Somatic symptom profile in patients with chronic heart failure with and without depressive comorbidity.

Background: Patients with chronic heart failure (CHF) frequently suffer from depressive comorbidity. CHF and depressive comorbidity can cause somatic symptoms. The correct attribution of somatic symptoms is important. Thus, we aimed to assess potential differences in somatic symptom severity between CHF patients with and without depressive comorbidity. Methods: We evaluated depressive comorbidity using the Patient Health Questionnaire-9 (PHQ-9), somatic symptom severity with the Patient Health Questionnaire-15 (PHQ-15), and sociodemographic and medical variables in 308 CHF outpatients. To compare somatic symptom severity between CHF patients with and without depressive comorbidity, we conducted item-level analyses of covariance. Results: Of the 308 participating patients, 93 (30.3%) met the PHQ-9 criteria for depressive comorbidity. These patients did not differ from those without depressive comorbidity with regard to age, sex, left ventricular function, and multimorbidity. Patients with depressive comorbidity scored significantly higher on ten out of thirteen PHQ-15 items than patients without depressive comorbidity. The largest effect sizes (0.71-0.80) were shown for symptoms of headache, chest pain, shortness of breath, and palpitations, and the latter three were potentially attributable to heart failure. Conclusions: Among patients with CHF, somatic symptoms are more pronounced in those with depressive comorbidity than those without depressive comorbidity. This finding is especially true for cardiac symptoms independent of CHF severity. The potential interpretation of somatic symptoms as correlates of depressive comorbidity must be recognized in clinical practice.

Associations between NT-proBNP and psychosocial factors in patients with chronic systolic heart failure.

OBJECTIVE: B-type natriuretic peptides (BNPs) and their biologically inactive N-terminal parts, namely, NT-proBNPs, are used for diagnostic and prognostic purposes in patients with chronic heart failure (CHF). Associations of BNPs and NT-proBNPs with emotional factors may exist. As depressive and anxious comorbidities and decreases in quality of life (QoL) are common in CHF patients, we explored the associations between NT-proBNP and depression, anxiety, and QoL in patients with CHF using cross-sectional and longitudinal analyses. METHODS: We used baseline and one-year follow-up NT-proBNP measurements and sociodemographic and clinical data from 180 patients with systolic CHF from a case management study. Depression was assessed with the Patient Health Questionnaire 9 (PHQ-9), anxiety was assessed with the Generalized Anxiety Disorder Scale 7 (GAD-7), and QoL was determined using the Short Form 36 (SF-36) health survey. RESULTS: Univariate correlation analyses showed significant negative associations between NT-proBNP and the scores of four out of eight QoL domains (range: r = -0.159 to -0.285, p = .042 to 0.001) of the SF-36 but not between NT-proBNP and depression and anxiety scores. In cross-sectional and longitudinal multivariate regression analyses, no significant associations between NT-proBNP and psychometric variables were found. CONCLUSION: In patients with stable, chronic systolic heart failure, only weak relations between NT-proBNP and QoL exist, but no relations between NT-proBNP and depression and anxiety were found. These findings are placed in the current research context of this topic. Implications for future experimental studies are discussed.

Anxiety and self-care behaviour in patients with chronic systolic heart failure: A multivariate model.

