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Aims: Heart failure (HF) nurse practitioners (NPs) are an important part of the HF specialist team, and their impact on the cost-effectiveness of their role is unknown. The aim of this study was to determine the cost-effectiveness of a HF NP inpatient service compared with current practice of no HF NP service from a health system perspective at 12 months and 3 years., Methods and Results: We developed a Markov model to estimate costs, effects, and cost-effectiveness for hospitalized HF patients and seen by a HF NP service compared with usual care at 12 months and 3 years. Costs and effects were taken from a retrospective observational cohort study. Transition probabilities and utilities were derived from published studies. A total of 500 patients were included (250 patients in the HF NP service vs. 250 patients in usual care). Average age was 77.7 ± 11 years, and 54% were male. At 12 months, the HF NP group was cheaper and more effective compared with no HF NP [$23 031 vs. $25 111 (AUD), respectively; quality-adjusted life years (QALYs) were 0.68 in HF NP group compared with 0.66 in usual care]. The incremental cost-effectiveness ratio showed a savings of $109 474 per QALY gained at 12 months and a savings of $270 667 per QALY gained at 3 years in favour of the HF NP service., Conclusion: The HF NP service was cost-effective with lower costs and higher QALYs compared with no HF NP service. Economic evaluations alongside randomized controlled trials are warranted., Competing Interests: Conflict of interest: D.L.H. reports Consultancy, Advisory Board, Educational or Research Funds from Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Kaneka, Lundbeck, Merck, Novartis, Pfizer, Regeneron, Sanofi, Servier, and Vifor. The other authors declare that there is no conflict of interest., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: Heart failure nurse practitioners (HF NPs) are an emerging component of the heart failure (HF) specialist workforce but their impact in an inpatient setting is untested. The aim of this paper is to explore the impact of an inpatient HF NP service on 12-month all-cause rehospitalizations, emergency department (ED) presentations, and mortality in patients hospitalized with HF compared with usual hospital care., Methods and Results: Retrospective, two-group comparative design involving patients (n = 408) admitted via ED with acute HF to a metropolitan quaternary hospital between January 2013 and August 2017. Doubly robust estimation with augmented inverse probability weighting (DR-AIPW) was used to account for the non-random allocation of patients to usual hospital care or the HF NP service in addition to usual in-hospital care. Among 408 patients (186 usual care and 222 HF NP service) admitted with acute HF, the mean age was 76.5 [standard deviation (SD) 12.0] years and 56.4% (n = 230) were male. After IPW adjustment, patients seen by the HF NP service had a lower risk of 12-month rehospitalization (61.3 vs. 78.3% usual care; difference -16.9%, 95% CI: -26.4%, -6.6%) and ED presentations (12.6 vs. 22.0%; difference -9.4%, 95% CI: -17.3%, -1.4%) with no difference in 6- or 12-month mortality. The HF NP service improved referrals to a home visiting programme that was available to HF patients (64.4 vs. 45.4%; difference 19%, 95% CI: 8.8%, 28.8%)., Conclusion: Additional support by an inpatient HF NP service has the potential to significantly reduce rehospitalizations and ED presentations over 12 months. Further evidence from a multicentre randomized control trial is warranted., Competing Interests: Conflict of interest: D.L.H.: Consultancy, Advisory Board, Educational or Research Funds from Amgen, AstraZeneca, Bayer, Boehringer-Ingelheim, Kaneka, Lundbeck, Merck, Novartis, Pfizer, Regeneron, Sanofi, Servier, Vifor. Other authors declared no conflict of interest., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Introduction: This consensus statement of Australian clinicians provides new recommendations for the pharmacological management of heart failure based on studies reported since the publication of the 2018 Australian heart failure guidelines., Main Recommendations: ▪Use of sodium-glucose cotransporter 2 (SGLT2) inhibitors to prevent hospitalisation for heart failure in type 2 diabetes mellitus can be extended to patients with multiple cardiovascular risk factors, albuminuric chronic kidney disease, or atherosclerotic cardiovascular disease. ▪New evidence supports the use of a mineralocorticoid receptor antagonist (finerenone) to prevent heart failure in type 2 diabetes mellitus associated with albuminuric chronic kidney disease. ▪In addition to renin angiotensin system inhibitors (angiotensin receptor neprilysin inhibitor preferred), beta blockers and mineralocorticoid receptor antagonists, an SGLT2 inhibitor (dapagliflozin or empagliflozin) is recommended in all patients with heart failure with reduced left ventricular ejection fraction (LVEF ≤ 40%) (HFrEF). Lower quality evidence supports these therapies in patients with heart failure with mildly reduced LVEF (41-49%) (HFmrEF). ▪A soluble guanylate cyclase stimulator (vericiguat), selective cardiac myosin activator (omecamtiv mecarbil) and, if iron deficient, intravenous iron (ferric carboxymaltose) provide additional benefits in persistent HFrEF. ▪An SGLT2 inhibitor (empagliflozin) should be considered in patients with heart failure with preserved LVEF (≥ 50%) (HFpEF). Key changes in management from this statement: This document broadens the scope of angiotensin receptor neprilysin inhibitor use in patients with HFrEF and HFmrEF. SGLT2 inhibitor use expands to become a cornerstone therapy in HFrEF, with increasing evidence to support its use in HFmrEF and HFpEF., (© 2022 The Authors. Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

