Drugs for heart failure are still under-prescribed, years after initial study

Credit: CC0 Public Domain

A UCLA-led study found that many people with heart failure do not receive the medications recommended for them under guidelines set by the American College of Cardiology, American Heart Association and Heart Failure Society of America.

01 aug 2018--The research also found that doctors frequently prescribe medications at doses lower than those recommended by the guidelines, especially for older people, those with kidney disease, those with worsening symptoms or those who were recently hospitalized for heart failure. Further study is needed to determine why people in those four groups specifically were prescribed lower-than-recommended doses.
The study, which looked at the three categories of heart failure medications, found that between 27 percent and 67 percent of patients were not prescribed the recommended drugs. And when patients did receive the medications, they were generally at a lower-than-recommended dose. Less than 25 percent of patients simultaneously received all three medication types, and only 1 percent received the target doses of all three medication types.
About 5.7 million people in the United States have heart failure, according to a 2016 report by the American Heart Association. Heart failure is associated with a lower quality of life and frequent hospitalizations, and it contributes to more than 300,000 deaths each year in the U.S. In half of people with heart failure, the disease is caused by a weak heart muscle that prevents the heart from ejecting a normal amount of blood with each heartbeat, a condition called reduced ejection fraction.
Several medications have been proven in large clinical trials to help people with heart failure and reduced ejection fraction live longer and feel better. Research conducted between 2007 and 2009 showed that many patients were not receiving the recommended doses of these medications. The new study sought to determine if there have been improvements in prescribing practice as well as which patients are most likely to receive less medication than recommended.
The study included 3,518 patients from 150 primary care and cardiology practices who were enrolled in the Change the Management of Patients with Heart Failure registry, or CHAMP-HF, a study of adult outpatients who were diagnosed with heart failure with reduced ejection fraction.
The results suggest that use and dosing of heart failure medications has not improved over the past decade. The report says new strategies are needed to more effectively achieve and maintain recommended doses of heart failure medications and that there is a substantial opportunity to improve dosing of heart failure medications, which would improve the care and outcomes for people with heart failure.
The study appears in the July 24 issue of the Journal of the American College of Cardiology.

More information: Stephen J. Greene et al, Medical Therapy for Heart Failure With Reduced Ejection Fraction, Journal of the American College of Cardiology (2018). DOI: 10.1016/j.jacc.2018.04.070


Provided by University of California, Los Angeles

Antidepressant does not reduce hospitalization, death for HF patients with depression

In a study appearing in the June 28 issue of JAMA, Christiane E. Angermann, M.D., of University Hospital Wurzburg, Germany, and colleagues examined whether 24 months of treatment with the antidepressant escitalopram would improve mortality, illness, and mood in patients with chronic heart failure and depression.

28 jun 2016--Previous meta-analysis indicates that depression prevalence in patients with heart failure is 10 percent to 40 percent, depending on disease severity. Depression has been shown to be an independent predictor of mortality and rehospitalization in patients with heart failure, with incidence rates increasing in parallel with depression severity. Long-term efficacy and safety of selective serotonin reuptake inhibitors (SSRIs), which are widely used to treat depression, is unknown for patients with heart failure and depression.
For this study, 372 patients with chronic heart failure with reduced ejection fraction (a measure of heart function) and depression were randomly assigned to receive escitalopram or matching placebo in addition to optimal heart failure therapy. During a median participation time of 18.4 months (n = 185) for the escitalopram group and 18.7 months (n = 187) for the placebo group, the primary outcome of death or hospitalization occurred in 116 (63 percent) patients and 119 (64 percent) patients, respectively. There was no significant improvement on a measure of depression for patients in the escitalopram group.
"These findings do not support the use of escitalopram in patients with chronic systolic heart failure and depression," the authors write.

More information: JAMA, DOI: 10.1001/jama.2016.7207


Provided by The JAMA Network Journals

Cognitive impairment predicts worse outcome in heart failure

Cognitive impairment predicts worse outcome in elderly heart failure patients, reveals research presented today at Heart Failure 2015 by Hiroshi Saito, a physiotherapist at Kameda Medical Centre in Kamogawa, Japan. Patients with cognitive impairment had a 7.5 times greater risk of call cause death and heart failure readmission.

26 may 2015--Heart failure patients with cognitive impairment may get progressively worse at adhering to medications, leading to poorer prognosis.

Heart Failure 2015 is the main annual meeting of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) and takes place 23 to 26 May in Seville, Spain.

Mr Saito said: "Systematic reviews have shown that cognitive impairment is common in patients with chronic heart failure. However, the impact of cognitive impairment on the prognosis of heart failure patients is not known. Our study investigated whether cognitive impairment independently predicted the outcome of elderly patients with heart failure."

The study retrospectively included 136 patients aged 65 years or over with heart failure who were admitted to Kameda Medical Centre. The Mini Mental State Examination (MMSE) was conducted to evaluate the presence of cognitive disorder in all patients before discharge. Patients were divided into two groups: those with cognitive disorder (score below 27 on the MMSE) and those without (score 27 or above).

Patients were 82 years old on average and 47% were men. According to the MMSE, 101 patients (74%) had cognitive disorder. After a follow up of 161 days, 33 patients (24%) were readmitted due to heart failure or died.

The researchers found that the prognosis of patients in the cognitive impairment group was significantly worse than the non-cognitive impairment group. They also showed that cognitive impairment predicted a 7.5 times greater risk of worse prognosis in elderly patients with heart failure. The risk remained even after adjusting for other prognostic factors including age, gender, body mass index, albumin, haemoglobin, brain natriuretic peptide (BNP), C-reactive protein (CRP), ejection fraction, estimated glomerular filtration rate (eGFR) and blood urea nitrogen (BUN).

