Effectiveness of the European Society of Cardiology/Heart Failure Association website 'heartfailurematters.org' and an e-health adjusted care pathway in patients with stable heart failure: results of the 'e-Vita HF' randomized controlled trial.

BACKGROUND: Efficient incorporation of e-health in patients with heart failure (HF) may enhance health care efficiency and patient empowerment. We aimed to assess the effect on self-care of (i) the European Society of Cardiology/Heart Failure Association website 'heartfailurematters.org' on top of usual care, and (ii) an e-health adjusted care pathway leaving out 'in person' routine HF nurse consultations in stable HF patients. METHODS AND RESULTS: In a three-group parallel-randomized trial in stable HF patients from nine Dutch outpatient clinics, we compared two interventions ( heartfailurematters.org website and an e-health adjusted care pathway) to usual care. The primary outcome was self-care measured with the European Heart Failure Self-care Behaviour Scale. Secondary outcomes were health status, mortality, and hospitalizations. In total, 450 patients were included. The mean age was 66.8 ± 11.0 years, 74.2% were male, and 78.8% classified themselves as New York Heart Association I or II at baseline. After 3 months of follow-up, the mean score on the self-care scale was significantly higher in the groups using the website and the adjusted care pathway compared to usual care (73.5 vs. 70.8, 95% confidence interval 0.6-6.2; and 78.2 vs. 70.8, 95% confidence interval 3.8- 9.4, respectively). The effect attenuated, until no differences after 1 year between the groups. Quality of life showed a similar pattern. Other secondary outcomes did not clearly differ between the groups. CONCLUSIONS: Both the heartfailurematters.org website and an e-health adjusted care pathway improved self-care in HF patients on the short term, but not on the long term. Continuous updating of e-health facilities could be helpful to sustain effects. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov ID NCT01755988.

Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized Trial.

BACKGROUND: The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score is an easy-to-apply instrument to stratify patients with chest pain according to their short-term risk for major adverse cardiac events (MACEs), but its effect on daily practice is unknown. OBJECTIVE: To measure the effect of use of the HEART score on patient outcomes and use of health care resources. DESIGN: Stepped-wedge, cluster randomized trial. (ClinicalTrials.gov: NCT01756846). SETTING: Emergency departments in 9 Dutch hospitals. PATIENTS: Unselected patients with chest pain presenting at emergency departments in 2013 and 2014. INTERVENTION: All hospitals started with usual care. Every 6 weeks, 1 hospital was randomly assigned to switch to "HEART care," during which physicians calculated the HEART score to guide patient management. MEASUREMENTS: For safety, a noninferiority margin of a 3.0% absolute increase in MACEs within 6 weeks was set. Other outcomes included use of health care resources, quality of life, and cost-effectiveness. RESULTS: A total of 3648 patients were included (1827 receiving usual care and 1821 receiving HEART care). Six-week incidence of MACEs during HEART care was 1.3% lower than during usual care (upper limit of the 1-sided 95% CI, 2.1% [within the noninferiority margin of 3.0%]). In low-risk patients, incidence of MACEs was 2.0% (95% CI, 1.2% to 3.3%). No statistically significant differences in early discharge, readmissions, recurrent emergency department visits, outpatient visits, or visits to general practitioners were observed. LIMITATION: Physicians were hesitant to refrain from admission and diagnostic tests in patients classified as low risk by the HEART score. CONCLUSION: Using the HEART score during initial assessment of patients with chest pain is safe, but the effect on health care resources is limited, possibly due to nonadherence to management recommendations. PRIMARY FUNDING SOURCE: Netherlands Organisation for Health Research and Development.

Effect of training general practitioners in drug treatment of newly detected heart failure patients with reduced or preserved ejection fraction: A cluster randomized trial.