Background: Heart failure is increasing in prevalence, creating a greater public health and economic burden on our health care system. With a rising proportion of hospitalisations for heart failure with preserved ejection fraction (HFpEF) compared to heart failure with reduced ejection fraction (HFrEF) and lack of proven therapies for HFpEF, patient characterisation and defining clinical outcomes are important in determining optimal management of heart failure patients. There is scarce Australian-specific data with regards to the burden of disease of patients with HFpEF which further limits our ability to appropriately manage this syndrome., Aim: To determine the characteristics, management practices and outcomes of patients with HFpEF compared to patients diagnosed with HFrEF., Method: Data was sourced from the Victorian Cardiac Outcomes Registry-Heart Failure (VCOR-HF) snapshot of patients admitted with acute heart failure to one of 16 Victorian health services between 2014-2017 over one consecutive month annually. Outcomes measured were in-hospital mortality, and 30-day readmission and mortality., Results: Of the 1,132 HF patients, 436 patients were diagnosed with HFpEF and were more likely to be female (59%) and older (81.5±9.8 vs 73.2±14.5 years). They were also more likely to have hypertension (80%), atrial fibrillation (59.9%), chronic obstructive airways disease (36.2%) and chronic kidney disease (68.8%). Patients with HFrEF were more likely to have ischaemic heart disease with a history of previous myocardial infarction (36.6%), percutaneous coronary intervention and cardiac bypass surgery (35.2%). There were no significant differences in 30-day mortality between HFpEF and HFrEF (10.2% vs 7.8%; p=0.19, respectively) and 30-day readmission rates (22.1% vs 25.9%; p=0.15, respectively)., Conclusion: VCOR-HF Snapshot data provides important insight into the burden of acute heart failure. Whilst patients with HFpEF and HFrEF have differing clinical profiles, morbidity, mortality and re-admission rates are similar., (Copyright © 2021. Published by Elsevier B.V.)