Mr Saito said: "Our study shows that cognitive impairment is common in elderly patients with heart failure, occurring in three-quarters of patients. We also found that cognitive impairment is an independent predictor of worse prognosis in elderly heart failure patients, who had a 7.5 times greater risk of all cause death or heart failure readmission."

He added: "We expect that heart failure patients with cognitive impairment tend to get progressively worse at adhering to medications. It is possible that this could explain why they have a worse prognosis. Cardiologists and other medical staff should assess the cognitive status of elderly heart failure patients."

Mr Saito continued: "When cognitive status is impaired we should provide education on disease management to families to prevent heart failure readmission of their loved ones. The three major components of this are medication, nutrition, and exercise. Of these three components, medication is an especially important element. It is necessary for families to enhance medication adherence for patients who are unable to manage their medication by themselves."

He concluded: "There are no specific treatments for cognitive impairment in heart failure patients. If patients do not have shortness of breath resulting from their heart failure, we often recommend mild exercise such as walking to maintain their cognitive function. Clinicians need to be more aware of the cognitive status of their heart failure patients and families can play an important role in ensuring that patients take their medication, get some exercise and eat well."

More information: The scientific programme is available here.

Provided by European Society of Cardiology

Depression associated with five-fold increased mortality risk in heart failure patients

Moderate to severe depression is associated with a 5-fold increased risk of all cause mortality in patients with heart failure, according to research presented today at Heart Failure 2015. The results from OPERA-HF show that risk was independent of comorbidities and severity of heart failure. Patients who were not depressed had an 80% lower mortality risk.

24 may 2015--Heart Failure 2015 is the main annual meeting of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) and takes place 23 to 26 May in Seville, Spain.

Professor John Cleland, chief investigator of OPERA-HF and professor of cardiology at Imperial College London and the University of Hull, UK, said: "Patients with heart failure are at high risk of recurrent hospital admissions and death. Approximately 25% of patients admitted to hospital with heart failure are readmitted for a variety of reasons within one month. Within one year, most patients will have had one or more readmissions and almost half will have died."

He added: "OPERA-HF was designed to investigate in a more holistic fashion than previously the predictors of and reasons for readmission and death amongst patients with heart failure. This included social, mental and physical frailty, as well as comorbidities and the severity of heart failure. Depression has been reported to predict death in patients with heart failure but until now it was thought that this could be because depressed patients have more severe heart failure and more comorbidities."

OPERA-HF is an ongoing observational study enrolling patients hospitalised with heart failure. Depression was assessed using the Hospital Anxiety and Depression Scale (HADS-D) questionnaire and comorbidity was examined using the Charlson Comorbidity Index (CCI).

The results of the HADS-D questionnaire showed that 103 patients were not depressed (score 0-7), 27 had mild depression (score 8-10) and 24 had moderate to severe depression (score 11-21). Over a mean follow up of 302 days, 27 patients died.

Patients with moderate to severe depression had a 5-fold increased risk of death compared to those with no or mild depression. Moderate to severe depression remained an important predictor of all-cause mortality even after controlling for sex, age, hypertension, severity of heart failure (assessed by NT-proBNP) and comorbidities. Patients with a low HADS-D score (0-7) had an 80% lower risk of death.

Professor Cleland said: "Our results show that depression is strongly associated with death during the year following discharge from hospital after an admission for the exacerbation of heart failure; we expect that the link persists beyond one year. The association was independent of the severity of heart failure or the presence of comorbidities."

He added: "We know that depression is common in heart failure and affects 20-40% of patients. Depression is often related to loss of motivation, loss of interest in everyday activities, lower quality of life, loss of confidence, sleep disturbances and change in appetite with corresponding weight change. This could explain the association we found between depression and mortality."

Professor Cleland continued: "As doctors we are members of a caring profession and should be sympathetic to our patients' plight but I am not in favour of immediately prescribing anti-depressants. Studies suggest that they are not effective in reducing depression in patients with heart failure. Clinicians should, however, screen patients with heart failure for depression and consider referring those affected for counselling."

He concluded: "Our research clearly shows a strong association between depression and risk of death in the year after discharge from hospital. Recognition and management of depression may reduce mortality for patients with heart failure. More research is needed to find out what clinicians and patients themselves can do to manage depression. Better treatments for heart failure, co-morbidities as well as depression itself may be required."

More information: The HFA White Paper "Heart failure: preventing disease and death worldwide" is available here: www.escardio.org/static_file/E… epaper-15-May-14.pdf

Provided by European Society of Cardiology

Beta-blockers don't improve heart failure, A-fib outcomes 

06 sept 2014—Patients with heart failure and atrial fibrillation given β-blockers have no significant reduction in all-cause mortality compared to those given placebo treatment, according to research published online Sept. 2 in The Lancet. These findings were published to coincide with the annual European Society of Cardiology Congress, held from Aug. 30 to Sept. 3 in Barcelona, Spain.

Dipak Kotecha, Ph.D., from the University of Birmingham in the United Kingdom, and colleagues performed a meta-analysis of individual-patient data from 10 randomized controlled trials of the comparison of β-blockers versus placebo in heart failure.

The researchers found that, of the 18,254 patients assessed, 76 percent had sinus rhythm and 17 percent had atrial fibrillation at baseline. Over a mean follow-up of 1.5 years, the crude death rates were 16 percent (2,237 of 13,945) in patients with sinus rhythm and 21 percent (633 of 3,064) in patients with atrial fibrillation. There was a significant reduction in all-cause mortality in patients with sinus rhythm on β-blockers (hazard ratio, 0.73; 95 percent confidence interval, 0.67 to 0.80; P < 0.001), but not in patients with atrial fibrillation (hazard ratio, 0.97; 95 percent confidence interval, 0.83 to 1.14; P = 0.73), with a significant p value for interaction of baseline rhythm (P = 0.002). For all-cause mortality, β-blockers showed a lack of efficacy in all subgroups of atrial fibrillation, including age, sex, left ventricular ejection fraction, New York Heart Association class, heart rate, and baseline medical therapy.

