Appropriateness rating for the application of optimal medical therapy and multidisciplinary care among heart failure patients.

AIMS: Clinical guidelines for improving the patients' quality of care vary in clinical practice, particularly in super-aging societies, like in Japan. We aimed to develop a set of appropriate-use criteria (AUC) for contemporary heart failure (HF) management to assist physicians in decision making. METHODS AND RESULTS: With the use of the RAND methodology, a multidisciplinary writing group developed patient-based clinical scenarios in 10 selected key topics, stratified mainly by HF stage, age, and renal function. Nine nationally recognized expert panellists independently rated the clinical scenario appropriateness twice on a scale of 1-9, as 'appropriate' (7-9), 'may be appropriate' (4-6), or 'rarely appropriate' (1-3). Decisions were based on clinical evidence and professional opinions in the context of available resource use and costs. An interactive round-table discussion was held between the first and second ratings; the median score of the nine experts was then assigned to an appropriate-use category. Most clinical scenarios without strong evidence were evaluated as 'may be appropriate'. Frailty assessments in elderly patients (age ≥ 75 years), regardless of the HF stage, and advanced care planning in patients with stage C/D HF, regardless of age, were considered 'appropriate'. For HF with reduced ejection fraction, beta-blocker administration in elderly patients (age ≥ 75 years) with heart rate < 50 b.p.m. and mineral corticosteroid receptor antagonist use in elderly patients (age ≥ 75 years) with an estimated glomerular filtration rate < 30 mL/min/1.73 m2 were considered 'rarely appropriate'. CONCLUSIONS: The HF management AUC provide a practical guide for physicians regarding scenarios commonly encountered in daily practice.

Possible associations between palliative care conferences and positive outcomes when performing palliative care for patients with end-stage heart failure: a nationwide cross-sectional questionnaire survey.

Palliative care for end-stage heart failure should be provided by a multidisciplinary team. However, the influence of each occupational category on patients receiving palliative care for end-stage heart failure remains unclear. Thus, this study investigated the relationships between palliative care conferences and positive outcomes of palliative care for end-stage heart failure patients. We sent questionnaires to all cardiology training hospitals authorized by the Japanese Circulation Society (n = 1004); of these, responses from the directors at 554 institutions were analyzed. We divided the responding institutions into two groups according to their implementation of palliative care conferences for patients with end-stage heart failure. The institutions that had held such conferences (n = 223) had a larger number of hospital beds, beds in the cardiovascular department, and patients admitted to the cardiovascular department, compared with institutions that had not held these conferences (n = 321). The usage rates of opioids, non-steroidal anti-inflammatory drugs, and sedatives were significantly higher in institutions that held these conferences. Multivariate analysis revealed that nutritionists and medical social workers had greater involvement in the improvement of mental symptoms and ensuring that patients could stay where they wished, respectively. The presence of palliative care physicians, physical therapists, or pharmacists was associated with multiple positive outcomes. This study indicated that there are possible associations between palliative care conferences and positive outcomes when performing palliative care for patients with end-stage heart failure.

Nationwide Survey of Palliative Care for Patients With Heart Failure in Japan.

BACKGROUND: Palliative care for heart failure (HF) patients is recommended in Western guidelines, so this study aimed to clarify the current status of palliative care for HF patients in Japan.Methods and Results:A survey was sent to all Japanese Circulation Society-authorized cardiology training hospitals (n=1,004) in August 2016. A total of 544 institutions (54%) returned the questionnaire. Of them, 527 (98%) answered that palliative care is necessary for patients with HF. A total of 227 (42%) institutions held a palliative care conference for patients with HF, and 79% of the institutions had <10 cases per year. Drug therapy as palliative care was administered at 403 (76%) institutions; morphine (87%) was most frequently used. Among sedatives, dexmedetomidine (33%) was administered more often than midazolam (29%) or propofol (20%). Regarding the timing of end-of-life care, most institutions (84%) reported having considered palliative care when a patient reached the terminal stage of HF. Most frequently, the reason for the decision at the terminal stage was "difficulty in discontinuing cardiotonics." A major impediment to the delivery of palliative care was "difficulty predicting an accurate prognosis." CONCLUSIONS: This large-scale survey showed the characteristics of palliative care for HF in Japan. The present findings may aid in the development of effective end-of-life care systems.