Background: Acute decompensated heart failure (ADHF) is the most common cause of hospital admission in patients over 65, with poorer outcomes demonstrated in rural versus metropolitan areas. The aim of this study was to compare the in-hospital and post-discharge management of ADHF patients admitted to rural versus metropolitan hospitals in Victoria., Methods: Data from the Victorian Cardiac Outcomes Registry, Heart Failure (VCOR-HF) project was used. This was a prospective, observational, non-randomised study of consecutive patients admitted to participating hospitals in Victoria, Australia, with ADHF as their primary diagnosis over four 30-day periods during consecutive years. All patients were followed up for 30 days post discharge., Results: 1,357 patients (1,260 metropolitan, 97 rural) were admitted to study hospitals with ADHF during the study periods. Cohorts were similar in age (average 76.87±13.12 yrs) and percentage of male gender (56.4% overall). Metropolitan patients were more likely to have diabetes (44.4% vs 34.0%, p=0.046), kidney disease (65.8% vs 37.1%, p<0.01) and anaemia (31.9% vs 19.6%, p=0.01). There was no significant difference in length of stay between metropolitan and rural patients (7.49 vs 6.37 days, p=0.12). There was no significant difference between metropolitan and rural patients in 30-day rehospitalisations (19.1% vs 11.6%, p=0.07, respectively) and all-cause 30-day mortality (8.2% vs 4.1%, p=0.15, respectively). Metropolitan patients were significantly more likely to have seen their general practitioner (GP) (68.1% vs 53.2%, p<0.01) or attend an outpatient clinic (35.9% vs 10.6%, p<0.01) by 30 days. There was no significant difference in number of days to follow-up of any kind between groups. Referrals to a heart failure home visiting program remained low overall (19.9%)., Conclusion: There was no significant difference in 30-day rehospitalisations or mortality between patients admitted to rural versus metropolitan hospitals. Geographical discrepancies were noted in follow-up by 30 days, with significantly more metropolitan patients having seen a doctor by 30 days post-discharge. Overall follow-up rates remain suboptimal., (Copyright © 2021 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Iron deficiency and depression are prevalent comorbidities in the setting of heart failure. Both conditions are associated with poorer patient outcomes including mortality, hospitalisation and quality of life. Iron replacement has come to the fore as a means to improve patient outcomes. This review aims to assess the current literature regarding the benefits of iron supplementation for iron deficient heart failure patients including potential improvements in depression., Methods and Results: The databases of Medline, EMBASE, the Cochrane library of systematic reviews, Central Register of Controlled Trials, PubMed, Web of Science and ClinicalTrials.gov were searched for studies with relevant patient outcomes. A total of 18 studies were identified and included in the review. In essence, intravenous iron was found to be beneficial for New York Heart Association (NYHA) classification, quality of life measures, heart failure (HF) hospitalisation and aerobic capacity. Oral iron however was not beneficial. Research surrounding intravenous iron improving cardiovascular mortality, time to first hospitalisation and changes in depression status is lacking., Conclusions: Further research is required to elucidate the advantages of intravenous iron for iron deficient heart failure patients on their depression, mortality and first admission to hospital. Consensus is required regarding which form of iron and the treatment regime that should be adopted for future clinical guidelines., (Copyright © 2021. Published by Elsevier B.V.)

Congestive Heart Failure (CHF) is an emerging epidemic. Within one generation, the medical community has learned much of CHF syndromes. It has two distinct mechanisms, systolic and diastolic abnormalities, to account for the common CHF presentation. It is complex as it challenges the available health care services, resource, and funding models in providing an equitable service across the health continuum. Despite the improvement in many cardiovascular diseases, some CHF outcomes like readmissions and costs have increased. The reinvigoration of evidence- based medicine, the development of health services models of care, and standardisation of disease processes with taxonomies have also occurred within the same time span. These processes, however, need to be linked with health policy as presented in white papers. In this paper, we explore achieving optimal CHF guideline-recommended outcomes as the science approaches realworld translation., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

At least half of all heart failure (CHF) patients will have a comorbidity that could be undertreated, requires additional speciality input and/or polypharmacy. These patients are then at risk of iatrogenic and disease-related complications and readmissions if not closely supervised. Common comorbidities of relevance are cardiorenal and cardiometabolic syndromes (DM, obesity, OSA), chronic airways disease, elderly age, and accompanying pharmacotherapies. The structure of community practice often leaves primary, speciality, and allied health care in silos. For example, cardiology speciality training in Australia creates excellent sub-specialists to deliver diagnostic and therapeutic advances. A casualty of this process has been the gradual alienation of general cardiology toward general internal medical specialists and primary care practitioners. The consequences are largely noticed in community practice. The issue is compounded by suboptimal communication of information. This review explores these issues from a cardiology sub-speciality lens; firstly cross speciality areas that are important for cardiologists to maintain their skill, and finally, to obtain a brief overview of disease management and identify game-changing common denominators such as endothelial dysfunction and self-management., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Purpose: The Minnesota Living with Heart Failure Questionnaire (MLHFQ) is a widely used condition-specific measure of quality of life (QoL) in patients with heart failure. To use information from the MLHFQ in an economic evaluation, the MLHFQ must be mapped onto a preference-based measure of QoL. This study aims to develop a mapping algorithm between the MLHFQ and the Assessment of Quality of Life (AQoL) 8D utility instrument in patients with dilated cardiomyopathy (DCM)., Methods: MLHFQ and AQoL-8D data were collected on 61 Australian adults with idiopathic DCM or other non-hypertrophic cardiomyopathies. Three statistical methods were used as follows: ordinary least squares (OLS) regression, the robust MM estimator, and the generalised linear models (GLM). Each included a range of explanatory variables. Model performance was assessed using key goodness-of-fit measures, the mean absolute error (MAE), and the root-mean-square error (RMSE)., Results: The MLHFQ summary score and AQoL-8D utility scores were strongly correlated (r =  - 0.83, p < 0.0001) and the two subscales of the MLHFQ were correlated with the eight dimensions of the AQoL-8D. Utility scores were predicted with acceptable precision based on responses to the MLHFQ physical, emotional, social, and other subscales. OLS and GLM performed similarly with MAE and RMSE ranging 0.086-0.106 and 0.114-0.130, respectively., Conclusion: The mapping algorithm developed in this study allows the derivation of AQoL-8D utilities from MLHFQ scores for use in cost-effectiveness analyses and most importantly, enables the economic evaluation of alternative heart failure therapy options when only the MLHFQ has been collected.

