Effects of a Tablet Computer on Self-care, Quality of Life, and Knowledge: A Randomized Clinical Trial.

BACKGROUND: Conflicting results have been reported for telemonitoring in patients with heart failure (HF). We wanted to evaluate whether patients using a tablet computer aimed at improving self-care behavior could do so and also whether it affects quality of life and health-related quality of life, disease knowledge, and in-hospital days. METHODS AND RESULTS: Patients with HF (n = 82) were randomized to the intervention group (IG) with a tablet computer (giving information and advice) or the control group (CG) that was subject to standard care. Study was completed by 72 patients, with a mean (SD) age of 75 (8) years, 68% male, and 74% NYHA class III. Self-care behavior measured with the 9-item European Heart Failure Self-Care Behaviour Scale, health related quality of life measured by the Kansas City Cardiomyopathy Questionnaire, quality of life measured by the Swedish version of the Health Survey, knowledge measured by the Dutch Heart Failure Knowledge Scale, days in hospital, and adherence were analyzed. The IG displayed better 9-item European Heart Failure Self-Care Behaviour Scale score (median IG, 16.5 [interquartile range {IQR}, 12-22], vs median CG, 23.5 [IQR, 18.8-30.0]; P < .05) and improved health related quality of life (median IG, 72.7 [IQR, 50.8-87.9], vs median CG, 51.8 [IQR, 40.9-62.8]; P < .05). A significant difference in knowledge was seen, with an 11% increase in IG and a 1% decrease in CG (P < .05), as well as a reduction in hospital days in IG by 2.7 days per patient (relative risk, 0.72; 95% confidence interval, 0.61-0.84; P < .05). CONCLUSION: The tablet computer significantly improved self-care behavior and health related quality of life, increased HF knowledge, and reduced hospital days.

Characteristics and survival of adult Swedish PAH and CTEPH patients 2000-2014.

OBJECTIVES: The Swedish Pulmonary Arterial Hypertension Register (SPAHR) is an open continuous register, including pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) patients from 2000 and onwards. We hereby launch the first data from SPAHR, defining baseline characteristics and survival of Swedish PAH and CTEPH patients. DESIGN: Incident PAH and CTEPH patients 2008-2014 from all seven Swedish PAH-centres were specifically reviewed. RESULTS: There were 457 PAH (median age: 67 years, 64% female) and 183 CTEPH (median age: 70 years, 50% female) patients, whereof 77 and 81%, respectively, were in functional class III-IV at diagnosis. Systemic hypertension, diabetes, ischaemic heart disease and atrial fibrillation were common comorbidities, particularly in those >65 years. One-, 3- and 5-year survival was 85%, 71% and 59% for PAH patients. Corresponding numbers for CTEPH patients with versus without pulmonary endarterectomy were 96%, 89% and 86% versus 91%, 75% and 69%, respectively. In 2014, the incidence of IPAH/HPAH, associated PAH and CTEPH was 5, 3 and 2 per million inhabitants and year, and the prevalence was 25, 24 and 19 per million inhabitants. CONCLUSION: The majority of the PAH and CTEPH patients were diagnosed at age >65 years, in functional class III-IV, and exhibiting several comorbidities. PAH survival in SPAHR was similar to other registers.

Patient-centred home-based management of heart failure. Findings from a randomised clinical trial evaluating a tablet computer for self-care, quality of life and effects on knowledge.

