Primary care heart failure service identifies a missed cohort of heart failure patients with reduced ejection fraction.

AIMS: We explored whether a missed cohort of patients in the community with heart failure (HF) and left ventricular systolic dysfunction (LVSD) could be identified and receive treatment optimization through a primary care heart failure (PCHF) service. METHODS AND RESULTS: PCHF is a partnership between Inspira Health, National Health Service Cardiologists and Medtronic. The PCHF service uses retrospective clinical audit to identify patients requiring a prospective face-to-face consultation with a consultant cardiologist for clinical review of their HF management within primary care. The service is delivered via five phases: (i) system interrogation of general practitioner (GP) systems; (ii) clinical audit of medical records; (iii) patient invitation; (iv) consultant reviews; and (v) follow-up. A total of 78 GP practices (864 194 population) have participated. In total, 19 393 patients' records were audited. HF register was 9668 (prevalence 1.1%) with 6162 patients coded with LVSD (prevalence 0.7%). HF case finder identified 9725 additional patients to be audited of whom 2916 patients required LVSD codes adding to the patient medical record (47% increase in LVSD). Prevalence of HF with LVSD increased from 0.7% to 1.05%. A total of 662 patients were invited for consultant cardiologist review at their local GP practice. The service found that within primary care, 27% of HF patients identified for a cardiologist consultation were eligible for complex device therapy, 45% required medicines optimization, and 47% of patients audited required diagnosis codes adding to their GP record. CONCLUSION: A PCHF service can identify a missed cohort of patients with HF and LVSD, enabling the optimization of prognostic medication and an increase in device prescription.

The renin-angiotensin-aldosterone system in heart failure for the non-specialist: the past, the present and the future.

Heart failure is one of the major public health challenges facing the Western world. Its prevalence is increasing as the population ages and modern techniques are implemented to manage cardiac disease. In response, there has been a sustained effort to develop novel strategies to address the high levels of associated morbidity and mortality. Indeed, agents that target the renin-angiotensin-aldosterone system (RAAS) have transformed the way in which we manage heart failure. Despite this, mortality in heart failure is poorer than in many malignancies and a large burden of morbidity and recurrent hospitalisation remains. Here, we review the role of RAAS modulation within the field of systolic heart failure. In particular, we provide practical guidance on using current RAAS blockade agents and focus on the recent emergence of new agents that promise additional substantial benefit to those living with left ventricular systolic dysfunction.

The transfemoral approach for cardiac resynchronization therapy.

Cardiac resynchronization (CRT) is a well-established treatment for heart failure and standard superior implantation has a high success rate with acceptable risk profile. When the superior approach is not feasible, surgical epicardial leads are considered. We present a case of transfemoral CRT as a viable alternative to surgical systems and discuss implant factors including lead choice and deep vein thrombosis.

The exercise pressor response to indoor rock climbing.

This paper assessed the blood pressure, heart rate, and mouth-pressure responses to indoor rock climbing (bouldering) and associated training exercises. Six well-trained male rock climbers (mean ± SD age, 27.7 ± 4.7 yr; stature, 177.7 ± 7.3 cm; mass, 69.8 ± 12.1 kg) completed two boulder problems (6b and 7a+ on the Fontainebleau Scale) and three typical training exercises [maximum voluntary contraction (MVC) isometric pull-up, 80% MVC pull-ups to fatigue, and campus board to fatigue]. Blood pressure and heart rate were measured via an indwelling femoral arterial catheter, and mouth pressure via a mouthpiece manometer. Bouldering evoked a peak systolic pressure of 200 ± 17 mmHg (44 ± 21% increase from baseline), diastolic pressure of 142 ± 26 mmHg (70 ± 32% increase), mean arterial pressure of 163 ± 18 mmHg (56 ± 25% increase), and heart rate of 176 ± 22 beats/min (76 ± 35% increase). The highest systolic pressure was observed during the campus board exercise (218 ± 33 mmHg), although individual values as high as 273/189 mmHg were recorded. Peak mouth pressure during climbing was 31 ± 46 mmHg, and this increased independently of climb difficulty. We concluded that indoor rock climbing and associated exercises evoke a substantial pressor response resulting in high blood pressures that may exceed those observed during other upper-limb resistance exercises. These findings may inform risk stratification for climbers.NEW & NOTEWORTHY This case study provides original data on the exercise pressor response to indoor rock climbing and associated training exercises through the use of an indwelling femoral arterial catheter. Our subjects exhibited systolic/diastolic blood pressures that exceeded values often reported during upper-limb resistance exercise. Our data extend the understanding of the cardiovascular stress associated with indoor rock climbing.