Background: Patients admitted to hospital with acute heart failure (AHF) are at increased risk of readmission and mortality post-discharge. The aim of the study was to examine health service utilisation within 30 days post-discharge from an AHF hospitalisation., Methods: This was a prospective, observational, non-randomised study of consecutive patients hospitalised with acute HF to one of 16 Victorian hospitals over a 30-day period each year and followed up for 30 days post-discharge. The project was conducted annually over three consecutive years from 2015 to 2017., Results: Of the 1,197 patients, 56.3% were male with an average age of 77±13.23 years. Over half of the patients (711, 62.5%) were referred to an outpatient clinic and a third (391, 34.4%) to a HF disease management program. In-hospital mortality was 5.1% with 30 day-mortality of 9% and readmission rate of 24.4%. Patients who experienced a subsequent readmission less than 10 days post-discharge and between 11 and 20 days post-discharge had a five- to six-fold increase in risk of mortality (adjusted OR 5.02, 95% CI 2.11-11.97; OR 6.45, 95% CI 2.69-15.42; respectively) compared to patients who were not readmitted to hospital. An outpatient appointment within 30 days post-discharge significantly reduced the risk of 30-day mortality by 81% (95% CI 0.09-0.43)., Conclusion: Patients admitted to hospital with AHF who experience a subsequent readmission within 20 days post-discharge are at increased risk of dying. However, early follow-up post-discharge may reduce this risk. Early post-discharge follow-up is vital to address this vulnerable period after a HF admission., (Copyright © 2020 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Objective: Depression exacerbates the burden of heart failure and independently predicts mortality. The aim of this study was to investigate which specific symptoms of depression predict all-cause mortality in systolic heart failure patients., Methods: Consecutive outpatients with heart failure and impaired left ventricular ejection fraction (LVEF), attending an Australian metropolitan heart function clinic between 2001 and 2011, were enrolled. The Cardiac Depression Scale (CDS) was completed as a component of usual care. Baseline clinical characteristics were drawn from hospital databases. The primary end-point was all-cause mortality, obtained from the Australian National Death Index., Results: A total of 324 patients (68.5% male) were included (mean age at enrolment = 66.8 ± 14.36 years), with a median follow-up time of 6.7 years (95% CI 5.97-7.39) and a mortality rate of 50% by the census date. Mean LVEF = 31.0 ± 11.31%, with 25% having NYHA functional class of III or IV. Factor analysis of the CDS extracted six symptom dimensions: Hopelessness, Cognitive Impairment, Anhedonia/Mood, Irritability, Worry, and Sleep Disturbance. Cox regression analyses identified Hopelessness (HR 1.024, 95% CI 1.004-1.045, p = .018) and Cognitive Impairment (HR 1.048, 95% CI 1.005-1.093, p = .028) as independent risk markers of all-cause mortality, following adjustment of known prognostic clinical factors., Conclusion: Hopelessness and cognitive impairment are stronger risk markers for all-cause mortality than other symptoms of depression in systolic heart failure. These data will allow more specific risk assessment and potentially new targets for more effective treatment and management of depression in this population., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Exercise confidence predicts exercise adherence in heart failure (HF) patients. The association between simple tests of functional capacity on exercise confidence are not known., Objectives: To evaluate the association between a single 6-min walk test (6MWT) and exercise confidence in HF patients., Methods: Observational study enrolling HF outpatients who completed the Cardiac Depression Scale and an Exercise Confidence Survey at baseline and following the 6MWT. Paired t-test was used to compare repeated-measures data, while Repeated Measures Analysis of Covariance was used for multivariate analysis., Results: 106 HF patients were enrolled in the study (males, 82%; mean age, 64 ± 12 years). Baseline Exercise Confidence was inversely associated with age (p < 0.01), NYHA class (p < 0.001), and depression (p < 0.001). The 6MWT was associated with an improvement in Exercise Confidence (F(1,92) = 5.0, p = 0.03) after adjustment for age, gender, HF duration, NYHA class and depression., Conclusions: The 6MWT is associated with improved exercise confidence in HF patients., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Chronic heart failure (CHF) is a common, debilitating condition associated with significant health and economic burden. CHF management is multidisciplinary, however, achieving better health relies on a collaborative effort and patient engagement in self-care. Despite the importance of self-care in CHF, many patients have poor adherence to their medical and lifestyle regimens, in particular with regards to engaging in physical exercise. The patient's confidence in their ability, otherwise known as self-efficacy, is an important determinant of CHF health outcomes, most likely due to its effect on the uptake of CHF self-care activities especially exercise initiation and maintenance. Self-efficacy is responsive to experience such as exercise training, however the critical components of exercise interventions to improve self-efficacy have yet to be determined. This narrative review provides an overview of the role of self-efficacy in exercise adherence in CHF., (Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Hospital admissions for heart failure are predicted to rise substantially over the next decade placing increasing pressure on the health care system. There is an urgent need to redesign systems of care for heart failure to improve evidence-based practice and create seamless transitions through the continuum of care. The aim of the review was to examine systems of care for heart failure that reduce hospital readmissions and/or mortality., Method: Electronic databases searched were: Ovid MEDLINE, EMBASE, CINAHL, grey literature, reviewed bibliographies and Cochrane Central Register of Controlled Trials for randomised controlled trials, non-randomised trials and cohort studies from 1 st January 2008 to 4 th August 2015. Inclusion criteria for studies were: English language, randomised controlled trials, non-randomised trials and cohort studies of systems of care for patients diagnosed with heart failure and aimed at reducing hospital readmissions and/or mortality. Three reviewer authors independently assessed articles for eligibility based on title and abstract and then full-text. Quality of evidence was assessed using Newcastle-Ottawa Scale for non-randomised trials and GRADE rating tool for randomised controlled trials., Results: We included 29 articles reporting on systems of care in the workforce, primary care, in-hospital, transitional care, outpatients and telemonitoring. Several studies found that access to a specialist heart failure team/service reduced hospital readmissions and mortality. In primary care, a collaborative model of care where the primary physician shared the care with a cardiologist, improved patient outcomes compared to a primary physician only. During hospitalisation, quality improvement programs improved the quality of inpatient care resulting in reduced hospital readmissions and mortality. In the transitional care phase, heart failure programs, nurse-led clinics, and early outpatient follow-up reduced hospital readmissions. There was a lack of evidence as to the efficacy of telemonitoring with many studies finding conflicting evidence., Conclusion: Redesigning systems of care aimed at improving the translation of evidence into clinical practice and transitional care can potentially improve patient outcomes in a cohort of patients known for high readmission rates and mortality.