Design of a nationwide survey on palliative care for end-stage heart failure in Japan.

BACKGROUND: The term palliative care has historically been associated with support for individuals with advanced incurable cancer, so cardiologists and cardiac nurses may be unfamiliar with its principles and practice. However, palliative care is now a part of end-stage heart failure management. We conducted the first nationwide survey to investigate the status of palliative care for heart failure in Japan. METHODS AND RESULTS: A self-reported questionnaire was mailed to all Japanese Circulation Society - authorized cardiology training hospitals (n=1004) in August 2016. The response deadline was December 2016. The survey focused on the following topics: basic information about the facility and multidisciplinary team, patient symptoms for palliative care, positive outcomes after providing palliative care, drug therapy as palliative care for patients with heart failure, advance care planning with patients and their families, and impediments to providing palliative care to patients with heart failure. The results of the survey will be reported in detail elsewhere. CONCLUSIONS: Current guidelines on palliative care do not specifically address what team members should be involved, what drugs should be used, or when palliative care should be started. This survey collected information to improve the quality of palliative care and provide more specialized palliative care within the limits of resources.

Home Medical Care for Heart Failure.

As heart failure progresses to the end stage, it becomes more difficult to maintain the same level of quality of life using the established therapy for the heart failure patients. We believe that an innovative home medical care for heart failure therapy that focuses on the individual's quality of daily living and early intervention is necessary. The roles of home medical care include: early discharge to home as opposed to long hospitalization; the prevention of re-hospitalization; the provision of good care; treatment of any exacerbations; and options available at the end of the patient's life at home. Being able to provide all of the above will allow heart failure patients to live at their home. Home medical care for heart failure requires collaborative teamwork among multiple institutions and medical professionals. Among this collaborative group, the role of pharmacists is critical. Since many of the elderly with heart failure are taking multiple medications, it is important to evaluate the compliance and to intervene for improvement. Pharmacists visiting the patient's home will be able to check the patient's living environment, to evaluate medication compliance, to reconsider the necessary medications for the specific patient, and to consult physicians. Pharmacists can also explain clearly to patients and their family members any changes in medical therapy, as the conditions for an end-stage heart failure patient may change drastically in a short time. By achieving all of the above, it may be possible to prevent re-hospitalization and to help maintain the quality of life for heart failure patients.

Long-Term Prognostic Role of the Diagnostic Criteria for Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia.

OBJECTIVES: The aim of this study was to evaluate the long-term prognostic role of the 2010 task force criteria (TFC)-based scoring in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D). BACKGROUND: Categories of the 2010 TFC include the risk factors for cardiovascular mortality and sudden cardiac death in patients with ARVC/D. METHODS: Ninety patients with ARVC/D who met the definitive diagnosis of the 2010 TFC were retrospectively studied. ARVC/D risk score was calculated as the sum of major (2 points) and minor (1 point) criteria in all 6 subdivided categories of the TFC and was divided into tertile groups of scores; group A (4 to 6 points), group B (7 to 9 points), and group C (10 to 12 points). The primary endpoints were major adverse cardiovascular events: cardiovascular death, heart failure hospitalization, and sustained ventricular tachycardia or ventricular fibrillation. RESULTS: During the follow-up period of 10.2 ± 7.1 years, 19 patients died because of cardiovascular causes, 28 patients were admitted because of worsened heart failure, and 47 patients experienced sustained ventricular tachycardia or ventricular fibrillation. Patients in groups B and C were at increased risk for major adverse cardiovascular events compared with those in group A (hazard ratio [HR]: 4.80; 95% confidence interval [CI]: 1.87 to 12.33; p = 0.001; and HR: 6.15; 95% CI: 2.20 to 17.21; p = 0.001, respectively). Patients in groups B and C were at increased risk for sustained ventricular tachycardia or ventricular fibrillation compared with those in group A (HR: 6.64; 95% CI: 2.00 to 22.03; p = 0.002; and HR: 9.18; 95% CI: 2.60 to 32.40; p = 0.001, respectively). CONCLUSIONS: Our study suggests that risk scoring based on the 2010 TFC is useful to predict major adverse cardiovascular events in patients with ARVC/D.