"Based on our findings, β-blockers should not be used preferentially over other rate-control medications and not regarded as standard therapy to improve prognosis in patients with concomitant heart failure and atrial fibrillation," the authors write.

Several authors disclosed financial ties to pharmaceutical companies, including Menarini Farmaceutica Internazionale, which partially funded the study.

More information: Abstract
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Digoxin use associated with higher risk of death for patients diagnosed with heart failure

Digoxin, a drug commonly used to treat heart conditions, was associated with a 72 percent higher rate of death among adults with newly diagnosed systolic heart failure, according to a Kaiser Permanente study that appears in the current online issue of Circulation: Cardiovascular Quality and Outcomes.

22 sept 2013--Digoxin is a drug derived from digitalis, a plant that has been used for more than 200 years to treat heart failure.

"These findings suggest that the use of digoxin should be reevaluated for the treatment of systolic heart failure in contemporary clinical practice" said Alan S. Go, MD, senior author of the study and research scientist at the Kaiser Permanente Division of Research.

The results of this study contrast with the findings of a randomized trial by the Digitalis Investigation Group conducted between 1991 and 1993, which showed that digoxin did not lower mortality among therapy patients with systolic heart failure, or, a malfunction in the way the left ventricle of the heart pumps blood. Following the group's study, professional societies issued clinical guidelines endorsing the use of digoxin for patients with systolic dysfunction.

The current study was conducted among 2,891 adults within Kaiser Permanente in Northern California who had newly diagnosed systolic heart failure between 2006 and 2008 and no prior digoxin use. Eighteen percent of the participants initiated digoxin during the study period.

Researchers followed the patients through December 31, 2010, to evaluate the effectiveness and safety of digoxin therapy. They found that digoxin use was associated with higher mortality but no significant difference in the risk of heart failure hospitalization.

There were a total of 801 deaths (737 off digoxin and 64 on digoxin). After adjustment for potential confounders, digoxin use was associated with a 72 percent higher relative rate of death.

There were 1,723 hospitalizations for heart failure overall (1,596 off digoxin, 127 on digoxin). However, after adjustment for potential confounders, digoxin use was not significantly associated with hospitalization for heart failure.

"Our community-based study population is more likely to represent patients with systolic heart failure in the modern era with regard to pathogenesis and treatment patterns," Dr. Go said. "Therefore, our results may more accurately represent the outcomes expected with digoxin for patients with systolic heart failure in typical present-day practices. As with all medication, treatment, or therapy plans, care decisions should always be made by physicians and their patients working together, with the patient's particular care needs and goals in mind."

Provided by Kaiser Permanente

Physician continuity after patients leave hospital for heart failure can help survival rates

Patients with heart failure who see a physician in the first month after leaving hospital are more likely to survive than those who do not see a doctor, reports a new study in CMAJ (Canadian Medical Association Journal). The effect is slightly more pronounced in patients who see their regular physician rather than an unfamiliar physician.

20 aug 2013--In the United States and Canada, more than $20 billion is spent every year on patients who are readmitted to hospital within 30 days after discharge. Heart failure is one of the most common reasons for hospitalization and has a high risk of readmission and early death.

To determine whether continuity of care resulted in better outcomes for patients with heart failure, researchers looked at data on all adults aged 20 years and over in Alberta who were discharged after hospitalization for heart failure. Patients were elderly with various health issues and had used the health care system in the year before their hospitalization for heart failure.

"Intuitively, one might consider physician continuity important for heart-failure patients discharged from hospital, given their age, high comorbidity burdens and complex therapy regimens," writes Dr. Finlay McAlister, University of Alberta, Edmonton, with coauthors. "However, a robust evidence base and multiple guidelines with consistent messaging on key management principles have made physician continuity potentially less important."

Of the total 24 373 discharged patients, 5336 (22%) did not see a physician within the first month, 16 855 (69%) saw a familiar physician (one they had seen at least twice in the year prior) and 2182 (9%) saw an unfamiliar physician. The researchers found that patients who saw a familiar physician had a lower risk of urgent readmission and death compared with patients who saw an unfamiliar physician or who did not visit a doctor.

"Early follow-up was associated with a lower risk of death or urgent readmission over 6 months, compared with no visits in the first month after discharge, regardless of whether the follow-up was with familiar or unfamiliar physicians. However, when we examined follow-up patterns throughout the 6 months after discharge, continuity with a familiar physician was associated with a significantly lower risk of death or readmission than follow-up with an unfamiliar physician, with similar effect estimates for specialist and nonspecialist follow-up," the authors write.

"The absolute reduction of 3% to 8% in risk of death or urgent readmission … observed over 3–12 months in association with follow-up in the first month after discharge was in the same range as the absolute benefits seen in placebo-controlled randomized trials of angiotensin-converting-enzyme inhibitor or b-blocker therapy. …Thus, we believe that physicians should strive to optimize continuity with their heart-failure patients after discharge and that strategies are needed in the health care system to ensure early follow-up after discharge with the patient's regular physician," the authors conclude.

More information: Paper: www.cmaj.ca/lookup/doi/10.1503/cmaj.130048

Provided by Canadian Medical Association Journal

Exercise protects against heart failure even at advanced ages 

Among older adults, physical activity may protect against heart failure, as indicated by lower levels of N-terminal pro-B-type natriuretic peptide and cardiac troponin T, according to a study published online Nov. 14 in the Journal of the American College of Cardiology.

18 nov 2012—Among older adults, physical activity may protect against heart failure, as indicated by lower levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and cardiac troponin T (cTnT), according to a study published online Nov. 14 in the Journal of the American College of Cardiology.