Chronic heart failure (CHF) among Aboriginal/Indigenous Australians is endemic. There are also grave concerns for outcomes once acquired. This point is compounded by a lack of prospective and objective studies to plan care. To capture the essence of the presented topic it is essential to broadly understand Indigenous health. Key words such as 'worsening', 'gaps', 'need to do more', 'poorly studied', or 'future studies should inform' occur frequently in contrast to CHF research for almost all other groups. This narrative styled opinion piece attempts to discuss future directions for CHF care for Indigenous Australians. We provide a synopsis of the problem, highlight the treatment gaps, and define the impediments that present hurdles in optimising CHF care for Indigenous Australians.

Congestive heart failure (CHF) therapeutics is generated through a well-described evidence generating process. Phases 1 - 3 of this process are required prior to approval and widespread clinical use. Phase 3 in almost all cases is a methodologically sound randomized controlled trial (RCT). After this phase it is generally accepted that the treatment has a significant, independent and prognostically beneficial effect on the pathophysiological process. A major criticism of RCTs is the population to whom the result is applicable. When this population is significantly different from the trial cohort the external validity comes into question. Should the continuation of the evidence generating process continue these problems might be identified. Post marketing surveillance through phase 4 and comparative effectiveness studies through phase 5 trials are often underperformed in comparison to the RCT. These processes can help identify remote adverse events and define new hypotheses for community level benefits. This review is aimed at exploring the post-marketing scene for CHF therapeutics from an Australian health system perspective. We explore the phases of clinical trials, the level of evidence currently available and options for ensuring greater accountability for community level CHF clinical outcomes.

