increasingly being used as a quality metric, a basis for hospital reimbursement, and an outcome measure in HF clinical trials. In order to effectively prevent HF readmissions and improve overall outcomes, it is important to have a complete and longitudinal characterization of HHF patients. This paper highlights management strategies that when properly implemented may help reduce HF rehospitalizations and include adopting a mechanistic approach to cardiac abnormalities, treating noncardiac comorbidities, increasing utilization of evidence-based therapies, and improving care transitions, monitoring, and disease management.
Pub.: 12 Dec '12, Pinned: 26 Aug '17
Abstract: Guidelines on how to diagnose and treat patients with heart failure (HF) are published regularly. However, many patients do not fulfil the diagnostic criteria and are not treated with recommended drugs. The Swedish Heart Failure Registry (S-HFR) is an instrument which may help to optimize the handling of HF patients.The S-HFR is an Internet-based registry in which participating centres (units) can record details of their HF patients directly online and transfer data from standardized forms or from computerized patient documentation. Up to December 2007, 16,117 patients from 78 units had been included in the S-HFR. Of these, 10,229 patients had been followed for at least 1 year, and 2133 deaths were recorded. Online reports from the registry showed that electrocardiograms were available for 97% of the patients. Sinus rhythm was found in 51% of patients and atrial fibrillation in 38%. Echocardiography was performed in 83% of the patients. Overall, 77% of patients were treated with angiotensin converting enzyme inhibitors or angiotensin II receptor blockers, 80% were on beta-blockers, 34% on aldosterone antagonists, and 83% on diuretics.The S-HFR is a valuable tool for improving the management of patients with HF, since it enables participating centres to focus on their own potential for improving diagnoses and medical treatment, through the online reports provided.
Pub.: 22 Dec '09, Pinned: 26 Aug '17
Abstract: The management of heart failure (HF) is complex. As a consequence, most cardiology society guidelines now state that HF care should be delivered in a multiprofessional manner. The evidence base for this approach now means that the establishment of HF management programmes is a priority. This document aims to summarize the key elements which should be involved in, as well as some more desirable features which can improve the delivery of care in a HF management programme, while bearing in mind that the specifics of the service may vary from site to site. We envisage a situation whereby all patients have access to the best possible care, including improved access to palliative care services, informed by and responsive to advances in diagnosis management and treatment. The goal should be to provide a 'seamless' system of care across primary and hospital care so that the management of every patient is optimal, no matter where they begin or continue their health-care journey.
Pub.: 17 Dec '10, Pinned: 26 Aug '17
Abstract: Coronary artery disease (CAD) is the most common cause of heart failure in Western countries. Selected patients who have low left ventricular ejection fraction (LVEF) and CAD clearly benefit from coronary revascularization with coronary artery bypass grafting (CABG). CABG results seem to be superior to percutaneous coronary intervention (PCI) in the few comparative studies of the two approaches in patients who have CAD and low LVEF completed to date. Clinical improvement should be expected in most patients who undergo CABG. This is important for patients who have a limited life span that they could spend with a good functional status rather than being hospitalized for multiple repeat PCIs or symptomatic deterioration.
Pub.: 24 Jul '07, Pinned: 26 Aug '17
Abstract: Coronary artery disease is the most common underlying cause of heart failure, yet there is little consensus on the role of revascularization in the management of patients with ischemic cardiomyopathy. The concept of recovery of dysfunctional but viable myocardium forms the pathophysiologic basis for the benefit of revascularization. Data from observational studies suggest that patients with coronary disease and left ventricular dysfunction may have improved outcomes after surgical revascularization or percutaneous coronary intervention (PCI) compared to medical treatment. Viability testing may be useful in selecting a population of patients who will receive differential benefit. In the clinical management of patients with heart failure, clinicians face challenging decisions about whether to recommend revascularization especially in patients who do not have angina. As data from randomized trials are awaited, PCI and coronary artery bypass grafting may be considered as complimentary revascularization approaches. Registry data suggest a benefit of coronary artery bypass grafting over PCI in patients with reduced ejection fraction; however, in patients with focal disease and comorbidities including previous surgery, PCI is reasonable, especially if complete revascularization is possible.
Pub.: 31 Mar '07, Pinned: 26 Aug '17
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