European Society of Cardiology quality indicators update for the care and outcomes of adults with heart failure. The Heart Failure Association of the ESC.

AIMS: To update the European Society of Cardiology (ESC) quality indicators (QIs) for the evaluation of the care and outcomes of adults with heart failure. METHODS AND RESULTS: The Working Group comprised experts in heart failure including members of the ESC Clinical Practice Guidelines Task Force for heart failure, members of the Heart Failure Association, and a patient representative. We followed the ESC methodology for QI development. The 2023 focused guideline update was reviewed to assess the suitability of the recommendations with strongest association with benefit and harm against the ESC criteria for QIs. All the new proposed QIs were individually graded by each panellist via online questionnaires for both validity and feasibility. The existing heart failure QIs also underwent voting to 'keep', 'remove' or 'modify'. Five domains of care for the management of heart failure were identified: (1) structural QIs, (2) patient assessment, (3) initial treatment, (4) therapy optimization, and (5) patient health-related quality of life. In total, 14 'main' and 3 'secondary' QIs were selected across the five domains. CONCLUSION: This document provides an update of the previously published ESC QIs for heart failure to ensure that these measures are aligned with contemporary evidence. The QIs may be used to quantify adherence to clinical practice as recommended in guidelines to improve the care and outcomes of patients with heart failure.

Non-pharmacological methods in the treatment of resistant hypertension.

INTRODUCTION: Arterial hypertension is the most common chronic cardiovascular disease affecting about 25% of the adult population. Meta-analyses have demonstrated a linear relationship between blood pressure and the risk of cardiovascular events. Resistant hypertension defined as failure to reach blood pressure targets despite treatment with three antihypertensive drugs including a diuretic represents a serious clinical problem. It has been estimated that it affects between 8.9% and 12.8% of all treated hypertensive subjects. In resistant hypertension the optimal blood pressure is illusive despite very well tailored therapy. OBJECTIVE: Management of resistant hypertension is exactly the field where blood pressure-controlling non-pharmacological methods fit best. The present article aims at throwing light on these methods' principles of action, on who the target patient groups are and the respective results. Two methods are especially reviewed here: the carotid baroreflex stimulation and the transcatheter renal sympathetic denervation. Current results from the use of renal denervation suggest stable efficiency of the method, the results becoming significant 6 months after the procedure is applied and sustained for two years in the follow-up. As much as 90% of the treated patients respond to the procedure. The transcatheter renal denervation is associated with only 2.61% of procedural complications. The baroreflex carotid stimulation, too, is known to produce a stable effect on blood pressure: the effect become obvious at 12 months in 88% of the treated subjects. The neurologic complications associated with the procedure are reported to occur in 4.4% of cases. CONCLUSION: The present review article clearly demonstrates that non-pharmacological methods for treatment of resistant hypertension show great promise despite some open questions concerning their long term effects and procedural safety.

Group-based cardiac rehabilitation interventions. A challenge for physical and rehabilitation medicine physicians: a randomized controlled trial.

BACKGROUND: In recent decades, many studies are focused on different training modalities comparison in patients with cardiac diseases. High intensity aerobic interval training (HIAIT) has been considered as an alternative approach to moderate-intensity continuous training (MICT) in rehabilitation of patients with chronic heart failure (CHF). AIM: To highlight the superiority of the modified group-based HIAIT intervention (m-Ullevaal) compared to the moderate-intensity continuous training (MICT), also to encourage physical and rehabilitation medicine (PRM) physicians to apply the m-Ullevaal intervention in routine cardiac rehabilitation (CR) practice. DESIGN: А single-blind, prospective randomized controlled trial. SETTING: Medical Center of Rehabilitation and Sports Medicine, Plovdiv, Bulgaria outpatients were enrolled. POPULATION: One hundred and twenty subjects of both genders, mean age of 63.73±6.68 years, with stable CHF, NYHA classes II to IIIB, were randomly assigned to m-Ullevaal group (N.=60) or to MICT (N.=60) group. Both CR protocols were conducted throughout a 12-week period. METHODS: Functional exercise capacity (FEC), assessed with six-minute walk test, and peak oxygen uptake (VO2peak), left ventricular ejection fraction (LVEF), m-Borg's perceived exertion scale (mBPES), and quality of life (QoL) were outcome measures evaluated. RESULTS: Significant improvement in FEC (P<0.001), LVEF (P<0.001), mBPES and QoL (P<0.001), was observed 12 weeks after both CR interventions (T2). However, the participants performed m-Ullevaal protocol achieved a greater improvement compared to those performed MICT (P<0.001). CONCLUSIONS: The m-Ullevaal protocol seems to be more beneficial and more effective compared to MICT. PRM physicians can efficiently apply the m-Ullevaal protocol in CHF patients rehabilitation. CLINICAL REHABILITATION IMPACT: Group-based HIAIT interventions can be widely applied by PRM physicians in CHF patients rehabilitation.