Congestive heart failure (CHF) is a chronic and often devastating cardiovascular disorder with no cure. There has been much advancement in the last two decades that has seen improvements in morbidity and mortality. Clinicians have also noted variations in the responses to therapies. More detailed observations also point to clusters of diseases, phenotypic groupings, unusual severity and the rates at which CHF occurs. Medical genetics is playing an increasingly important role in answering some of these observations. This developing field in many respects provides more information than is currently clinically applicable. This includes making sense of the established single gene mutations or uncommon private mutations. In this thematic series which discusses the many factors that could be relevant for CHF care, once established treatments are available in the communities; this section addresses a contextual role for medical genetics.

Psychosocial factors play an important role in the development and progression of cardiovascular diseases (CVD), such as chronic heart failure (CHF). In particular, psycho-cognitive disturbance is common in CHF, which presents additional challenges to secondary prevention and management strategies. This review provides a summary of the contemporary psycho-cardiology literature, including coverage of common mood and cognitive symptoms, and explores some of the pathophysiologic evidence linking psycho-cognition to CHF, with particular emphasis on sympathetic nervous system activation and neuroendocrine functioning. Social support is identified as a strategy by which to reduce depressive symptoms, manage cognitive impairment and to, potentially, improve health outcomes through improved patient self care and adherence. Recent research outcomes suggest that the integration of family caregivers into CHF psycho-educational disease management programs, as providers and recipients of support, may achieve best outcomes. In this regard, couples-oriented strategies that promote communication, emotional attachment and support may enhance healthpromoting behaviours in patients and their partners.

Background: Beta-adrenergic blockade has been shown to improve left ventricular function, reduce hospital admissions and improve survival in chronic heart failure with reduced ejection fraction (HFrEF), with mortality reduction starting early after beta-adrenergic receptor blocker initiation and being dose-related. The aim of this pilot study was to determine the effectiveness of a nurse-led titration clinic in improving the time required for patients to reach optimal doses of the beta-adrenergic receptor blocking agents., Method: We conducted a prospective pilot randomized controlled trial. Twenty eight patients with CHF were randomized to optimisation of beta-adrenergic receptor blocker therapy over six months by either a nurse-led titration (NLT) clinic, led by a nurse specialist with the support of a cardiologist in a CHF clinic, or by their primary care physician (usual care (UC)). The primary endpoint was time to maximal beta-adrenergic receptor blocker dose. The secondary end-point was the proportion of patients reaching the target dose of beta-adrenergic receptor blocker by six months., Results: The patients were predominantly men (72%), age 67 ± 16 years; New York Heart Association (NYHA) functional class I (32%), II (44%) and III (20%); baseline left ventricular ejection fraction 33 ± 10%, and a low mean Charlson co-morbidity score of 2.5 ± 1.4. The time to maximum dose was shorter in the NLT group compared to the UC group (90 ± 14 vs 166 ± 8 days, p < 0.0005). At six months, in the NLT group there were nine patients (82%) on high dose and one patient (9%) on low dose beta-adrenergic receptor blocker compared to the UC group with five (42%) patients reaching maximum dose and five (42%) patients on low dose (p = 0.04). The patients allocated to the NLT group also had significantly less worsening of depression between baseline and six months (p = 0.006)., Conclusion: A NLT clinic improves optimisation of beta-adrenergic receptor blocker therapy through increasing the proportion of patients reaching maximal dose and facilitating rapid up-titration of beta-adrenergic receptor blocker agents in patients with chronic HFrEF., Trial Registration: Australian Clinical Trials Registry (ACTRN012606000383561).

Prevalence of Heart Failure with Preserved Ejection (HFPEF) has been rising steadily in the recent past. Studies have shown that at least half of patients presenting with symptoms and signs of heart failure (HF) have preserved left ventricular ejection fraction, i.e. HFPEF, and that this portion of the HF population consists predominantly of women, older age group, and people with hypertension and other cardiovascular risk factors. The morbidity and mortality associated with HFPEF are much higher than the normal population. Chronic hypertension is the most common cause in addition to age, with suggestion of up to 60% of patients with HFPEF being hypertensive. Addressing the specific aetiology and aggressive risk factor modification remain the mainstay in the treatment of HFPEF. Current guidelines recommend the management should involve treatment of hypertension, control of heart rate, venous pressure reduction, and prevention of myocardial ischemia. This review aims to discuss the role of hypertension in the pathophysiology, risk stratification and prognosis of HFPEF, as well as the current available data on various antihypertensive options in this population.

