Lung Ultrasound for Heart Failure Diagnosis in Primary Care.

BACKGROUND: Lung ultrasound (LUS) is useful for diagnosing pulmonary congestion, but its value in primary care remains unclear. We investigated whether LUS improved diagnostic accuracy in outpatients with heart failure (HF) suspicion. METHODS AND RESULTS: LUS was performed on 2 anterior (A), 2 lateral (L), and 2 posterior (P) areas per hemithorax. An area was positive when ≥3 B-lines were observed. Two diagnostic criteria were used: for LUS-C1, 2 positive areas of 4 (A-L) on each hemithorax; and for LUS-C2, 2 positive areas of 6 (A-L-P) on each hemithorax. A cardiologist blinded to LUS validated HF diagnosis. 162 patients were included (age 75.6 ± 9.4 years, 70.4% women). Both LUS criteria, alone and combined with other HF diagnostic criteria, were accurate for identifying HF. LUS-C2 outperformed LUS-C1, showing remarkable specificity (0.99) and positive predictive value (0.92). LUS-C2, together with Framingham criteria, N-terminal pro-B-type natriuretic peptide, and electrocardiogram, added diagnostic value (area under the receiver operating characteristic curves 0.90 with LUS-C2 vs 0.84 without; P = .006). In the absence of N-terminal pro-B-type natriuretic peptide, LUS-C2 significantly reclassified one-third of patients above Framingham criteria and electrocardiogram (net reclassification improvement 0.65, 95% confidence interval 0.04-1.1). CONCLUSIONS: LUS was accurate enough to rule-in HF in a primary care setting. The accuracy of diagnostic workup for HF in primary care is enhanced by incorporating LUS, irrespective NT-proBNP availability.

The prognostic value of blood pressure control delay in newly diagnosed hypertensive patients.

OBJECTIVE: Various studies have suggested that a delay in the time between diagnosing hypertension and its correct control (D-C, diagnostic-control time) is linked to a worse prognosis. The aim of this study was to examine the relationship between D-C time and all-cause mortality, or the incidence of cardiovascular events, in patients more than 60 years newly diagnosed with hypertension. METHODS: This is a longitudinal, retrospective, population study employing data gathered from the electronic medical records of patients recently diagnosed with hypertension in 45 primary healthcare centres located in Barcelona (Catalonia). A multivariable logistic regression and Cox regression models were constructed. Goodness-of-fit was assessed through the Hosmer & Lemeshow test. RESULTS: A total of 18 721 newly diagnosed hypertensive patients were included between 2007 and 2012. The follow-up lasted until October 2015, or the appearance of a cardiovascular event or death because of any cause. The median D-C time was 49 days and its distribution by tertiles was the following: 29 days or less, 30-124 days, and at least 125 days. Higher hypertensive status, obesity, diabetes mellitus, and male sex were independently associated with longer D-C time (≥125 days). At 5.4 years follow-up, patients with longer D-C times presented statistically significant greater incidence of all-cause mortality. CONCLUSION: A delay in blood pressure control is significantly associated with an increase in the rate of all-cause mortality.

Transitions of Care Between Acute and Chronic Heart Failure: Critical Steps in the Design of a Multidisciplinary Care Model for the Prevention of Rehospitalization.

Despite advances in the treatment of heart failure, mortality, the number of readmissions, and their associated health care costs are very high. Heart failure care models inspired by the chronic care model, also known as heart failure programs or heart failure units, have shown clinical benefits in high-risk patients. However, while traditional heart failure units have focused on patients detected in the outpatient phase, the increasing pressure from hospital admissions is shifting the focus of interest toward multidisciplinary programs that concentrate on transitions of care, particularly between the acute phase and the postdischarge phase. These new integrated care models for heart failure revolve around interventions at the time of transitions of care. They are multidisciplinary and patient-centered, designed to ensure continuity of care, and have been demonstrated to reduce potentially avoidable hospital admissions. Key components of these models are early intervention during the inpatient phase, discharge planning, early postdischarge review and structured follow-up, advanced transition planning, and the involvement of physicians and nurses specialized in heart failure. It is hoped that such models will be progressively implemented across the country.