BACKGROUND: While comprehensive evidence exists regarding negative effects of depression on self-care behaviours in patients with chronic heart failure (CHF), the relation between anxiety and self-care behaviours in patients with CHF is not clear. The aim of this study was to analyse the interactions between anxiety, depression and self-care behaviours in patients with CHF. METHODS: The self-care behaviour of CHF outpatients was measured using the European Heart Failure Self-care Behaviour Scale (EHFScBS). The Patient Health Questionnaire (PHQ) was used to assess anxiety, the PHQ-9 was used to measure depression severity. Differences between patients with and without anxiety were assessed with the respective tests. Associations between anxiety, self-care and other predictors were analysed using linear regressions. RESULTS: Of the 308 participating patients, 35 (11.4%) fulfilled the PHQ criteria for an anxiety disorder. These patients took antidepressants more frequently (11.8% versus 2.3%, p = .02), had had more contacts with their general practitioner within the last year (11.8 ± 16.1 versus 6.7 ± 8.6, p = .02), and had a higher PHQ-9 depression score (12.9 ± 5.7 versus 6.5 ± 4.7, p < .01) than patients without anxiety disorder. Anxiety and self-care were negatively associated (ß = -0.144, r2 = 0.021, p = 0.015). The explanation of variance was augmented in a multivariate regression with the predictors age, sex, education, living with a partner, and New York Heart Association (NYHA) class ( r2 = 0.098) when anxiety was added ( r2 = 0.112). Depression further increased the explanation of variance (ß = -0.161, r2 = 0.131, p = 0.019). CONCLUSIONS: Anxiety is negatively associated with self-care behaviour in patients with CHF. However, this effect disappears behind the stronger influence of depression on self-care. The consideration of mental comorbidities in patients with CHF is important.

Incidence rates and predictors of major and minor depression in patients with heart failure.

AIMS: Depression is common in heart failure (HF) and associated with adverse outcomes. This study aimed to investigate incidence rates and predictors of depression in patients sampled from four subprojects of the German Competence Network Heart Failure. METHODS: Eight hundred thirty nine symptomatic HF patients free of depression at baseline underwent repeat depression screening (Patient Health Questionnaire, PHQ-9) after 12 months. Ordered logistic regression analysis was employed to search for predictors of incident depression. RESULTS: Incident minor (major) depression was observed in 61 (7.3%) and 47 (5.6%) of the population. Depression was recurrent in 15 (25%) and 16 (34%), respectively. Multiple regression analysis revealed seven variables predicting minor or major depression: Previous depressive episode (odds ratio [OR] 4.04, 95% confidence interval [CI] 2.37-6.89, p ≤ 0.001), previous resuscitation (OR 2.44, CI 1.23-4.81, p=0.010), current smoking (OR 2.06, CI 1.08-3.50, p=0.008), >4 visits/year to general practitioner (OR 1.67, CI 1.06-2.63, p=0.026), New York Heart Association class (OR 1.54/class, 95% CI 1.05-2.25, p=0.027), PHQ-9 baseline sum-score (OR 1.18/point, CI 1.11-1.27, p<0.001), and SF-36 physical functioning (OR 1.08/-5 points, CI 1.03-1.13, p=0.002). CONCLUSIONS: In these HF patients initially free of depression annual incidence rates were high. Several independent predictors allowed identification of patients at particular risk. Although obtained in a selected cohort these findings call, in view of the grave prognosis of HF patients with comorbid depression, for regular depression screening and development of specific supportive strategies to improve patient care and outcomes in HF.

Barriers to guideline implementation and educational needs of general practitioners regarding heart failure: a qualitative study.

OBJECTIVES: A clinical practice guideline (CPG) contains specifically developed recommendations that can serve physicians as a decision aid in evidence-based practice. The implementation of heart failure (HF) CPGs represents a challenge in general practice. As part of the development of a tailored curriculum, aim of this study was to identify barriers of guideline adherence and needs for medical education (CME) in HF care. METHODS: We conducted a modified focus group with elements of a workshop of three hours duration. Thirteen GPs collected and discussed together and parallel in smaller groups barriers of guideline implementation. Afterwards they performed a needs assessment for a tailored CME curriculum for chronic HF. The content of the discussions was analysed qualitatively according to Mayring and categorised thematically. RESULTS: Barriers of guideline adherence were found in the following areas: doctor: procedural knowledge (knowledge gaps), communicative and organisational skills (e.g. time management) and attitude (dissatisfaction with time-money-relation). PATIENTS: individual case-related problems (multimorbidity, psychiatric comorbidity, expectations and beliefs). Doctor and patient: Adherence and barriers of communication. Main measures for improvement of care concerned the areas of the identified barriers of guideline adherence with the focus on application-oriented training of the abovementioned procedural knowledge and skills, but also the supply of tools (like patient information leaflets) and patient education. CONCLUSION: For a CME-curriculum for HF tailored to the needs of GPs, a comprehensive educational approach seems necessary. It should be broad-based and include elements of knowledge and skills to be addressed and trained case-related. Additional elements should include support in the implementation of organisational processes in the practice and patient education.