Christopher R. deFilippi, M.D., of the University of Maryland School of Medicine in Baltimore, and colleagues measured levels of NT-proBNP and cTnT at baseline and after two to three years in 2,933 community-dwelling adults aged 65 and older who were free of heart failure. The authors sought to assess the association between physical activity and changes in levels of these markers and the subsequent risk of heart failure.

The researchers identified an inverse correlation between biomarker concentration at baseline and follow-up visits and physical activity score. After adjustment for comorbidities and baseline levels, participants with the highest score were 50 percent less likely to have an increase in NT-proBNP and 70 percent less likely to have an increase in cTNT levels compared to those with the lowest physical activity scores. Overall, an increase in either biomarker indicated a higher risk of heart failure, and higher physical activity scores were associated with a lower long-term incidence of heart failure.

"Our findings raise the possibility that the trajectory of biomarker change and the subsequent heart failure risk associated with increasing levels may be modifiable by changes in lifestyle even at an advanced age," the authors write.

Several authors disclosed financial ties to Roche Diagnostics and Abbott.

More information: Abstract
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Diastolic dysfunction appears to worsen over time; associated with increased risk of heart failure

A follow-up of participants in a heart function study finds that the prevalence of left ventricular diastolic dysfunction (left ventricular filling [with blood] is abnormal and is accompanied by elevated filling pressures) had increased; that diastolic function had worsened in a nearly a quarter of patients; and that participants who had diastolic dysfunction were more likely to develop heart failure, according to a study in the August 24/31 issue of JAMA.

05 sept 2011--"There is an emerging emphasis on understanding the progression from heart failure risk factors to asymptomatic ventricular dysfunction and eventually to symptomatic heart failure and death. Therefore, it is important to have population-based information on changes in cardiac function over time," according to background information in the article. "… little is known about time-dependent changes in diastolic function or their relationship to clinical heart failure."

Garvan C. Kane, M.D., Ph.D., of the Mayo Clinic and Medical School, Rochester, Minn., and colleagues conducted a study to measure changes in diastolic function over time and to determine the relationship between diastolic dysfunction and the risk of subsequent heart failure. The study included participants enrolled in the Olmsted County Heart Function Study (OCHFS). Randomly selected participants 45 years or older (n = 2,042) underwent clinical evaluation, medical record abstraction, and echocardiography (examination 1 [1997-2000]). Diastolic left ventricular function was graded as normal, mild, moderate, or severe via testing. After 4 years, participants were invited to return for examination 2 (2001-2004). The group of participants returning for examination 2 (n = 1,402 of 1,960 surviving [72 percent]) then underwent follow-up testing for determination of new-onset heart failure (2004-2010).

The researchers found that from examination 1 to examination 2, the prevalence of diastolic dysfunction of any degree increased from 23.8 percent to 39.2 percent. Moderate or severe diastolic dysfunction increased from 6.4 percent to 16.0 percent. Over 4 years, 23.4 percent of participants experienced worsening of diastolic function, 67.8 percent remained unchanged, and 8.8 percent experienced improved diastolic function. Age was predictive of the development of diastolic dysfunction, especially ages 65 years or older.

In the analysis of the diastolic function of healthy participants (without hypertension, diabetes, coronary artery disease, heart failure, or use of cardiovascular medications), incidence of diastolic dysfunction of any degree increased from 11.3 percent at examination 1 to 29.8 percent at examination 2. Among 423 healthy participants, 19.9 percent showed worsening diastolic function, 75.2 percent remained the same, and 5.0 percent improved.

During 6.3 years of additional follow-up, 81 participants developed heart failure. Age 65 years or older was the strongest predictor of heart failure. The authors found that persistent or worsening diastolic dysfunction was associated with heart failure. "Cumulative heart failure incidence was 2.6 percent in participants whose diastolic function remained normal or normalized between examinations; 7.8 percent in those with persistent, or progression to mild diastolic dysfunction; and 12.2 percent in those with persistent, or progression to moderate or severe diastolic dysfunction."

"Longitudinal evaluation of participants in the population-based OCHFS cohort reveals that left ventricular diastolic dysfunction is highly prevalent, tends to worsen over time, and is associated with advancing age. Worsening diastolic function can be detected even in apparently healthy persons. Although confirmation in other studies would be helpful, our data suggest that persistence or progression of diastolic dysfunction is a risk factor for heart failure in elderly persons," the researchers conclude.

More information: JAMA. 2011;306[8]:856-863.

Weakness in aging tied to leaky muscles

There is a reason exercise becomes more difficult with age. A report in the August Cell Metabolism, a Cell Press publication, ties the weakness of aging to leaky calcium channels inside muscle cells. But there is some good news: the researchers say a drug already in Phase II clinical trials for the treatment of heart failure might plug those leaks.

08 aug 2011--Earlier studies by the research team led by Andrew Marks of Columbia University showed the same leaks underlie the weakness and fatigue that come with heart failure and Duchenne muscular dystrophy.

"It's interesting, normal people essentially acquire a form of muscular dystrophy with age," Marks said. "The basis for muscle weakness is the same." Extreme exercise like that done by marathon runners also springs the same sort of leaks, he added, but in that case damaged muscles return to normal after a few days of rest.

The leaks occur in a calcium release channel called ryanodine receptor 1 (RyR1) that is required for muscles to contract. Under conditions of stress, those channels are chemically modified and lose a stabilizing subunit known as calstabin1.

"Calstabin1 is like the spring on a screen door," Marks explained. "It keeps the door from flopping open in the breeze."

Calcium inside of muscle cells is usually kept contained. When it is allowed to leak out into the cell that calcium itself is toxic, turning on an enzyme that chews up muscle cells. Once the leak starts, it's a vicious cycle. The calcium leak raises levels of damaging reactive oxygen species, which oxidize RyR1 and worsen the leak.