Iron deficiency is a key determinant of health-related quality of life in patients with chronic heart failure regardless of anaemia status.

AIMS: To evaluate the effect of iron deficiency (ID) and/or anaemia on health-related quality of life (HRQoL) in patients with chronic heart failure (CHF). METHODS AND RESULTS: We undertook a post-hoc analysis of a cohort of CHF patients in a single-centre study evaluating cognitive function. At recruitment, patients provided baseline information and completed the Minnesota Living with Heart Failure questionnaire (MLHFQ) for HRQoL (higher scores reflect worse HRQoL). At the same time, blood samples were taken for serological evaluation. ID was defined as serum ferritin levels <100 ng/mL or serum ferritin <800 ng/mL with transferrin saturation <20%. Anaemia was defined as haemoglobin ≤12 g/dL. A total of 552 CHF patients were eligible for inclusion, with an average age of 72 years and 40% in NYHA class III or IV. The MLHFQ overall summary scores were 41.0 ± 24.7 among those with ID, vs. 34.4 ± 26.4 for non-ID patients (P = 0.003), indicating worse HRQoL. When adjusted for other factors associated with HRQoL, ID was significantly associated with worse MLHFQ overall summary (P = 0.008) and physical dimension scores (P = 0.002), whereas anaemia was not (both P > 0.05). Increased levels of soluble transferrin receptor were also associated with impaired HRQoL (P ≤ 0.001). Adjusting for haemoglobin and C-reactive protein, ID was more pronounced in patients with anaemia compared with those without (P < 0.001). CONCLUSION: In patients with CHF, ID but not anaemia was associated with reduced HRQoL, mostly due to physical factors.

Transiciones de cuidados entre insuficiencia cardiaca aguda y crónica: pasos críticos en el diseño de un modelo de atención multidisciplinaria para la prevención de la hospitalización recurrente / Transitions of care between acute and chronic heart failure: Critical steps in the design of a multidisciplinary care model for the prevention of rehospitalization

Pese a los avances en el tratamiento de la insuficiencia cardiaca, la mortalidad, el volumen de reingresos y sus costes sanitarios son muy elevados. Los modelos de atención a la insuficiencia cardiaca inspirados en el modelo de atención crónica, también denominados programas o unidades de insuficiencia cardiaca, han demostrado beneficios clínicos en pacientes de alto riesgo. Sin embargo, mientras que las unidades de insuficiencia cardiaca tradicionales se han centrado en los pacientes detectados en su fase ambulatoria, la presión creciente de la hospitalización está desplazando el foco de interés hacia programas multidisciplinarios alrededor de las transiciones, especialmente entre las fases aguda y tras el alta. Estos nuevos modelos de atención sanitaria integrada para la insuficiencia cardiaca pivotan sus intervenciones en los momentos de transiciones, son de carácter multidisciplinario, centrados en el paciente, están diseñados para asegurar la continuidad asistencial y han demostrado una reducción de las hospitalizaciones potencialmente evitables. Componentes clave de estos modelos son la intervención precoz durante la hospitalización, planificación del alta, visita precoz y seguimiento estructurado tras el alta, planificación de transiciones avanzadas y la participación de médicos y enfermeras especializados en insuficiencia cardiaca. Es de esperar la progresiva implantación de estos modelos en nuestro entorno (AU)

Despite advances in the treatment of heart failure, mortality, the number of readmissions, and their associated health care costs are very high. Heart failure care models inspired by the chronic care model, also known as heart failure programs or heart failure units, have shown clinical benefits in high-risk patients. However, while traditional heart failure units have focused on patients detected in the outpatient phase, the increasing pressure from hospital admissions is shifting the focus of interest toward multidisciplinary programs that concentrate on transitions of care, particularly between the acute phase and the postdischarge phase. These new integrated care models for heart failure revolve around interventions at the time of transitions of care. They are multidisciplinary and patient-centered, designed to ensure continuity of care, and have been demonstrated to reduce potentially avoidable hospital admissions. Key components of these models are early intervention during the inpatient phase, discharge planning, early postdischarge review and structured follow-up, advanced transition planning, and the involvement of physicians and nurses specialized in heart failure. It is hoped that such models will be progressively implemented across the country (AU)