Physician and patient predictors of evidence-based prescribing in heart failure: a multilevel study.

BACKGROUND: The management of patients with heart failure (HF) needs to account for changeable and complex individual clinical characteristics. The use of renin angiotensin system inhibitors (RAAS-I) to target doses is recommended by guidelines. But physicians seemingly do not sufficiently follow this recommendation, while little is known about the physician and patient predictors of adherence. METHODS: To examine the coherence of primary care (PC) physicians' knowledge and self-perceived competencies regarding RAAS-I with their respective prescribing behavior being related to patient-associated barriers. Cross-sectional follow-up study after a randomized medical educational intervention trial with a seven month observation period. PC physicians (n = 37) and patients with systolic HF (n = 168) from practices in Baden-Wuerttemberg. Measurements were knowledge (blueprint-based multiple choice test), self-perceived competencies (questionnaire on global confidence in the therapy and on frequency of use of RAAS-I), and patient variables (age, gender, NYHA functional status, blood pressure, potassium level, renal function). Prescribing was collected from the trials' documentation. The target variable consisted of ≥50% of recommended RAAS-I dosage being investigated by two-level logistic regression models. RESULTS: Patients (69% male, mean age 68.8 years) showed symptomatic and objectified left ventricular (NYHA II vs. III/IV: 51% vs. 49% and mean LVEF 33.3%) and renal (GFR<50%: 22%) impairment. Mean percentage of RAAS-I target dose was 47%, 59% of patients receiving ≥50%. Determinants of improved prescribing of RAAS-I were patient age (OR 0.95, CI 0.92-0.99, p = 0.01), physician's global self-confidence at follow-up (OR 1.09, CI 1.02-1.05, p = 0.01) and NYHA class (II vs. III/IV) (OR 0.63, CI 0.38-1.05, p = 0.08). CONCLUSIONS: A change in physician's confidence as a predictor of RAAS-I dose increase is a new finding that might reflect an intervention effect of improved physicians' intention and that might foster novel strategies to improve safe evidence-based prescribing. These should include targeting knowledge, attitudes and skills.

Gender differences in health-related quality of life after coronary bypass surgery: results from a 1-year follow-up in propensity-matched men and women.

OBJECTIVE: To examine whether the predictive value of gender for health-related quality of life (HRQoL) is independent of clinical health status and depression. Women undergoing coronary bypass surgery generally report a poorer HRQoL than men. METHODS: A total of 990 (20% women) patients completed study questionnaires 1 day before coronary bypass surgery and 1 year after surgery. Physical aspects of HRQoL were assessed with the Short Form 36 Health Survey. Depression was measured with the self-reported Patient Health Questionnaire. Propensity score matching was applied to match men and women with respect to 65 clinical variables. Of 198 women, 157 (79.3%) could be matched to a partner, resulting in an excellent balance of clinical variables between the matched groups. RESULTS: At baseline, propensity-matched men and women differed in physical functioning (p < .001) and role functioning (p = .007), but not in bodily pain and general health perception. In both men and women, HRQoL outcomes improved over 1 year. Preoperative depression predicted worse physical HRQoL in all outcomes, except general health perception 1 year after surgery. After adjusting for depression, gender lost its predictive power with respect to physical functioning. However, compared with women, men still reported a better role functioning. CONCLUSION: Our data suggest that gender is a marker for role functioning, independent of the clinical health status and depression. Rehabilitation measures designed for the specific needs of women might help to improve their HRQoL.

Patient- and provider-related determinants of generic and specific health-related quality of life of patients with chronic systolic heart failure in primary care: a cross-sectional study.