OBJECTIVES: To evaluate whether a new home intervention system (HIS, OPTILOGG(®)) consisting of a specialised software, a tablet computer (tablet) wirelessly connected to a weight scale may improve self-care behaviour, health-related quality of life (HRQoL), knowledge about heart failure (HF) and reduce hospital days due to HF. DESIGN: 82 patients (32% females) with mean age: 75 ± 8 years hospitalised with HF were randomised at discharge to an intervention group (IG) equipped with the HIS or to a control group (CG) receiving standard HF information only. The tablet contained information about HF and lifestyle advice according to current guidelines. It also showed present dose of diuretic, changes in patient-measured weight and HRQoL over time. RESULTS: After 3 months the IG displayed a dramatic improvement in self-care with p < 0.05 (median IG: 17 [IQR: 13, 22] and CG: 21 [IQR: 17, 25]). The disease-specific HRQoL was measured by Kansas City Cardiomyopathy Questionnaire. The IG had significantly higher score (median IG: 65.1 [IQR: 38.5, 83.3] vs. CG: 52.1 [IQR: 41.1, 64.1] p < 0.05) and an improved physical limitation (median IG: 54.2 [IQR: 37.7, 83.3] vs. CG: 45.8 [IQR: 25.0, 54.2] p < 0.05) There was no difference in knowledge. IG showed fewer HF-related days in the hospital, with 1.3 HF-related hospital days/patient versus 3.5 in CG (risk ratio: 0.38; 95% confidence interval: 0.31-0.46; p < 0.05). CONCLUSION: HF patients with a HIS tablet computer and scale improved in self-care and HRQoL. Days in hospital due to HF were reduced. A medical device that is easy to use can be a valuable tool for improving self-care and outcome in patients with HF.

Exenatide infusion decreases atrial natriuretic peptide levels by reducing cardiac filling pressures in type 2 diabetes patients with decompensated congestive heart failure.

BACKGROUND: The vascular effects exerted by GLP-1 are mediated by several synergistic mechanisms such as involvement of nitric oxide and natriuresis. Recently, it was demonstrated that atrial natriuretic peptide (ANP) is essential for the glucagon-like peptide-1 (GLP-1)-stimulated vascular smooth muscle relaxation that mediates anti-hypertensive action in rodents. Therefore a GLP-1-ANP axis has been suggested. The aim of this study was to investigate whether this effect can be demonstrated in patients with type 2 diabetes and congestive heart failure. METHODS: The study was a post hoc analysis of a randomized double-blinded, placebo-controlled trial. Twenty male patients with type 2 diabetes and congestive heart failure were randomized to receive a 6-h infusion of exenatide or placebo. Cardiac filling pressures were measured by right heart catheterization, and plasma levels of ANP, N-terminal pro-brain natriuretic peptide, and exenatide were measured at baseline and at the end of the exenatide infusion. RESULTS: Exenatide infusion resulted in a significant decrease of circulating ANP levels compared with placebo, concomitant with a decrease in pulmonary capillary wedge pressure (PCWP), pulmonary artery pressure (PAP) and right arterial pressure (RAP), and increased cardiac output. There was no correlation between plasma ANP levels and exenatide levels. A negative correlation between ANP levels and PCWP, PAP, and RAP, which remained significant after adjustment for plasma exenatide levels, was demonstrated during exenatide infusion. CONCLUSIONS: Exenatide infusion decreases cardiac filling pressure and ANP levels. The reduction of ANP levels was primarily because of the reduction in cardiac filling pressure, independent of exenatide levels. It seems unlikely that this was mediated via ANP. TRIAL REGISTRATION: http://www.isrctn.org/ISRCTN47533126.

Heart failure diagnosis in primary health care: clinical characteristics of problematic patients. A clinical judgement analysis study.