OBJECTIVE: To assess the effect of training general practitioners (GPs) in the optimization of drug treatment for newly detected heart failure (HF). DESIGN: Cluster randomized trial comparing the training programme to care as usual. PARTICIPANTS: Community-dwelling older persons with a new HF diagnosis after diagnostic work-up. METHODS: Thirty GPs were randomized to care as usual or the training. Sixteen GPs of the latter group received a half-day training on optimizing HF medication in HF patients with a reduced (HFrEF), or with a preserved ejection fraction (HFpEF). At baseline and after six months of follow-up, the 46 HF patients in the intervention group and the 46 cases in the care as usual group were assessed on medication use, functionality, health status, and health care visits. RESULTS: After 6months, uptake of HF medication and health status were similar in the two groups. Interestingly, patients in the intervention group had a longer walking distance with the six-minute walk test than those in the care as usual group (mean difference in all-type HF 28.0 (95% CI 2.9 to 53.1) meters; HFpEF patients 28.2 (95% CI 8.8 to 47.5) meters and HFrEF patients 55.9 (95% CI -16.3 to 128.1) meters). They also had more HF-related GP visits (RR 1.8, 95% CI 1.3 to 2.5) and fewer visits to the cardiologist (RR 0.6, 95% CI 0.3 to 1.1). CONCLUSIONS: Training GPs in optimization of drug treatment of newly detected HFrEF and HFpEF did not clearly increase HF medication, but resulted in improvement in walking distance.

Extended prediction rule to optimise early detection of heart failure in older persons with non-acute shortness of breath: a cross-sectional study.

OBJECTIVES: There is a need for a practical tool to aid general practitioners in early detection of heart failure in the elderly with shortness of breath. In this study, such a screening rule was developed based on an existing rule for detecting heart failure in older persons with a diagnosis of chronic obstructive pulmonary disease. The original rule included a history of ischaemic heart disease, body mass index, laterally displaced apex beat, heart rate, elevated N-terminal pro B-type natriuretic peptide and an abnormal ECG. DESIGN: Cross-sectional data were used to validate, update and extend the original prediction rule according to a standardised state-of-the-art stepwise approach. SETTING: Primary care with 30 participating general practices. PARTICIPANTS: Community-dwelling people aged ≥ 65 years with shortness of breath on exertion. METHODS AND RESULTS: Validation of the existing screening rule in our population showed satisfying discrimination with a concordance statistic of 0.84 (range 0.80-0.85), but poor calibration. Performance measures were most improved by adding the predictors age >75 years, peripheral oedema and systolic murmur, resulting in a concordance statistic of 0.88 (range 0.85-0.90) and a net reclassification improvement of 31%. A risk score was computed, which showed high accuracy with a negative predictive value of 87% and a positive predictive value of 73%. Evaluating the improved rule in the derivation set and an independent set of patients with type 2 diabetes aged 60 years or older showed satisfying generalisability of the rule. CONCLUSIONS: Our rule resulted in excellent prediction of heart failure in the large domain of the elderly with shortness of breath, and would help general practitioners to select those needing echocardiography. TRIAL REGISTRATION NUMBER: NCT01202006.

Epidemiology of heart failure: the prevalence of heart failure and ventricular dysfunction in older adults over time. A systematic review.

The 'epidemic' of heart failure seems to be changing, but precise prevalence estimates of heart failure and left ventricular dysfunction (LVD) in older adults, based on adequate echocardiographic assessment, are scarce. Systematic reviews including recent studies on the prevalence of heart failure and LVD are lacking. We aimed to assess the trends in the prevalence of LVD, and heart failure with reduced (HFrEF) and preserved ejection fraction (HFpEF) in the older population at large. A systematic electronic search of the databases Medline and Embase was performed. Studies that reported prevalence estimates in community-dwelling people ≥60 years old were included if echocardiography was used to establish the diagnosis. In total, 28 articles from 25 different study populations were included. The median prevalence of systolic and 'isolated' diastolic LVD was 5.5% (range 3.3-9.2%) and 36.0% (range 15.8-52.8%), respectively. A peak in systolic dysfunction prevalence seems to have occurred between 1995 and 2000. 'All type' heart failure had a median prevalence rate of 11.8% (range 4.7-13.3%), with fairly stable rates in the last decade and with HFpEF being more common than HFrEF [median prevalence 4.9% (range 3.8-7.4%) and 3.3% (range 2.4-5.8%), respectively]. Both LVD and heart failure remain common in the older population at large. The prevalence of diastolic dysfunction is on the rise and currently higher than that of systolic dysfunction. The prevalence of the latter seems to have decreased in the 21st century.