BACKGROUND: Identifying the determinants of health-related quality of life (HRQOL) in patients with systolic heart failure (CHF) is rare in primary care; studies often lack a defined sample, a comprehensive set of variables and clear HRQOL outcomes. Our aim was to explore the impactof such a set of variables on generic and disease-specific HRQOL. METHODS: In a cross-sectional study, we evaluated data from 318 eligible patients. HRQOL measures used were the SF-36 (Physical/Mental Component Summary, PCS/MCS) and four domains of the KCCQ (Functional status, Quality of life, Self efficacy, Social limitation). Potential determinants (instruments) included socio-demographical variables (age, sex, socio-economic status: SES), clinical (e.g. NYHA class, LVEF, NT-proBNP levels, multimorbidity (CIRS-G)), depression (PHQ-9), behavioural (EHFScBs and prescribing) and provider (e.g. list size of and number. of GPs in practice) variables. We performed linear (mixed) regression modelling accounting for clustering. RESULTS: Patients were predominantly male (71.4%), had a mean age of 69.0 (SD: 10.4) years, 12.9% had major depression, according to PHQ-9. Across the final regression models, eleven determinants explained 27% to 55% of variance (frequency across models, lowest/highest ß): Depression (6×, -0.3/-0.7); age (4×, -0.1/-0.2); multimorbidity (4×, 0.1); list size (2×, -0.2); SES (2×, 0.1/0.2); and each of the following once: no. of GPs per practice, NYHA class, COPD, history of CABG surgery, aldosterone antagonist medication and Self-care (0.1/-0.2/-0.2/0.1/-0.1/-0.2). CONCLUSIONS: HRQOL was determined by a variety of established individual variables. Additionally the presence of multimorbidity burden, behavioural (self-care) and provider determinants may influence clinicians in tailoring care to individual patients and highlight future research priorities.

[Depression, social support and compliance in patients with chronic heart failure]. / Depression, soziale Unterstützung und Compliance bei chronisch herzinsuffizienten Patienten.

Depressive patients with chronic heart failure (CHF) show less social integration and greater physical impairment as well as poorer compliance than non depressive CHF patients. Using multiple regression analyses, this study (n=84) investigated a potential mediating effect of depression on the relationship between compliance and both social support and physical functioning. Results did not support the hypothesized mediating effect of depression. However, the variables age, depression, left ventricular ejection fraction (LVEF) and social support were associated with self-reported compliance. Therefore, a lack of social support and depression should be considered as possible reasons, if patients are noncompliant during the treatment process.

Iterative cardiac output measurement for optimizing cardiac resynchronization therapy: a randomized, blinded, crossover study.

BACKGROUND: Many invasive and noninvasive methods have been proposed for guiding optimal programming of cardiac resynchronization therapy (CRT) devices. However, results are not satisfying. Preliminary results suggest that cardiac output (CO) measurements using inert gas rebreathing (IGR) might be an eligible method to tailor atrioventricular (AV) and ventriculo-ventricular (VV) programming. The aims of the present study were: (1) to evaluate whether an optimization of CRT can be obtained by noninvasive CO measurements and (2) to evaluate whether acute hemodynamic improvements obtained by this approach relate into increase in cardiac exercise capacity. METHODS: In 24 patients on CRT, iterative VV- and AV-delay optimization was done using the IGR method. This blinded, randomized, crossover study compared the responses to optimization during two periods: a 4-week optimized and a 4-week standard programming. Exercise capacity after optimization was assessed after each period by New York Heart Association (NYHA) classification, a 6-minute walking test, and quality of life (QoL) questionnaire. RESULTS: CO could be determined by IGR in all patients. The NYHA class decreased by 17.8% (2.8 ± 0.3 vs 2.3 ± 0.4, P < 0.001), the mean (± standard deviation) distance walked in 6 minutes was 9.3% greater after optimization (456 ± 140 m vs 417 ± 134 m, P < 0.001), and the QoL improved by 14.5% (41.8 ± 10.4 vs 36.5 ± 9.5, P < 0.001). The portion of responders to CRT increased from 66.5% to 87.5%. CONCLUSION: CRT optimization by iterative CO measurements leads to an increase in CO and an improvement of exercise capacity. Our results suggest that this method might become an important additive tool to adjust CRT programming.