BACKGROUND: Early detection of chronic heart failure has become increasingly important since the introduction of effective treatment. However, clinical diagnosis of heart failure is known to be difficult, especially in mild cases or early in the course of the disease. The purpose of this study is to analyse how patient characteristics contribute to difficulties in diagnosing systolic heart failure. DESIGN: A Clinical Judgement Analysis study of 40 case vignettes based on authentic patients, including relevant clinical data except echocardiography. SETTING: Primary health care and two cardiology outpatient clinics in Stockholm. SUBJECTS: 70 participants with different types of clinical experience; 27 specialists in general practice, 22 cardiologists, and 21 medical students. MAIN OUTCOME MEASURES: The assessed probability of heart failure for each case vignette, and the disagreement between the participants. The number of clinical variables (cues) indicative of heart failure in the case vignettes. RESULTS: The ten case vignettes with the least diverging assessments more often had increased relative cardiac volume and atrial fibrillation. No further specific clinical patterns could be found in subgroups of the case vignettes. The ten case vignettes with the most diverging assessments were those with an intermediate number of clinical variables. The case vignettes with the least diverging assessments more often represented patients with cardiac enlargement and atrial fibrillation. CONCLUSION: Diagnosing mild heart failure is difficult, as these patients are not easy to characterise. In our study, a larger number of positive cues resulted in more diagnostic conformity among the participants, and the most important information was cardiac enlargement. The importance of more objective diagnostic methods in diagnosing suspected cases of heart failure should be emphasised.

Percutaneous left-ventricular support with the Impella-2.5-assist device in acute cardiogenic shock: results of the Impella-EUROSHOCK-registry.

BACKGROUND: Acute cardiogenic shock after myocardial infarction is associated with high in-hospital mortality attributable to persisting low-cardiac output. The Impella-EUROSHOCK-registry evaluates the safety and efficacy of the Impella-2.5-percutaneous left-ventricular assist device in patients with cardiogenic shock after acute myocardial infarction. METHODS AND RESULTS: This multicenter registry retrospectively included 120 patients (63.6±12.2 years; 81.7% male) with cardiogenic shock from acute myocardial infarction receiving temporary circulatory support with the Impella-2.5-percutaneous left-ventricular assist device. The primary end point evaluated mortality at 30 days. The secondary end point analyzed the change of plasma lactate after the institution of hemodynamic support, and the rate of early major adverse cardiac and cerebrovascular events as well as long-term survival. Thirty-day mortality was 64.2% in the study population. After Impella-2.5-percutaneous left-ventricular assist device implantation, lactate levels decreased from 5.8±5.0 mmol/L to 4.7±5.4 mmol/L (P=0.28) and 2.5±2.6 mmol/L (P=0.023) at 24 and 48 hours, respectively. Early major adverse cardiac and cerebrovascular events were reported in 18 (15%) patients. Major bleeding at the vascular access site, hemolysis, and pericardial tamponade occurred in 34 (28.6%), 9 (7.5%), and 2 (1.7%) patients, respectively. The parameters of age >65 and lactate level >3.8 mmol/L at admission were identified as predictors of 30-day mortality. After 317±526 days of follow-up, survival was 28.3%. CONCLUSIONS: In patients with acute cardiogenic shock from acute myocardial infarction, Impella 2.5-treatment is feasible and results in a reduction of lactate levels, suggesting improved organ perfusion. However, 30-day mortality remains high in these patients. This likely reflects the last-resort character of Impella-2.5-application in selected patients with a poor hemodynamic profile and a greater imminent risk of death. Carefully conducted randomized controlled trials are necessary to evaluate the efficacy of Impella-2.5-support in this high-risk patient group.

Intravenous levosimendan vs. dobutamine in acute decompensated heart failure patients on beta-blockers.