The researchers made their discovery by studying the skeletal muscles of young and old mice. They also showed that 6-month-old mice carrying a mutation that made their RyR1 channels leaky showed the same muscular defects and weakness characteristic of older mice.

When older mice were treated with a drug known as S107, the calcium leak in their muscles slowed and the animals voluntarily showed about a 50 percent increase in the amount of time spent wheel running. Now in clinical trials for patients with heart failure, the drug is known to work by restoring the connection between costabilin and RyR1.

Despite considerable effort to understand and reverse age-related muscle wasting, there are no established treatments available. The new work suggests there may be hope in approaching the problem from a different angle.

"Most research has focused on making more muscle mass," Marks said. "What's different here is that we are focused not on muscle mass but on muscle function. More muscle doesn't help if it is not functional."

Provided by Cell Press

Biomarker may be able to help predict risk of heart failure, cardiovascular death

Certain measures of the blood biomarker cardiac troponin T (cTnT), a cardiac-specific protein, using a highly sensitive test, are associated with the development of heart failure or cardiovascular death in older adults, according to a study that will appear in the December 8 issue of JAMA. The study is being released early online because it will be presented at the American Heart Association's annual meeting.

18 nov 2010--"Older adults comprise the majority of new-onset heart failure (HF) diagnoses, but traditional risk-factor prediction models have limited accuracy in this population to identify those at highest risk for hospitalization or death," according to background information in the article. Blood-based biomarkers, including troponins, have been advocated for use as supplemental to clinical risk factors to identify older adults at high risk for adverse cardiovascular outcomes, but studies examining the prognostic value of these markers have reported inconsistent results.

Prior studies have used standard troponin assays that are only able to detect circulating troponin levels in a small proportion of individuals. Recently, a highly sensitive cardiac troponin T assay has been developed, designed to improve accuracy. "This assay has detected circulating cTnT in almost all patients with chronic HF or ischemic heart disease and provides independent prognostic information with respect to HF admission and cardiovascular death in these patients," the authors write.

Christopher R. deFilippi, M.D., of the University of Maryland School of Medicine, Baltimore, and colleagues examined the ability to detect a measurable cTnT concentration in older adults using the highly sensitive cTnT assay and whether higher concentrations would be associated with a greater risk of new-onset HF and cardiovascular death. The researchers analyzed data from the Cardiovascular Health study and included 4,221 community-dwelling adults ages 65 years or older without prior HF who had cTnT measured using the highly sensitive assay at the beginning of the study (1989-1990) and repeated after 2 to 3 years (n = 2,918). Concentrations of cTnT were equal to or more than the limit of detection in 2,794 participants (66.2 percent).

During a median (midpoint) follow-up of 11.8 years from the initial cTnT measurement, 1,279 participants experienced new-onset HF and 1,103 cardiovascular deaths occurred, with a greater risk of both end points associated with higher cTnT concentrations. Also, the risks of HF and cardiovascular death were higher among those participants with detectable compared with undetectable levels at follow-up, irrespective of the baseline level.

Analysis indicated that for participants with measurable cTnT levels at the beginning of the study, an increase of more than 50 percent was associated with an increased risk of HF and a greater risk of cardiovascular death, adjusting for baseline cTnT and risk factors. In contrast, a decrease of more than 50 percent was associated with a risk-factor adjusted lower risk of HF and lower risk of cardiovascular death compared with those participants with 50 percent or less change.

For the prediction of both outcomes, the addition of baseline cTnT measurements to clinical risk factor models only modestly but statistically significantly improved classification.

"Detectable cTnT levels as measured by a highly sensitive assay were present in the majority of community-dwelling older adults in this cohort, and higher concentrations—within a normal range established for a younger general population—reflect a greater burden of cardiovascular risk factors and imaging evidence of cardiac disease. Independent of these comorbidities, cTnT concentrations were associated with risk of new-onset HF and cardiovascular death. Furthermore, longitudinal changes in cTnT concentrations were common in this cohort and correspond with a dynamic change in risk levels over time," the authors conclude.

More information: JAMA. 2010;304[22]:doi:10.1001/jama.2010.1708

Provided by JAMA and Archives Journals

Synchronizing a failing heart

November 14, 2010 – One of the largest, most extensive worldwide investigations into heart failure, led by the University of Ottawa Heart Institute (UOHI), conclusively proves that a new therapeutic implant synchronizes and strengthens a fading heart beat while reducing risk of death by 24% compared to the current treatment.

15 nov 2010--The research, co-led by Dr. Anthony Tang and Dr. George Wells at the Heart Institute, brings the promise of life-saving treatment for patients with symptoms of mild to moderate heart failure – an increasingly common condition among an aging population that can lead to sudden cardiac death. Each year, more than 500,000 Canadians and five million Americans suffer heart failure.

"This kind of device brings the potential to save thousands of lives in Canada alone and offers new hope to so many heart patients and their families. Helping the lower chambers of the heart beat strongly and in unison can improve a person's quality of life, keep them out of hospital longer and reduce their risk of sudden death," said Dr. Tang.

Results of the clinical trial, which got under way in 2003, were published online today in the prestigious New England Journal of Medicine and coincided with the release of the Heart Institute analysis at the Scientific Sessions of the American Heart Association in Chicago. The research represents one of the largest international medical device trials undertaken in 2003, comprising 1,798 patients in 24 centres in Canada, Australia, Europe and Turkey.

The Ottawa team consisted largely of top electrophysiologists – cardiologists specializing in surgical procedures to regulate a faulty heart rhythm. Heart failure patients were implanted with either a basic miniature defibrillator (ICD) or with a new device carrying insulated wires called leads to transmit signals and electrical impulses to the heart in an effort to stimulate and coordinate the heart to be beating in-sync. This therapy is called cardiac resynchronization therapy (CRT).