Case management for patients with chronic systolic heart failure in primary care: the HICMan exploratory randomised controlled trial.

BACKGROUND: Chronic (systolic) heart failure (CHF) represents a clinical syndrome with high individual and societal burden of disease. Multifaceted interventions like case management are seen as promising ways of improving patient outcomes, but lack a robust evidence base, especially for primary care. The aim of the study was to explore the effectiveness of a new model of CHF case management conducted by doctors' assistants (DAs, equivalent to a nursing role) and supported by general practitioners (GPs). METHODS: This patient-randomised controlled trial (phase II) included 31 DAs and employing GPs from 29 small office-based practices in Germany. Patients with CHF received either case management (n = 99) consisting of telephone monitoring and home visits or usual care (n = 100) for 12 months. We obtained clinical data, health care utilisation data, and patient-reported data on generic and disease-specific quality of life (QoL, SF-36 and KCCQ), CHF self-care (EHFScBS) and on quality of care (PACIC-5A). To compare between groups at follow-up, we performed analyses of covariance and logistic regression models. RESULTS: Baseline measurement showed high guideline adherence to evidence-based pharmacotherapy and good patient self-care: Patients received angiotensin converting enzyme inhibitors (or angiotensin-2 receptor antagonists) in 93.8% and 95%, and betablockers in 72.2% and 84%, and received both in combination in 68% and 80% of cases respectively. EHFScBS scores (SD) were 25.4 (8.4) and 25.0 (7.1). KCCQ overall summary scores (SD) were 65.4 (22.6) and 64.7 (22.7). We found low hospital admission and mortality rates. EHFScBS scores (-3.6 [-5.7;-1.6]) and PACIC and 5A scores (both 0.5, [0.3;0.7/0.8]) improved in favour of CM but QoL scores showed no significant group differences (Physical/Mental SF-36 summary scores/KCCQ-os [95%CI]: -0.3 [-3.0;2.5]/-0.1 [-3.4;3.1]/1.7 [-3.0;6.4]). CONCLUSIONS: In this sample, with little room for improvement regarding evidence-based pharmacotherapy and CHF self-care, case management showed no improved health outcomes or health care utilisation. However, case management significantly improved performance and key intermediate outcomes. Our study provides evidence for the feasibility of the case management model. TRIAL REGISTRATION NUMBER: ISRCTN30822978.

A network against failing hearts--introducing the German "Competence Network Heart Failure".

Heart failure (HF) has been identified as one of the most threatening diseases for the western civilisation, posing a risk to health for a rising number of patients. Acknowledging the medical problem of HF to be both economically and socially threatening the German Federal Ministry of Research and Education (BMBF) initiated a nationwide research network aiming to find new ways in prevention, alleviation and treatment of the widespread disease. The "Competence Network Heart Failure" (CNHF), initiated in 2003, bundles the scientific expertise in a large-scale research network; its aims are the coordination of basic and applied clinical research as well as dissemination of findings into clinical practice in order to consolidate and perpetuate the achieved improvements. The scope of this paper is to introduce the CNHF and to provide an overview of the tasks and hitherto attained achievements to a broad spectrum of health care providers.

Self-care and depression in patients with chronic heart failure.

BACKGROUND: Although chronic heart failure (CHF) is often complicated by comorbid depression and poor self-care, little is known about their specific association in patients with CHF. OBJECTIVE: To investigate self-care behavior among patients with CHF with different degrees of depression severity. METHODS: A total of 287 patients with documented CHF, New York Heart Association functional class II to IV, completed the European Heart Failure Self-Care Behavior Scale. The Structured Clinical Interview for DSM (SCID) IV served as the criterion standard for the presence of a depressive disorder. RESULTS: Analyses of covariance and linear regression analyses revealed that patients with CHF with minor depression reported significantly lower levels of self-care than patients with major depression (P = .003) and nondepressed patients (P = .014). In addition to minor depression, age (P < or = .001), multimorbidity (P = .01), left ventricular ejection fraction (P = .001), and family status (P = .01) were determinants of self-care. CONCLUSION: Our results demonstrate that patients with CHF with minor depression and not major depression are at higher risk for poor self-care and its resulting consequences, such as symptom deterioration and frequent hospitalization.