Current issues in thromboprophylaxis in the elderly.

The elderly are at particularly high risk for arterial and venous thromboembolism, both of which are associated with significant morbidity and mortality in this age group. However, this age group often receives inadequate thromboprophylaxis because of concerns about bleeding risk, which is often over-estimated, denying patients the benefit of proven antithrombotic regimens. Guidelines advocate active and comprehensive thromboprophylactic strategies across all age groups and recent studies have addressed age considerations in both arterial and venous embolic disorders. Pharmacological thromboprophylaxis has repeatedly been shown to have a favourable risk-benefit profile, including in elderly populations. The benefits of thromboprophylaxis have long been recognized in surgical patients and recent studies have confirmed the safety and efficacy of thromboprophylaxis in medical patients, with most trials having included elderly cohorts. Given the difficulties and inconvenience associated with use of current anticoagulants, new drugs are under development and whilst some have been associated with significant adverse effects, others have demonstrated low bleeding risks without the need for coagulation monitoring. Meanwhile, other new agents currently on the market, such as fondaparinux sodium, have gained license for use in orthopaedic and general surgery patients, although clinical experience with these agents in elderly populations is limited. This article discusses the latest developments and current opinions regarding thromboprophylaxis, with particular emphasis on its relevance to the elderly population.

Clinical characteristics and survival in cardiogenic shock admissions to a UK heart transplant unit.

AIM: We describe the characteristics and outcomes of cardiogenic shock (CS) admissions to a UK transplant unit, which is previously unreported. PATIENTS & METHODS: Fifty-nine unselected, consecutive patients over a 38-month period in CS (INTERMACS ≤2) and potentially eligible for transplant were retrospectively reviewed. RESULTS: Patients were predominantly male (76.3%), young (mean age 42.2 years) and with severe end-organ dysfunction (acute liver/kidney injury 83%, mean lactate 3.5 mmol/l). 57.6% required mechanical support and 28.8% cardiac transplant. 30 days, discharge and 1-year survival were 78, 68 and 63%, respectively. Predictors of death included no transplant, increasing age and increasing creatinine. CONCLUSION: Patients with CS and potential for transplant require significant resource input but demonstrate favorable outcomes in our experience.

Prolonged asystole in a patient with an isolated left ventricular assist device.

Left ventricular assist devices (LVADs) are well established in the management of end-stage heart failure as either destination therapy, a bridge prior to cardiac transplantation or during myocardial recovery. Despite LVADs requiring adequate left ventricular preload to effectively augment systemic circulation, there have been rare cases of patients with LVADs surviving sustained, normally fatal arrhythmias, such as ventricular fibrillation and asystole. Whilst current reports describe an LVAD patient surviving 15 days with such an arrhythmia, we describe the case of a patient with an LVAD surviving 104 days of asystole via a Fontan mechanism of circulation, which we believe is the longest known survival of a sustained fatal arrhythmia. This case highlights the physiology of circulations supported by LVADs and the unique challenges that may arise in managing ambulant LVAD patients, such as predicting prognosis. Given the increasing use of LVADs to treat end-stage heart failure, these issues are likely to become more frequently encountered in the future.

Myocardial recovery with mechanical circulatory support.

Mechanical circulatory support (MCS) is instituted in patients with advanced heart failure, some of who may experience sufficient recovery in cardiac function to allow withdrawal of mechanical support. The incidence of left ventricular recovery with MCS is unclear as reported series in the literature demonstrate widely divergent rates. A number of clinical parameters (including echocardiographic, haemodynamic and physiological) are used to indicate likely left ventricular recovery during pump speed reduction but no internationally agreed definition exists. Withdrawal of MCS is not without risk and so robust clinical and biochemical definitions are important to minimize patient morbidity and mortality. Here we review our current understanding of left ventricular recovery with MCS.

British Society for Heart Failure 17th annual autumn meeting.