The study, which followed patients for an average of 40 months, showed that patients with CRT live longer with a reduction of the rate of death. In addition, patients with CRT were less likely to be admitted to hospital for worsening of heart failure.

Until now, no research had been undertaken to examine the specific benefits and survival rates in heart failure patients who have been implanted with a CRT along with an ICD.

"This trial represents a tremendous research success for cardiovascular scientists and demonstrates the importance of clinical evaluative research," said Dr. Alain Beaudet, President of the Canadian Institutes of Health Research, which co-funded the research. "We congratulate the Heart Institute for its efforts, which will lead to better health outcomes and longer lives for heart patients."

"Medtronic recognizes the expertise of Canadian electrophysiologists and congratulates them for their leadership in participating and leading this key clinical trial to investigate the benefits of cardiac device therapy in heart failure patients," said Neil Fraser, President of Medtronic of Canada Ltd., which also co-funded the research. "This trial demonstrates that a broader population of heart failure patients could benefit from our therapies, including those with mild symptoms, and they should receive them."

Provided by University of Ottawa Heart Institute

Moderate Chocolate Intake Tied to Lower Heart Failure Risk

However, protective association not observed with intake of one or more servings daily

22 aug 2010-- Regular, moderate chocolate consumption is linked to a lower rate of heart failure hospitalization or death, but no protective association is seen in individuals consuming one or more servings of chocolate daily, according to a study published online Aug. 16 in Circulation: Heart Failure.

In a prospective cohort study, Elizabeth Mostofsky, of Harvard Medical School in Boston, and colleagues followed 31,823 women, aged 48 to 83 years, without baseline diabetes or a history of heart failure or myocardial infarction from Jan. 1, 1998, through Dec. 31, 2006.

During nine years of follow-up, the investigators found that 419 women were hospitalized for incident heart failure (379) or died of heart failure (40). The multivariate adjusted rate ratio of heart failure was 0.74 for those consuming one to three servings of chocolate per month, 0.68 for those consuming one to two servings per week, 1.09 for those consuming three to six servings per week, and 1.23 for those consuming one or more servings per day, compared to those not regularly consuming chocolate.

"Further studies are needed to confirm or refute these findings and to determine the optimal dose and type of chocolate and to clarify the mechanisms involved," the authors write.

Abstract
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Older Unsupported Women More Likely To Have Heart Failure With Preserved Systolic Function

10 jan 2010--Older women who have less social support and live in nursing homes are more likely to have heart failure with preserved systolic function than those who are married or living in their own home, according to the results of research published in the Medical Journal of Australia.

Dr Sepehr Shakib, from the Royal Adelaide Hospital, and his co-authors, including cardiologists Dr Dennis Wong and Dr Ben Dundon with social epidemiologist Dr Robyn Clark from the Samson Institute, University of South Australia, undertook a retrospective analysis of clinical data for 2961 patients admitted with chronic heart failure over a period of 10 years.

The authors found patients who had heart failure with preserved systolic function (HFPSF) were predominantly older women with less social support and a greater burden of comorbid conditions such as renal impairment, anaemia and atrial fibrillation compared with those with left ventricular systolic dysfunction.

There was also an increase in the risk of re-hospitalisation among patients with HFPSF. Dr Shakib said lack of social and carer support and a greater burden of comorbid conditions in patients with HFPSF may have played a significant predisposing role in hospitalisation and readmissions. "Our study is the first to identify significant differences in the social environment of these patients," Dr Shakib said.

"We propose that the burden of reduced survival in HFPSF may relate more to comorbid conditions than suboptimal cardiac management."

In an accompanying editorial in the MJA, Prof Peter MacDonald, Conjoint Professor of Medicine at the University of New South Wales, writes that there is an urgent need to gain a better understanding of the pathogenesis of HFPSF in order to identify additional preventive and treatment approaches. Prof MacDonald said this would be particularly challenging in a population exposed to multiple comorbid conditions, increasing physical frailty and social isolation.

"Optimal management of these patients will require a multidisciplinary approach with the general practitioner taking the central role," he said.

Source
Medical Journal of Australia

Medication Reviews Can Keep Hospitalization Rates Down

Australian veterans with heart failure benefit from physician/pharmacist collaborations

28 aug 2009-- Collaborative medicine reviews for patients treated with heart failure medicines are effective in delaying the time to next hospitalization for heart failure, according to a study published online Aug. 19 in Circulation: Heart Failure.

Elizabeth E. Roughead, Ph.D., of the University of South Australia in Adelaide, and colleagues used administrative claims data to study veterans in Australia aged 65 years and older taking bisoprolol, carvedilol or metoprolol succinate for heart failure. There were 273 patients exposed to home medicine reviews (consisting of a physician referral, a home visit by a pharmacist, and a pharmacist report with follow-up by the physician) and 5,444 unexposed patients.

The researchers found that the median number of comorbidities was eight in the exposed group and seven in the unexposed group. Adjusted results showed a 45 percent reduction in the rate of hospitalization for heart failure at any time (hazard ratio, 0.55) in patients who had received the home medicine review versus those who had not. They found that 5.5 percent of the exposed group and 12 percent of the unexposed group were hospitalized within one year.

"If the findings of this study are replicated in other patient groups who are at high risk of medication misadventure and consequent re-hospitalization, there will be an even stronger case to require pharmacists to be involved in this extension of their role in collaboration with physicians," the authors conclude.

Abstract
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4 risk factors raise probability of developing precursor of heart failure

Four well-known risk factors for heart attack significantly increased the size of the heart's left ventricle, a key precursor of heart failure, according to a study in Circulation: Journal of the American Heart Association.

11 june 2009--High blood pressure, excessive weight, smoking and diabetes were strongly correlated with greater size of the heart's left ventricle over the short term (four years) and the long term (16 years) in a study of more than 4,217 people.