Exploring potential associations of suicidal ideation and ideas of self-harm in patients with congestive heart failure.

OBJECTIVE: To determine the factors, which are associated with suicidal ideation and ideas of self-harm in patients with congestive heart failure (CHF). METHODS: We examined 294 patients with documented CHF, New York Heart Association (NYHA) functional class II-IV, in a cross sectional study at three cardiac outpatient departments. Measures included self-reports of suicidal ideation and self-harm (PHQ-9), depression (SCID), health-related quality of life (SF-36), multimorbidity (CIRS-G), consumption of alcoholic beverages, as well as comprehensive clinical status. Data were analyzed using logistic regression analyses. RESULTS: 50 patients (17.1%) reported experiencing suicidal ideation and/or ideas of self-harm on at least several days over the past two weeks. The final regression model revealed significant associations with health-related quality of life, physical component (odds ratio [OR] 0.56; 95% confidence interval [CI]: 0.35-0.91), and mental component (OR 0.50; 95% CI: 0.31-0.82), consumption of alcoholic beverages (OR 1.27; 95% CI: 1.05-1.54), first-episode depression (OR 3.92; 95% CI: 1.16-13.22), and lifetime depression (OR 10.89; 95% CI: 2.49-47.72). Age was only significant in the univariable (P=.03) regression analysis. NYHA functional class, left ventricular ejection fraction (LVEF), etiology of CHF, medication, cardiovascular interventions, multimorbidity, gender, and living situation were not significantly associated with suicidal ideation or ideas of self-harm. CONCLUSIONS: Lifetime depression, in particular, increases the risk of suicidal ideation and ideas of self-harm in CHF patients. Furthermore, the findings of our study underline the necessity of differentiating between first-episode and lifetime depression in CHF-patients in future research and clinical practice.

Primary care-based multifaceted, interdisciplinary medical educational intervention for patients with systolic heart failure: lessons learned from a cluster randomised controlled trial.

BACKGROUND: Chronic (systolic) heart failure (CHF) is a common and disabling condition. Adherence to evidence-based guidelines in primary care has been shown to improve health outcomes. The aim was to explore the impact of a multidisciplinary educational intervention for general practitioners (GPs) (Train the trainer = TTT) on patient and performance outcomes. METHODS: This paper presents the key findings from the trial and discusses the lessons learned during the implementation of the TTT trial. Primary care practices were randomly assigned to the TTT intervention or to the control group. 37 GPs (18 TTT, 19 control) were randomised and 168 patients diagnosed with ascertained CHF (91 TTT, 77 control) were enrolled. GPs in the intervention group attended four meetings addressing clinical practice guidelines and pharmacotherapy feedback. The primary outcome was patient self-reported quality of life at seven months, using the SF-36 Physical Functioning scale. Secondary outcomes included other SF-36 scales, the Kansas City Cardiomyopathy Questionnaire (KCCQ), total mortality, heart failure hospital admissions, prescribing, depressive disorders (PHQ-9), behavioural change (European Heart Failure Self-Care Behaviour Scale), patient-perceived quality of care (EUROPEP) and improvement of heart failure using NT-proBNP-levels. Because recruitment targets were not achieved an exploratory analysis was conducted. RESULTS: There was high baseline achievement in both groups for many outcomes. At seven months, there were no significant mean difference between groups for the primary outcome measure (-3.3, 95%CI -9.7 to 3.1, p = 0.30). The only difference in secondary outcomes related to the prescribing of aldosterone antagonists by GPs in the intervention group, with significant between group differences at follow-up (42 vs. 24%, adjusted OR = 4.0, 95%CI 1.2-13; p = 0.02). CONCLUSION: The intervention did not change the primary outcome or most secondary outcomes. Recruitment targets were not achieved and the under-recruitment of practices and patients alongside a selection bias of participating GPs, prohibit definite conclusions, but the CI indicates a non-effectiveness of the intervention in this sample. We describe the lessons learned from conducting the trial for the future planning and conduct of confirmatory trials in primary care. TRIAL REGISTRATION: ISRCTN08601529.