Oxygen uptake efficiency slope in patients with chronic heart failure and coexisting respiratory disease.

BACKGROUND: Oxygen uptake efficiency slope (OUES) is proposed as an objective index of cardiorespiratory functional reserve. The AIM of the present study was to evaluate the effect of coexisting respiratory diseases on OUES in patients with chronic heart failure (CHF) (New York Heart Association class II-III) during incremental exercise testing. PATIENTS AND METHODS: Fifty-five males were allocated to three groups: group 1-19 patients with only CHF (CHF); group 2-17 patients with CHF and a history of respiratory disease (CHF-RD); group 3-19 matched controls (C). They all underwent comprehensive lung function testing and symptom-limited ramp cardiopulmonary exercise test on a cycle ergometer. RESULTS: The patients with a history of respiratory diseases had the lowest value of OUES, but their results were not significantly different from those of the CHF patients (OUES mL.min(-1).logL(-1)= 1461 +/- 268 vs. 1571 +/- 383 vs. 2112 +/- 263 in controls). Significant correlation was found between OUES and important functional variables: VO2peak (r=0.833), V(E)/NCO2 slope (r = -0.757), FEV1 (r=0.582), T(L,CO) (r=0.574), and EF% (r=0.350). CONCLUSIONS: OUES is significantly reduced in patients with CHF and tends to be lower in the presence of a respiratory disease. It can be regarded as an useful, reliable physiologic marker of reduced ventilatory efficiency and cardiorespiratory reserve in chronic heart failure.

Association between angiographic coronary stenosis morphology and acute coronary syndrome manifestation in patients with ischemic heart disease.

AIM: Patients with acute coronary syndrome (ACS) often show complex morphology of coronary stenosis at angiography. In the present study we evaluated the association between different clinical forms of manifestation of acute coronary syndrome and the angiographic morphological patterns of coronary stenosis. PATIENTS AND METHODS: A total of 112 patients with angiographically verified single vessel coronary artery disease were divided into two groups: a control group of 44 patients with simple coronary stenosis at angiography and a study group of 66 patients with complex coronary stenosis. Angiographic analysis was performed using a modified Ambrose classification. The two groups were compared according to the manifestation and distribution of the acute coronary syndrome based on Braunwald classification. RESULTS: There were no statistically significant differences between the mean values of stenosis severity in the group with simple stenosis (79.8% +/- 10.7%) and the group with complex stenosis (82.7% +/- 8.2%) (P > 0.05). The incidence of current acute coronary syndrome - unstable angina or myocardial infarction - was higher in the group with complex stenosis (30.00% +/- 8.37% vs. 52.00% +/- 7.07%, P < 0.05). Patients with previous ACS were prevailing in the group with simple stenosis (70.00% +/- 8.37% vs. 48.00% +/- 7.07%, P < 0.05). CONCLUSION: Complex coronary stenosis is associated with higher prevalence of acute coronary syndrome in acute clinical stage while simple coronary stenosis is associated with higher prevalence of previous acute coronary syndrome. A possible metamorphosis of coronary stenoses is taken into consideration.

Nonrheumatic atrial fibrillation and left ventricular hypertrophy in the prognosis of reversible ischaemic neurological deficit.

Nonrheumatic atrial fibrillation (NRAF) and left ventricular hypertrophy (LVH) have long been recognised as risk factors for cerebral ischaemia and as predictors of recurrent vascular events. In the present study we aimed at determining the value of NRAF and LVH as predictors of recurrent vascular events in a cohort of patients with a first-ever episode of reversible ischemic neurological deficit (RIND). The study included 54 patients (37 men and 17 women, aged 62 +/- 9.6 yrs) who had suffered RIND; they were followed up for 30 days after the stroke in clinical conditions and for 12 months as outpatients. The patients were studied during the hospital stay by means of routine tests (electrocardiography, standard laboratory tests) and specialised studies (computer tomography, echocardiography). By the end of the one-year outpatient follow up there were 8 (14.8%) recurrent cerebrovascular events. By combining the statistically significant cerebrovascular risk factors (male sex, sudden onset of the event and moderately high systolic and diastolic blood pressure) with factors not reaching statistical significance (LVH, NRAF) we developed a statistically significant prediction model for patients with RIND.