Aims and Objectives: To compare the efficacy of chronic heart failure management programmes (CHF-MPs) according to a scoring algorithm used to quantify the level of applied interventions-the Heart Failure Intervention Score (HF-IS)., Background: The overall efficacy of heart failure programmes has been proven in several meta-analyses. However, the debate continues as to which components are essential in a heart failure programme to improve patient outcomes., Design: Prospective cohort study of patients participating in heart failure programmes., Method: Forty-eight of 62 (77%) programmes in Australia participating in a national register of CHF-MPs were evaluated using the HF-IS: derived from a summed and weighted score of each intervention applied by the CHF-MP (27 interventions overall). The CHF-MPs were prospectively categorised as relatively low (HF-IS < 190 - n = 39 programmes & 407 patients) or high (HF-IS ≥ 190 - n = 9 programmes & 166 patients) in complexity. Six-month morbidity and mortality rates in 573 consecutively recruited patients with systolic dysfunction and in New York Heart Association Class II-IV were prospectively examined., Results: Patients exposed to CHF-MPs with a high HF-IS had a lower rate of unplanned, all-cause hospitalisation (n = 24, 14% vs. n = 102, 25%) compared with CHF-MPs with a low HF-IS within six months. On an adjusted basis, CHF-MPs with a high HF-IS were associated with a reduced risk of unplanned hospitalisation and/or death within six months and remained event-free longer., Conclusion: High complexity CHF-MPs applying more evidence-based interventions are associated with a higher event-free survival over six months., Relevance to Clinical Practice: The HF-IS is an easy-to-use evidence-based tool to assist programme coordinators to improve the quality of their heart failure programme which may also improve patient outcomes., (© 2013 Blackwell Publishing Ltd.)

Anemia and chronic kidney disease are common in patients with heart failure (HF) and are associated with adverse outcomes. We analyzed the effect of cardiorenal anemia (CRA) syndrome, defined as anemia (hemoglobin <130 g/L for men, <120 g/L for women) and stage 3 or greater chronic kidney disease (estimated glomerular filtration rate <60 ml/min/1.73 m(2)), in outpatients with HF. Consecutive patients with HF were prospectively enrolled from 2000 to 2005 (n = 748). The baseline clinical characteristics, pathology test results, and medication use were compared between those with and without CRA syndrome. The primary end point was all-cause mortality. The mean follow-up was 2.5 ± 1.6 years, with a left ventricular ejection fraction <45% present in 70% of patients. Angiotensin-converting enzyme inhibitors, β blockers, and spironolactone were used in 87%, 67%, and 37%, respectively. CRA syndrome was present in 224 patients (30%). These patients had greater all-cause mortality (51% vs 26%, p <0.001), older age (mean 77 ± 8 vs 67 ± 14 years, p <0.001), and greater rates of diabetes mellitus (35% vs 23%, p <0.001) and ischemic heart disease (50% vs 35%, p <0.001). The independent predictors of mortality were CRA syndrome (hazard ratio 2.0, 95% confidence interval 1.4 to 2.8, p <0.001), left ventricular systolic dysfunction per grade (hazard ratio 1.5, 95% confidence interval 1.3 to 1.8, p <0.001), the absence of a β blocker (hazard ratio 1.6, 95% confidence interval 1.1 to 2.2, p = 0.005), New York Heart Association class per class (hazard ratio 1.5, 95% confidence interval 1.2 to 1.9, p <0.01), and age per decade (hazard ratio 1.6, 95% confidence interval 1.4 to 2.0, p <0.001). In conclusion, CRA syndrome was common in patients with HF and was an independent predictor of all-cause mortality. Consideration should be given to identifying CRA syndrome and modifying reversible factors., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: There is a high prevalence of depression in patients with heart failure (HF) that is associated with worsening prognosis. The value of using a reliable and valid instrument to measure depression in this population is therefore essential. We validated the Cardiac Depression Scale (CDS) in heart failure patients using a model of ordinal unidimensional measurement known as Mokken scaling., Findings: We administered in face-to-face interviews the CDS to 603 patients with HF. Data were analysed using Mokken scale analysis. Items of the CDS formed a statistically significant unidimensional Mokken scale of low strength (H<0.40) and high reliability (Rho>0.8)., Conclusions: The CDS has a hierarchy of items which can be interpreted in terms of the increasingly serious effects of depression occurring as a result of HF. Identifying an appropriate instrument to measure depression in patients with HF allows for early identification and better medical management.