Doctors' assistants' views of case management to improve chronic heart failure care in general practice: a qualitative study.

AIM: This paper is a report of a study to explore the views, concerns and experiences of doctors' assistants of case management for patients with chronic heart failure, while experiencing the new role of being a case manager within the Heidelberg Integrated Case Management trial. BACKGROUND: Case management is being investigated as part of a randomised controlled trial aiming to improve care for patients with chronic systolic heart failure. In a complex, multifaceted intervention, trained doctors' assistants (equivalent to a nursing role) adopted new tasks using standardised case management involving telephone monitoring, home visits and diagnostic screening. METHOD: In April 2007, 3 months after implementation of the intervention programme, 27 doctors' assistants participated in four focus group interviews discussing their views on, and experiences of, case management. Thematic analysis of the data was undertaken. FINDINGS: Participants believed that the most positive factors in case management were about interaction with patients, including opportunities for identifying disease and psychosocial problems. However, barriers included lack of time allocated to perform case management in addition to their normal role and poor cooperation within the practice team. According to the doctors' assistants, the routine implementation of case management was acceptable, feasible and effective in improving the management of patients with chronic systolic heart failure. CONCLUSION: Case management enhanced the role of doctors' assistants, leading to increased awareness of the perspective of patients with chronic disease. In the wider international primary care practice nursing context, the orchestrated delegation of tasks using specific case management may be a promising strategy for improving the quality of care of chronically ill patients and enabling patient self-management.

The Biomaterialbank of the German Competence Network of Heart Failure (CNHF) is a valuable resource for biomedical and genetic research.

Genetic research on heart failure (HF) requires large cohorts of well-phenotyped patients. The German Competence Network of Heart Failure (CNHF) organized a biobank in 2004 to supply the necessary infrastructure and standard operating procedures (SOPs) for a centralized collection of blood specimen. We centralized data and collected serum, plasma and DNA of well characterized HF subjects all over Germany. Different pseudonyms were created automatically to address data safety and other concerns about privacy. Thus far, we have collected 85,000 sample specimen from 9,500 prospectively evaluated patients with HF. Detailed medical data were prospectively acquired together with corresponding blood samples. In 2008 clinician-scientists can apply for access to the material. Our biobank represents a major facet of the CNHF and has already documented research and clinical utility.

Improved guideline adherence to pharmacotherapy of chronic systolic heart failure in general practice--results from a cluster-randomized controlled trial of implementation of a clinical practice guideline.

RATIONALE AND AIMS: Clinical practice guidelines (CPG) reflect the evidence of effective pharmacotherapy of chronic (systolic) heart failure (CHF) which needs to be implemented. This study aimed to evaluate the effect of a new, multifaceted intervention (educational train-the-trainer course plus pharmacotherapy feedback = TTT) compared with standard education on guideline adherence (GA) in general practice. METHOD: Thirty-seven participating general practitioners (GPs) were randomized (18 vs. 19) and included 168 patients with ascertained symptomatic CHF [New York Heart Association (NYHA) II-IV]. Groups received CPG, the TTT intervention consisted of four interactive educational meetings and a pharmacotherapy feedback, while the control group received a usual lecture (Standard). Outcome measure was GA assessed by prescription rates and target dosing of angiotensin converting enzyme (ACE) inhibitors (ACE-I) or angiotensin receptor blockers (ARB), beta-blockers (BB) and aldosterone antagonists (AA) at baseline and 7-month follow-up. Group comparisons at follow-up were adjusted to GA, sex, age and NYHA stage at baseline. RESULTS: Prescription rates at baseline (n = 168) were high (ACE-I/ARB 90, BB 79 and AA 29%) in both groups. At follow up (n = 146), TTT improved compared with Standard regarding AA (43% vs. 23%, P = 0.04) and the rates of reached target doses of ACE-I/ARB (28% vs. 15%, P = 0.04). TTT group achieved significantly higher mean percentages of daily target dose (52% vs. 42%, mean difference 10.3%, 95% CI 0.84-19.8, P = 0.03). CONCLUSION: Despite of pre-existing high GA in both groups and an active control group, the multifaceted intervention was effective in quality of care measured by GA. Further research is needed on the choice of interventions in different provider populations.