The British Society for Heart Failure recently held its 17th annual meeting in London, attracting over 700 delegates for the 2-day conference. The meeting covered a wide range of topics, including common co-morbidities, diagnostic dilemmas, latest guidelines/clinical trials and managing clinically challenging scenarios. The British Society for Heart Failure meeting provides an entertaining and informative forum to learn from internationally renowned experts in both the field of heart failure and allied specialties. Future meetings are highly recommended.

Is foxglove effective in heart failure?

BACKGROUND: Digoxin is the oldest known treatment for heart failure (HF) and has been demonstrated to reduce admissions for worsening heart failure in a large randomized trial recruiting patients in sinus rhythm with heart failure and ejection fraction <45%. This study forms the basis for current international guidelines recommending that digoxin should be considered in patients with symptomatic HF despite optimal doses of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, ß-blockers, and mineralocorticoid receptor antagonists in addition to device therapy, if indicated. However, digoxin predates mortality reducing HF therapies, and this article reviews the historical and recent data. METHODS: Multiple PubMed searches were performed including, but not limited to, the search terms "digoxin," "heart failure," "efficacy," "treatment," "side-effects," "morbidity," "mortality," and "arrythmia." Articles were excluded if not relevant, not in English or without abstract. Reference lists of relevant articles were manually searched for further references. Due to the large number of articles retrieved, a selection was reviewed based on the authors' best judgement. RESULTS: Three randomized controlled trials and three large contemporary observational reports of digoxin therapy in heart failure and sinus rhythm were retrieved. Other studies were noted that included patients with heart failure and atrial fibrillation, which were also reviewed. CONCLUSION: Definitive randomized evidence of digoxin efficacy as add-on therapy in HF is lacking because most landmark trials of modern HF disease modifying agents postdate the randomized studies of digoxin. Furthermore, questions remain regarding the optimum dose of digoxin and there are signals that digoxin may be harmful in some patients with HF. All contemporary data for digoxin in HF are derived from observational studies and the findings are conflicting. Despite two centuries of experience using cardiac glycosides to treat HF, fundamental questions regarding the efficacy and safety of digoxin in HF remain unanswered.

Effect of antipsychotic medications on glucose and lipid levels.

Severe mental illnesses, such as schizophrenia and bipolar affective disorder, are associated with excess cardiovascular morbidity and mortality. Cardiovascular risk in psychiatric disorders is partly related to antipsychotic therapy, especially second-generation or atypical antipsychotics. Some antipsychotic medications are associated with proatherogenic conditions including insulin resistance and dyslipidemia. In particular, olanzapine and clozapine have been consistently demonstrated to promote insulin resistance and dyslipidemia. Ziprasidone and amisulpiride may be associated with more favorable metabolic effects. Many of the published data relating to metabolic effects of anti-psychotics originate from retrospective studies. However, prospective randomized-controlled data are emerging, and the latest evidence is described here.

Review article: Thiazolidinediones and heart failure.

DM is an independent risk factor for the development of HF and its presence confers an adverse prognosis for those already diagnosed with HF.TZDs are potent insulin-sensitisers associated with a number of beneficial cardiovascular effects. However,TZDs increase renal sodium and water reabsorption, leading to fluid retention and overt signs of HF in patients with diabetes. Rosiglitazone has also been associated with an increased risk of myocardial infarction and cardiovascular mortality. However, pioglitazone may have macrovascular benefits. The majority of data on the cardiovascular safety of TZDs are based on non-cardovascular outcome trials and meta-analyses. Concerns regarding the risk of HF and cardiovascular safety of TZDs have led to restrictions on their use in patients with HF. This review addresses the latest evidence for HF with each of the TZD drugs currently available and reflects on the current guidelines regarding their prescription in at-risk patients.

Neuroendocrine effects on the heart and targets for therapeutic manipulation in heart failure.

Chronic heart failure (CHF) involves derangements in multiple neurohormonal axes leading to a procatabolic state and wasting syndrome associated with significant mortality. Catabolic abnormalities include excess catecholamines and glucocorticoids. Anabolic defects include deficiencies of sex steroids, insulin resistance, and growth hormone (GH) resistance. These abnormalities are also correlated with increased morbidity and mortality in CHF. Anabolic axes have been augmented in pilot studies in CHF with testosterone, GH, insulin-like growth factor-1, and GH secretagogues. Results have been varied although some treatments have been associated with improved surrogate endpoints. This review article explores the current understanding of metabolic derangements in CHF and highlights potential neuroendocrine treatment strategies.