Prevalence of unrecognized heart failure in older persons with shortness of breath on exertion.

AIMS: The majority of patients with heart failure are diagnosed in primary care, but underdiagnosis is common. Shortness of breath is a prevalent complaint of older persons and one of the key symptoms of heart failure. We assessed the prevalence of unrecognized heart failure in elderly patients presenting to primary care with shortness of breath on exertion. METHODS AND RESULTS: This was a cross-sectional selective screening study. Patients aged 65 years or over presenting to primary care with shortness of breath on exertion in the previous 12 months were eligible when not known to have an established, echocardiographic confirmed diagnosis of heart failure. All participants underwent history taking, physical examination, electrocardiography, and a blood test of N-terminal pro B-type natriuretic peptide (NTproBNP). Only those with an abnormal electrocardiogram or NTproBNP level exceeding the exclusionary cut-point for non-acute onset heart failure (>15 pmol/L (≈125 pg/mL) underwent open-access echocardiography. An expert panel established presence or absence of heart failure according to the criteria of the European Society of Cardiology heart failure guidelines. The mean age of the 585 participants was 74.1 (SD 6.3) years, and 54.5% were female. In total, 92 (15.7%, 95% CI 12.9-19.0) participants had heart failure: 17 (2.9%, 95% CI 1.8-4.7) had heart failure with a reduced ejection fraction (≤45%), 70 (12.0%, 95% CI 9.5-14.9) had heart failure with preserved ejection fraction, and five (0.9%, 95% CI 0.3-2.1) had isolated right-sided heart failure. CONCLUSION: Elderly primary care patients with shortness of breath on exertion often have unrecognized heart failure, mainly with preserved ejection fraction.

Strategy to recognize and initiate treatment of chronic heart failure in primary care (STRETCH): a cluster randomized trial.

BACKGROUND: Most patients with heart failure are diagnosed and managed in primary care, however, underdiagnosis and undertreatment are common. We assessed whether implementation of a diagnostic-therapeutic strategy improves functionality, health-related quality of life, and uptake of heart failure medication in primary care. METHODS/DESIGN: A selective screening study followed by a single-blind cluster randomized trial in primary care. The study population consists of patients aged 65 years or over who presented themselves to the general practitioner in the previous 12 months with shortness of breath on exertion. Patients already known with established heart failure, confirmed by echocardiography, are excluded. Diagnostic investigations include history taking, physical examination, electrocardiography, and serum N-terminal pro B-type natriuretic peptide levels. Only participants with an abnormal electrocardiogram or an N-terminal pro B-type natriuretic peptide level exceeding the exclusionary cutpoint for non-acute onset heart failure (> 15 pmol/L (≈ 125 pg/ml)) will undergo open-access echocardiography. The diagnosis of heart failure (with reduced or preserved ejection fraction) is established by an expert panel consisting of two cardiologists and a general practitioner, according to the criteria of the European Society of Cardiology guidelines.Patients with newly established heart failure are allocated to either the 'care as usual' group or the 'intervention' group. Randomization is at the level of the general practitioner. In the intervention group general practitioners receive a single half-day training in heart failure management and the use of a structured up-titration scheme. All participants fill out quality of life questionnaires at baseline and after six months of follow-up. A six-minute walking test will be performed in patients with heart failure. Information on medication and hospitalization rates is extracted from the electronic medical files of the general practitioners. DISCUSSION: This study will provide information on the prevalence of unrecognized heart failure in elderly with shortness of breath on exertion, and the randomized comparison will reveal whether management based on a half-day training of general practitioners in the practical application of an up-titration scheme results in improvements in functionality, health-related quality of life, and uptake of heart failure medication in heart failure patients compared to care as usual. TRIAL REGISTRATION: ClinicalTrials.gov NCT01202006.