Panic disorder in patients with chronic heart failure.

OBJECTIVE: Our objective was to assess the prevalence of panic disorder, its influence on quality of life (QoL), and the presence of further anxiety and depressive comorbid disorders in outpatients with chronic heart failure (CHF). METHODS: In a cross-sectional study, anxiety and depressive disorders were diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnostic criteria in patients with CHF who were aged > or =18 years and had New York Heart Association (NYHA) Functional Classes I-IV, using the Patient Health Questionnaire. Health-related QoL was evaluated using the Short-Form 36 Health Survey (SF-36). RESULTS: Of the 258 participating patients, 24 (9.3%) fulfilled diagnostic criteria for panic disorder. Seven of these (29.2%) were diagnosed with comorbid anxiety disorders, 11 (47.3%) were diagnosed with comorbid depressive disorder, and 5 (20.8%) were diagnosed with other anxiety disorders and any depressive disorder. Female gender [odds ratio (OR)=3.1; 95% confidence interval (95% CI)=1.2-7.8; P=.02] and a lower level of education (OR=0.3; 95% CI=0.1-0.9; P=.04) were associated with the presence of panic disorder. In patients with panic disorder, QoL was significantly more restricted on all subscales of the SF-36 as compared to those without panic disorder, even when age, gender, and NYHA functional class were controlled for (P=.05 to <.01). CONCLUSION: Approximately 1 of 10 patients with CHF suffers from panic disorder, many of whom also have additional anxiety or depressive comorbid disorders. Female gender and a low level of education are positively associated with the presence of panic disorder. QoL is severely limited by the presence of panic disorder. Diagnosis of mental disorders and treatment offers for affected patients should be available in patient care.

Depression profile in patients with and without chronic heart failure.

OBJECTIVE: Depression often goes undetected and untreated in patients with chronic heart failure (CHF). To investigate whether patients with CHF show a specific profile of depression symptoms, we compared depression symptoms in depressed patients with and without CHF. METHODS: Of a total of 921 patients from a CHF and a psychosomatic outpatient clinic, 137 met DSM-IV diagnostic criteria for major depressive disorder and 113 for other depressive disorders. Depressed patients with CHF (n=113) and without CHF (n=137) were compared with respect to severity of individual DSM-IV depressive symptoms, as measured with the PHQ-9. To stratify for depression severity, ANCOVAs with sociodemographic characteristics as covariates were performed separately for patients with major depressive disorder and other depressive disorders. RESULTS: Among the patients meeting the criteria for major depressive disorder, patients with CHF reported significantly lower levels of depressed mood (p=.006) and worthlessness/guilt (p=.019) than patients without CHF. In contrast, no significant group differences were found for any of the other depression symptoms. Group comparisons among the patients with other depressive disorders completely replicated these results (p< or =.001, and p=.04, respectively). LIMITATIONS: Our study population of CHF patients may not be representative for CHF patients recruited in the general population. CONCLUSIONS: The diagnostic features discriminating between depressed patients with and without CHF are the cognitive-emotional symptoms of depression, not the somatic symptoms. This finding may partially explain the low recognition rate of depression in patients with CHF. The different profile of depression symptoms in patients with and without CHF should be considered in diagnosis, treatment and medical education.