"Left ventricular mass has been associated in multiple studies with risk of cardiovascular disease, including risk of developing heart failure. We identified four risk factors that promote greater cardiac mass over the adult life course. These factors can be directly targeted for prevention and lowering these risk factors, therefore, could potentially lower the burden of heart failure." said Ramachandran S. Vasan, M.D., the study's senior author, a senior investigator at the Framingham Heart Study, and professor of medicine and the chief of the section of Preventive Medicine at Boston University School of Medicine.

Researchers assessed the effect of risk factors on left ventricular (LV) mass by analyzing longitudinal data from the Framingham (Mass.) Offspring Study. The participants averaged 45 years of age at study entry. Fifty-three percent were women. The Framingham Offspring Study enrolled children of participants of the original Framingham Heart Study, which began in 1948.

Researchers used data obtained at an initial exam in the 1970s and data from follow-up exams conducted at four-year intervals through the late 1990s, and evaluated short-term associations of LV mass using data from 2,605 of the participants.

Study members were divided into three groups: low, intermediate and high numbers of risk factors. High blood pressure, excessive weight, smoking and diabetes strongly correlated with greater left ventricular mass; age, and gender were also associated with heart muscle thickening, researchers said.

"People with fewer risk factors had almost no increase in LV mass with age," Vasan said. "People who had more risk factors had a steeper increase in LV mass with age."

Other findings included:

• In the 16-year risk analysis, women showed a greater and steeper rate of LV mass increase as they aged compared to men, something not found in the short-term analysis.
• People with diabetes — particularly women — had a steep increase in muscle thickening over time, even after adjusting for other risk factors.

In a second Circulation article, Vasan, Pencina and others describe a simple "calculator" they devised to predict an adult's 30-year risk of dying due to a coronary or cerebrovascular event or suffering a non-fatal heart attack or stroke.

Researchers analyzed data from 4,506 Framingham Offspring Study members (51.8 percent women, average age 36) at enrollment for "hard" cardiovascular disease (CVD) events — coronary death, heart attack, and fatal and nonfatal strokes. All participants were free of heart disease and cancer at the time of their first examination (1971�). Median follow-up was 32 years. Among the findings:

• Women — free of CVD at baseline — on average had a 7.6 percent 30-year risk of suffering a hard CVD event, after researchers adjusted for other causes of deaths, such as cancer and accidents.
• Men — free of CVD at baseline — on average had an 18.3 percent 30-year risk of such a CVD event after adjustment.
• Standard risk factors, including high blood pressure, cholesterol levels, smoking and diabetes, significantly increased an individual's long-term CVD risk.
• Excessive weight, as measured by body mass index was a statistically non-significant predictor of CVD events in the short-term observation period, but became significant over 30 years.
• Thirty-year risk estimates, made by extrapolating existing 10-year cardiovascular risk models, proved inadequate predictors of long-term risk.

The interactive calculator "will enable physicians to enter patient data and obtain the 30-year risk estimates for their patients," said Michael J. Pencina, Ph.D, the study's first author and an associate professor of biostatistics at Boston University. "My hope would be that we can increase awareness of cardiovascular risk in younger people, who may have lower 10-year risks but higher 30-year risks, and encourage them to take steps to maintain optimal levels of their risk factors."

For example, a 25-year-old woman who smokes and has hypertension and high-risk cholesterol levels has a 1.4 percent risk of suffering a hard CVD event by age 35 (10 years of follow-up), but her risk is 12 percent by age 55 (over a 30-year period).

###

Other co-authors of the first paper are Wolfgang Lieb, M.D.; Vanessa Xanthakis, M.S.; Lisa M. Sullivan, Ph.D.; Jayashri Aragam, M.D.; and Emelia J. Benjamin, M.D. Other co-authors of the second paper are Ralph B. D'Agostino Sr., Ph.D. and Joseph M. Massaro, Ph.D. Martin G. Larson, Sc.D, is a co-author on both papers. Author disclosures are on the manuscripts.

The National Heart, Lung, and Blood Institute funded both studies.

Depression raises heart failure risks: study

CHICAGO, 15 april 2009 - Heart patients who become depressed have a higher risk of developing heart failure, regardless of whether they take antidepressants, U.S. researchers said on Monday.

They said the study is the first to look at whether depression raises the risk for heart failure, a chronic condition affecting 5 million Americans in which the heart gradually loses its ability to pump blood efficiently.

"Our data suggest that depression is an important and emerging risk factor for heart failure among patients with coronary heart disease," Heidi May of Intermountain Medical Center in Utah, whose study appears in the Journal of the American College of Cardiology, said in a statement.

Prior studies have shown that depression is about three times more common after a heart attack and depressed patients are at higher risk of a second heart attack.

May wanted to see if heart disease and depression had an effect on heart failure, which strikes more than 550,000 people in the United States each year at an annual cost of about $35 billion a year, according to the American Heart Association.

The researchers studied nearly 14,000 people with clogged heart arteries. None of them had heart failure or depression at the time of their diagnosis. Patients were tracked until they developed heart failure or died.

When they checked heart failure rates among the 1,377 people who eventually developed depression, the researchers found much higher rates than among those who were not depressed.

The heart failure rate was 3.6 percent per 100 people among those who did not develop depression, but it was 16.4 percent in the group that did. While many of the patients took antidepressants, this did nothing to reduce heart failure risks.

"This finding may indicate that antidepressants may not be able to alter the physical or behavioral risks associated with depression and heart failure, despite a potential improvement in depressive symptoms," May said.

Studies have shown that depressed heart patients are more likely than others to stop taking their heart medications and are less likely to stay on heart-healthy diets or get regular exercise.

Depression can also bring about changes in the body, including reduced heart rate and increases in blood factors that encourage the formation of blood clots.

May said the findings suggest that although symptoms of depression may improve, the heart risks related to depression might not.

