Introduction of a new scoring tool to identify clinically stable heart failure patients.

INTRODUCTION: Heart failure (HF) poses a burden on specialist care, making referral of clinically stable HF patients to primary care a desirable goal. However, a structured approach to guide patient referral is lacking. METHODS: The Maastricht Instability Score-Heart Failure (MIS-HF) questionnaire was developed to objectively stratify the clinical status of HF patients: patients with a low MIS-HF (0-2 points, indicating a stable clinical condition) were considered for treatment in primary care, whereas high scores (> 2 points) indicated the need for specialised care. The MIS-HF was evaluated in 637 consecutive HF patients presenting between 2015 and 2018 at Maastricht University Medical Centre. RESULTS: Of the 637 patients, 329 (52%) had a low score and 205 of these 329 (62%) patients were referred to primary care. The remaining 124 (38%) patients remained in secondary care. Of the 308 (48%) patients with a high score (> 2 points), 265 (86%) remained in secondary care and 41 (14%) were referred to primary care. The primary composite endpoint (mortality, cardiac hospital admissions) occurred more frequently in patients with a high compared to those with a low MIS-HF after 1 year of follow-up (29.2% vs 10.9%; odds ratio (OR) 3.36, 95% confidence interval (CI) 2.20-5.14). No significant difference in the composite endpoint (9.8% vs 12.9%; OR 0.73, 95% CI 0.36-1.47) was found between patients with a low MIS-HF treated in primary versus secondary care. CONCLUSION: The MIS-HF questionnaire may improve referral policies, as it helps to identify HF patients that can safely be referred to primary care.

Effects of tailored telemonitoring on functional status and health-related quality of life in patients with heart failure.

BACKGROUND: Functional status and health-related quality of life (HRQoL) are important in patients with heart failure (HF). Little is known about the effect of telemonitoring on functional status and HRQoL in that population. METHODS AND RESULTS: A total of 382 patients with HF (New York Heart Association class 2-4) were included in a randomised controlled trial to investigate the effect of tailored telemonitoring on improving HRQoL and functional status in HF patients. Randomisation was computer-generated with stratification per centre. At baseline and after 12 months, patients' functional status was determined by metabolic equivalent scores (METS). HRQoL was measured with the EuroQol five dimensions questionnaire (EQ-5D), visual analogue scale (VAS) and Borg rating of perceived exertion scale (Borg). Additional outcome data included number of HF-related outpatient clinic visits and mortality. Telemonitoring was statistically significantly related to an increase in METS after 1 year (regression coefficient 0.318; p = 0.01). Telemonitoring did not improve Borg, EQ-5D or VAS scores after 1 year. EQ-5D [hazard ratio (HR) 0.20, 95% confidence interval (CI) 0.07-0.54], VAS (HR 0.98, 95% CI 0.96-0.99), Borg (HR 1.21, 95% CI 1.11-1.31) and METS (HR 0.73, 95% CI 0.58-0.93) at baseline were significantly associated with survival after 12 months. CONCLUSIONS: Tailored telemonitoring stabilised the functional status of HF patients but did not improve HRQoL. Therefore, telemonitoring may help to prevent deterioration of exercise capacity in patients with HF. However, because our study is a reanalysis of a randomised controlled trial (RCT), this is considered hypothesis-generating and should be confirmed by adequately powered RCTs.

Selection of patients for cardiac resynchronisation therapy (CRT) in an unselected heart failure population.

BACKGROUND: In patients with chronic heart failure (CHF), the presence of conduction delay across the myocardium is a well-known feature. During recent years an increasing number of CHF patients have been treated with cardiac resynchronisation therapy (CRT). So far in many protocols patients have been selected using the criteria of left ventricular ejection fraction (LVEF) ≤35% concomitant with signs of widening of the QRS on the surface electrocardiogram, either with or without left bundle branch block (LBBB) morphology. METHODS: In this article we discuss which of the patients admitted with CHF to a regular cardiology practice could be candidates for this therapy. Data were obtained from January 2000 to December 2004 on a total of 861 CHF patients, of whom 309 had an LVEF ≤35%. Of these patients, 123 patients showed a QRS width >120 msec, while 81 patient had a QRS width >140 msec. In total, 89 patients had an LBBB morphology on the electrocardiogram, while 21 patients had univentricular pacing devices in situ. In those patients with an LVEF >35%, QRS width was 108±27msec. CONCLUSION: A substantial number of patients presenting with CHF in a regular cardiology practice are suitable candidates for CRT therapy according to currently used criteria of QRS width and LVEF. This number could be increased even more if recent information concerning intraventricular conduction delay in CHF patients with less widening of the QRS complex were to be applied, as judged by echocardiographic techniques.

