Heart failure patient adherence: epidemiology, cause, and treatment.

Poor adherence to therapeutic regimens is a significant impediment to improving clinical outcomes in the HF population. Typical rates of adherence to prescribed medications, low-sodium diets, and aerobic exercise programs remain lower than that needed to decrease morbidity and mortality associated with HF. Factors contributing to poor adherence include multiple comorbidities, clinical depression, and decreased cognitive functioning. HF education and programs to enhance self-management skills have improved patient quality of life but have yet to decrease mortality or rehospitalization rates significantly. Telemonitoring to improve adherence behaviors and self-management interventions within broader HF management programs have demonstrated significant clinical improvements in this population.

Change in intrathoracic impedance measures during acute decompensated heart failure admission: results from the Diagnostic Data for Discharge in Heart Failure Patients (3D-HF) Pilot Study.

BACKGROUND: Despite the high number of admissions for acute decompensated heart failure (ADHF), there are no specific criteria for discharge readiness. A number of patients have implantable devices that might provide data to assist in determining readiness for discharge. METHODS AND RESULTS: The 3D-HF (Diagnostic Data for Discharge in Heart Failure Patients) study was a prospective observational pilot study enrolling HF patients with Optivol-capable cardiac devices within 48 hours of a hospital admission characterized by worsening HF symptoms. The primary end point was the difference in times from admission to 50% improvement in impedance and to when patient was medically ready for discharge. The nonparametric sign test was used to determine if the difference was significant. A total of 20 subjects were enrolled over a 24-month period. The median ADHF length of stay was 7 days. Of the 20 subjects, 18 achieved the intrathoracic impedance improvement threshold before discharge. The time to reach the threshold for improvement was 2.5 days (interquartile range 2.0-6.0). The difference between days to 50% impedance and days to provider's discharge decision was 3.0 (P = .0072). CONCLUSIONS: Intrathoracic impedance changes were evident over a short duration in the majority of patients admitted for ADHF and may be a potential criterion for discharge readiness.

Quality of Life Trajectory and Its Mediators in Older Patients With Acute Decompensated Heart Failure Receiving a Multi-Domain Rehabilitation Intervention: Results From the Rehabilitation Therapy in Older Acute Heart Failure Patients Trial.

BACKGROUND: As patients with heart failure experience worsening of their condition, including acute decompensated heart failure, quality of life deteriorates. However, the trajectory of quality of life changes and their determinants in the context of the Rehabilitation Therapy in Older Acute Heart Failure Patients trial physical rehabilitation intervention are unknown. METHODS: Patients ≥60 years old admitted for acute decompensated heart failure (n=349) were randomized to either attention control or intervention. Quality of life outcomes (Kansas City Cardiomyopathy Questionnaire; 12-Item Short-Form Health Survey) were measured at baseline (inpatient), 1 month, and 3 months. Intervention effects were assessed using linear mixed effects regression, including covariates to model the main effects of the intervention and timing of outcome assessments. Mediation analysis determined if changes in Kansas City Cardiomyopathy Questionnaire were due to improvement in physical function (short physical performance battery, 6-minute walk distance). RESULTS: Baseline Kansas City Cardiomyopathy Questionnaire summary score was similarly poor in the intervention and control arms (40.2±20.6 versus 41.5±20.6). Although the intervention experienced nominally greater Kansas City Cardiomyopathy Questionnaire improvement than control at 1 month (64.7±1.9 versus 61.1±1.9, P=0.13), the difference was not statistically significant until 3 months (67.7±1.9 versus 60.8±1.9, P=0.004). Twelve-Item Short-Form Health Survey Physical and Mental Composite Scores increased in both arms at 1 month and continued improvement only in the intervention. The 3-month improvement in short physical performance battery score explained 64.1% of the improvement in Kansas City Cardiomyopathy Questionnaire (P<0.001). CONCLUSIONS: In older patients hospitalized for acute decompensated heart failure, quality of life improves in the first month after discharge. The quality of life benefit of a post-discharge physical rehabilitation intervention is detected early with large significant improvements at 3 months achieved primarily through improvement in short physical performance battery. REGISTRATION: URL: https://clinicaltrials.gov; Unique identifier: NCT02196038.