Body Fat, Heart Failure Association Declines With Age

In middle-aged and older Swedes, body mass index, waist circumference linked to events

10 april 2009-- Overall and abdominal fat were linked to hospitalization or death due to heart failure in middle aged and older individuals, though the association lessened with age, according to research published online April 7 in Circulation: Heart Failure.

Emily Levitan, of the Beth Israel Deaconess Medical Center in Boston, and colleagues analyzed data from 80,360 middle-aged to elderly Swedish men and women. Subjects were free from heart failure at baseline, and were followed for a median seven years.

The researchers report that body mass index, waist circumference, waist-hip ratio and waist-height ratio were associated with heart failure mortality or hospitalization, with waist-hip ratio having the weakest association. Overall and abdominal adiposity appeared to be linked to heart failure events in men, the investigators found. For women and men, the association between adiposity and heart failure events seemed to diminish with age.

"In addition to the adverse effects of obesity on established cardiovascular risk factors such as blood lipids, blood pressure and diabetes, obesity is linked to increased blood volume, increased cardiac work load, diastolic dysfunction, hypertrophy and dilation of the left ventricle, and fat deposits in the heart which may lead to heart failure. Increased aortic stiffness, another precursor of heart failure, has been consistently associated with obesity in adults, particularly those with high levels of abdominal adiposity," the authors write.

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Electrode Placement Affects Heart Failure Monitoring

Monitoring more effective if leads are placed on the left side

22 mar 2009-- Monitoring of heart failure patients is more effective if electrodes are placed on the left side rather than the more commonly used right side, according to a study published in the March 24 issue of the Journal of the American College of Cardiology.

Noting that most monitoring of congestive heart failure relies on right-side heart sensors, Dirar S. Khoury, Ph.D., from Methodist Hospital Research Institute in Houston and colleagues implanted cardiac resynchronization therapy systems using standard leads in various configurations in 15 normal dogs, where five were implanted with an additional left atrial pressure lead sensor. They then measured steady-state impedance signals along six different vectors during induction of congestive heart failure over several weeks.

The researchers found that during induction of heart failure, impedance fell gradually at different rates for different vectors. Left ventricle-dependent vectors were superior to vectors solely dependent on right-sided cardiac measurements, having a greater reduction in magnitude, a better correlation with left ventricle end-diastolic volume, and a stronger association with left atrial pressure.

"Impedance vectors employing a left ventricle lead are highly responsive to physiologic changes during congestive heart failure," Khoury and colleagues conclude. "Measuring multiple impedance signals could be useful for optimizing ambulatory monitoring in heart failure patients."

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Some Elderly Heart Failure Patients Get Little Help From Meds, Study Finds

By Steven Reinberg

13 mar 2009-- Elderly people suffering from a type of heart disease called diastolic heart failure do not seem to benefit from the commonly prescribed heart failure drugs, researchers from Cedars-Sinai Medical Center in Los Angeles report.

As the population in the United States ages, more elderly people are being treated for heart failure. But even though they make up the majority of those treated for the disease, little is known about the effectiveness of treatment, researchers say.

"We really don't have many data on heart failure patients above the age of 80," said lead researcher Dr. Ernst R. Schwarz, medical director of the Cardiac Support Program and co-director of the Heart Transplant Program at the Cedars-Sinai Heart Institute.

In their study, the researchers looked at elderly people with diastolic dysfunction. In this condition, the systolic function of the heart is normal. "That means their pump function is normal, but their relaxation is impaired," Schwarz explained.

Diastolic dysfunction is common, affecting 50 percent of all heart failure patients, Schwarz said. It is highly prevalent among the elderly and among women, but often it is not diagnosed and not effectively treated, he said.

"We really don't know how to treat these patients because the guidelines from the American Heart Association and the American College of Cardiology are based on systolic heart failure," Schwarz said. "We do not have dedicated guidelines on the treatment of diastolic heart failure."

The report is published in the March 15 issue of the American Journal of Cardiology.

For the study, Schwarz's team studied 142 people with heart failure, who averaged 87 years old. During five years of follow-up, 69 percent of them died.

The researchers found that none of the usually prescribed drugs -- including statins, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, beta blockers, diuretics, calcium channel blockers, nitrates and digoxin -- seemed to make any significant difference in who survived and who died.

"At least for patients above the age of 80 with diastolic heart failure, whether they are treated or not with these kind of medications does not affect their mortality or their long-term outcome," Schwarz said.

Dr. Byron Lee, a cardiologist and assistant professor of medicine at the University of California, San Francisco, appeared skeptical of the findings.

"I would be very cautious when drawing conclusions from this study," Lee said. "This is not a randomized, controlled study. The patients on the cardiovascular drugs might have been much sicker than the comparison group. Therefore, the drugs may have actually had a big impact -- keeping the sicker patients alive as long as the ones not on heart medications."

Schwarz, however, speculated that lower doses of the drugs might be appropriate for people with diastolic heart failure. In any case, he said, more research is needed, as are better treatment guidelines.

"We really don't have a clue how to treat them and how to treat them better," Schwarz said. "We are at the beginning of a learning curve to try to understand the changes in the elderly organism, which might require more caution with certain drugs, more dose adjustments. We need too look at the very elderly patient in a different way."

Dr. Gregg C. Fonarow, a professor of cardiology at the University of California, Los Angeles, said that better treatments need to be found for people suffering from diastolic heart failure.

"Patients who have heart failure with preserved systolic function represent half of the 5 million patients with heart failure in the United States," Fonarow said. "These patients face substantial risk for morbidity and mortality."

Although a number of cardiovascular medications reduce mortality in people with heart failure and reduced systolic function, no medical therapy has yet shown, in randomized clinical trials, to reduce risk in people with diastolic heart failure, Fonarow said.

"There is a critical need for more research and clinical trials to identify therapies which will be effective in patients with heart failure and preserved systolic function," he said.