Measuring quality of life in heart failure: one versus multiple items.

BACKGROUND: Symptoms of heart failure and consequences of treatment can have a great impact on patients' lives. Improving quality of life is generally recognised as one of the major goals of treatment. The purpose of this study was to determine the relationship between a one-item quality-of-life measure (Ladder of Life) and the Minnesota Living with Heart Failure Questionnaire and possible equality. METHOD: 231 patients who were admitted with symptoms of chronic heart failure to a cardiology ward in a general hospital (53% male, age 75±11, LVEF 40±16) completed the Minnesota Living with Heart Failure Questionnaire (MLwHFQ) and were asked to rate their sense of well-being on the Ladder of Life (10= best possible life, 0= worst possible life). Demographic and clinical data were obtained by chart review. RESULTS: The overall well-being score on the Ladder of Life correlated significantly with the total MLwHFQ (r=-0.36, p<0.001). However, there is a large variation in MLwHFQ scores (12-83) in patients who score a relatively high overall well-being (>6, relatively good Q0L). A large variation in MLwHFQ scores (10-105) also exists in patients with a relatively low score on the Ladder of Life (<1, low QOL). CONCLUSION: Assessment of quality of life with a simple and practical tool using the one-item Ladder of Life can give clinicians and researchers important information on the quality of life of patients. Whether such a single-item question is responsive enough to detect changes in treatment and predict readmission needs to be studied in more detail.

Practical implications of having a dedicated heart failure programme.

BACKGROUND: The prevalence of heart failure (HF) is gaining epidemic proportions. Recent data stress the importance of multidisciplinary strategies for the management of HF patients, but the practical consequences of such programmes remain unclear. OBJECTIVE: To describe our experience with a dedicated heart failure programme involving two HF nurses and a cardiologist. METHOD: All patients admitted to the cardiology department with NYHA class III-IV heart failure were included. After admission, patients received optimal medical therapy according to current guidelines, and extensive instructions from a dedicated HF nurse. On discharge they were given comprehensive lists of medications and symptoms, and a weighing list. They were advised to call a nurse in case of questions or problems. RESULTS: 861 patients were included: 63% >75 years, 47% with LVEF >45%. From 2000 onwards, the number of patients admitted once a year increased but seemed to level off in 2004. Most phone calls involved weight changes as well as general physical complaints. In 1266 (46%) of calls, the medication change was a consequence of a problem raised by the patient. The nurse received and answered almost all phone calls. CONCLUSION: The patient group will grow substantially during the first years of the programme, but the number of patients seen in the outpatient clinic appears to stabilise after five years. Many issues regarding the care of these patients can be handled by the HF nurse.

Results of a heart failure outpatient clinic in a non-university hospital with a two-year follow-up.

The growing number of heart failure patients has stimulated the development of intensified guidance and follow-up of these patients using specific outpatient clinics and specialised nurses. This is also the case in the Netherlands, where the first positive results of this system have been obtained in academic settings. In this article we present data from an intensified programme for CHF patients as obtained at a non-university cardiology department. It demonstrates that also in this setting the use of a cardiologist, a heart failure outpatient clinic and a specialised nurse dedicated to these patients results in a significant decrease in readmission rate. Furthermore patient characteristics are described. Finally the important role of the nurse is stressed by indicating the number and content of telephone calls he is receiving, resulting in medication changes in 58% of calls.

[Education and guidance of a patient with chronic heart failure. A case study]. / Voorlichting en begeleiding van een patiënt met chronisch hartfalen. Een case studie.

The number of patients with heart failure is growing. To optimize care for these patients in hospital and at home, a supportive-educative intervention is developed. The intervention is guided by a standard nursing care plan which is developed from literature, existing standard nursing care plans, and interviews with nurses. A case study is used to explain and illustrate the intervention and to review the importance of the standard nursing care plan.