Percutaneous coronary intervention of totally occluded coronary venous bypass grafts: An exercise in futility?

BACKGROUND: Percutaneous coronary intervention (PCI) of diseased saphenous vein grafts (SVG) continues to pose a clinical challenge. Current PCI guidelines give a class III recommendation against performing PCI on chronically occluded SVG. However, contemporary outcomes after SVG intervention have incrementally improved with distal protection devices, intracoronary vasodilators, drug-eluting stents, and prolonged dual antiplatelet therapy. AIM: To reassess the procedural and long-term outcomes of PCI for totally occluded SVG with contemporary techniques. METHODS: This was a retrospective observational study conducted at a single university hospital. The study population consisted of 35 consecutive patients undergoing PCI of totally occluded SVG. Post-procedure dual antiplatelet therapy was continued for a minimum of one year and aspirin was continued indefinitely. Clinical outcomes were assessed at a mean follow-up of 1221 ± 1038 d. The primary outcome was freedom from a major adverse cardiac event (MACE) defined as the occurrence of any of the following: death, myocardial infarction, stroke, repeat bypass surgery, repeat PCI, or graft reocclusion. RESULTS: The study group included 29 men and 6 women with a mean age of 69 ± 12 years. Diabetes was present in 14 (40%) patients. All patients had Canadian Heart Classification class III or IV angina. Clinical presentation was an acute coronary syndrome in 34 (97%) patients. Mean SVG age was 12 ± 5 years. Estimated duration of occlusion was acute (< 24 h) in 34% of patients, subacute (> 24 h to 30 d) in 26%, and late (> 30 d) in 40%. PCI was initially successful in 29/35 SVG occlusions (83%). Total stent length was 52 ± 35 mm. Intraprocedural complications of distal embolization or no-reflow occurred in 6 (17%) patients. During longer term follow-up, MACE-free survival was only 30% at 3 years and 17% at 5 years. CONCLUSION: PCI of totally occluded SVG can be performed with a high procedural success rate. However, its clinical utility remains limited by poor follow-up outcomes.

Trends in Robotic-Assisted Coronary Artery Bypass Grafts: A Study of The Society of Thoracic Surgeons Adult Cardiac Surgery Database, 2006 to 2012.

BACKGROUND: Robotic technology is one of the most recent technological changes in coronary artery bypass graft (CABG) operations. The current analysis was conducted to identify trends in the use and outcomes of robotic-assisted CABG (RA-CABG). METHODS: A retrospective analysis was performed using data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database between 2006 and 2012. Patient and site-level characteristics were compared between traditional CABG and RA-CABG. Operative death, postoperative length of stay, and postoperative complications were compared between the two groups. RESULTS: The number of sites using RA-CABG remained relatively constant during the study period (from 148 in 2006 to 151 in 2012). The volume of RA-CABG as a percentage of the total CABG procedures increased slightly from 0.59% (872 RA-CABG of 127,717 total CABG) in 2006 to 0.97% (1,260 RA-CABG of 97,249 total CABG) in 2012. The RA-CABG patients were significantly younger (64 vs 65 years, p < 0.0001), had fewer comorbidities, and had lower rates of cardiopulmonary bypass use (22.4% vs 80.4%, p < 0.0001). RA-CABG patients had significantly lower unadjusted major complication rates (10.2% vs 13.5%, p < 0.0001), including postoperative renal failure (2.2% vs 2.9%, p < 0.0001), and shorter length of stay (4 vs 5 days, p < 0.0001). The difference in operative death was not significant (odds ratio, 1.10; 95% confidence interval, 0.92 to 1.30, p = 0.29). CONCLUSIONS: RA-CABG use remained relatively stagnant during the analysis period despite lower rates of major perioperative complications and no difference in operative deaths. Additional analysis is needed to fully understand the role that robotic technology will play in CABG operations in the future.