AIMS: The aim of this study is to compare the effects of a 24 h intravenous infusion of levosimendan and a 48 h infusion of dobutamine on invasive haemodynamics in patients with acutely decompensated chronic NYHA class III-IV heart failure. All patients were receiving optimal oral therapy including a beta-blocker. METHODS AND RESULTS: This was a multinational, randomized, double-blind, phase IV study in 60 patients; follow-up was 1 month. There was a significant increase in cardiac index and a significant decrease in pulmonary capillary wedge pressure (PCWP) at 24 and 48 h for both dobutamine and levosimendan. The improvement in cardiac index with levosimendan was not significantly different from dobutamine at 24 h (P = 0.07), but became significant at 48 h (0.44 +/- 0.56 vs. 0.66 +/- 0.63 L/min/m(2); P = 0.04). At 24 h, the reduction in the mean change in PCWP from baseline was similar for levosimendan and dobutamine, however, at 48 h the difference was more marked for levosimendan (-3.6 +/- 7.6 vs. -8.3 +/- 6.7 mmHg; P = 0.02). No difference was observed between the groups for change in NYHA class, beta-blocker use, hospitalizations, treatment discontinuations or rescue medication use. Reduction in B-type natriuretic peptide (BNP) was significantly greater with levosimendan at 48 h (P = 0.03). According to physician's assessment, the improvement in fatigue (P = 0.01) and dyspnoea (P = 0.04) was in favour of dobutamine treatment, and hypotension was significantly more frequent with levosimendan (P = 0.007). No increase in atrial fibrillation or ventricular tachycardia was seen in either group. CONCLUSION: A 24 h levosimendan infusion achieved haemodynamic and neurohormonal improvement that was at least comparable at 24 h and superior at 48 h to a 48 h dobutamine infusion.

Cardiovascular effects and cardiopulmonary plasma gradients following intravenous infusion of neuropeptide Y in humans: negative dromotropic effect on atrioventricular node conduction.

Neuropeptide Y (NPY) is co-released with noradrenaline from sympathetic nerves, has a strong vasoconstrictive action, and causes an attenuation of parasympathetic action in animal experiments. The plasma level of NPY is greatly elevated in patients with congestive heart failure, but the clinical relevance of this finding is unclear. Central haemodynamic effects, cardiac conduction system electrophysiology and coronary sinus blood flow were therefore studied in two sets of experiments, each carried out on seven healthy men. In the first series, NPY was given intravenously at doses of 3, 10 and 30 pmol.min(-1).kg(-1), and in the second it was given as a bolus injection of 90, 200 or 900 pmol/kg, which resulted in plasma concentrations similar to those seen in heart failure patients. During continuous infusion of NPY, systemic blood pressure increased slightly, but myocardial perfusion, cardiac output, pulmonary arterial pressure, cardiac conduction intervals and atrioventricular (AV) node functional measures remained unchanged. In contrast, the bolus injection of NPY evoked prolongation and block (in four out of seven subjects) of AV node conduction, but did not affect haemodynamic variables, apart from a minor increase in systemic blood pressure. Impaired AV node conduction is a novel observation, which might reflect a baroreceptor-mediated vagal reflex, or - more likely - an NPY-induced direct negative dromotropic effect, caused by a reduction of the L-type calcium current as observed in vitro, or a combination of the two.

Randomized controlled intervention in cardiovascular drug treatment in nursing homes.

OBJECTIVE: To study drug treatment of patients with cardiovascular diseases (heart failure, post-myocardial infarction, angina pectoris, hypertonia or cardiac valvular disease) in nursing homes and assess effect of medication advice. INTERVENTION: The patients were randomized to an intervention or control group. Medication reviews were made by one specialist in clinical pharmacology and one in cardiology. Symptoms related to heart failure or adverse reactions to cardiovascular drugs were recorded using a questionnaire. Quality of life and activities of daily living (ADL) were assessed and follow-ups performed after 2 weeks and 3 months. Outcome measures were changes of drug therapy and the global scores computed from symptoms scales. RESULTS: Eighty patients were randomized. They had a mean age of 87 years and their average number of drugs was 9.6. Changed drug therapy was suggested in 40 patients and the advice was followed by the responsible physicians in 19 patients. The physicians mostly followed advice for changed furosemide therapy but not for introducing an ACE-inhibitor, probably due to uncertain diagnosis and need for follow-up after initiation of such therapy. No significant changes from baseline to later follow-up were found in the mean total scores of any questionnaire. CONCLUSION: Intervention did not affect cardiovascular symptoms. Drug revisions should involve more than one class of drugs in order to be cost-effective.