Aim: The aim of this study was to develop a potential scoring algorithm for interventions in a chronic heart failure management programme--the Heart Failure Intervention Score--to facilitate quality improvement and programme auditing., Background: The overall efficacy of chronic heart failure management programmes has been demonstrated in several meta-analyses. However, meta-analyses did not determine individual interventions in a programme that resulted in beneficial patient outcomes., Design: A prospective cross-sectional survey design., Method: All chronic heart failure management programmes in Australia (n = 62), identified by a national register, were surveyed to determine programme characteristics and interventions., Results: Of the 62 national chronic heart failure management programmes, 48 (77%) completed the survey and 27 individual interventions were identified. Variability in the use of the key interventions was common among the programmes. Each intervention was given an arbitrary weighted score according to the level of supportive evidence available and a total score calculated. Programmes were then categorised into low or high complexity based on several interventions implemented and their weighted score. A total score of ≥190 (median = 178, interquartile range 176-195) was used to divide programmes into two groups. Nine programmes were categorised into high Heart Failure Intervention Score group and majority of these were based in the acute hospital setting (78%). In the low Heart Failure Intervention Score group, there were 39 programmes of which there were a higher proportion of community-based programmes (38%) and programmes in small community hospitals (10%)., Conclusion: The Heart Failure Intervention Score provides a potential evidence-based quality improvement tool through which a set of minimum standards can be developed. Implementation of the Heart Failure Intervention Score provides guidance to programme coordinators to enable monitoring of standards of heart failure programmes, which may potentially result in better patient outcomes., Relevance to Clinical Practice: The Heart Failure Intervention Score is an evidence-based tool that can be easily used by heart failure programme coordinators to ensure that their programme is evidence-based, which will improve the quality of their programme and potentially programme outcomes., (© 2011 Blackwell Publishing Ltd.)

Background: The Angiotensin Converting Enzyme (ACE) gene may influence the risk of heart disease and the response to various forms of exercise training may be at least partly dependent on the ACE genotype. We aimed to determine the effect of ACE genotype on the response to moderate intensity circuit resistance training in chronic heart failure (CHF) patients., Methods: The relationship between ACE genotype and the response to 11weeks of resistance exercise training was determined in 37 CHF patients (New York Heart Association Functional Class=2.3±0.5; left ventricular ejection fraction 28±7%; age 64±12years; 32:5 male:female) who were randomised to either resistance exercise (n=19) or inactive control group (n=18). Outcome measures included V˙O(2peak), peak power output and muscle strength and endurance. ACE genotype was determined using standard methods., Results: At baseline, patients who were homozygous for the I allele had higher V˙O(2peak) (p=0.02) and peak power (p=0.003) compared to patients who were homozygous for the D allele. Patients with the D allele, who were randomised to resistance training, compared to non-exercising controls, had greater peak power increases (ID p<0.001; DD p<0.001) when compared with patients homozygous for the I allele, who did not improve. No significant genotype-dependent changes were observed in V˙O(2peak), muscle strength, muscle endurance or lactate threshold., Conclusion: ACE genotype may have a role in exercise tolerance in CHF and could also influence the effectiveness of resistance training in this condition., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

A characteristic feature of chronic heart failure (CHF) is reduced exercise tolerance. Several factors contributing to this have been identified, including alterations in central haemodynamics, skeletal muscle oxygen utilisation and respiratory muscle dysfunction. This review focuses on abnormalities identified in respiratory muscle structure and function in CHF and recent evidence for the benefit of selective inspiratory muscle training in CHF. Included in this review are findings from original investigations, with a specific focus on recent published data., (Crown Copyright © 2011. Published by Elsevier B.V. All rights reserved.)

Background: The Cardiac Depression Scale (CDS) is a disease-specific instrument for measuring depression in cardiac patients. This study was designed to validate the CDS in an Iranian population., Methods: Translation and back-translation of the 26-item CDS scale was performed using recommended procedures. The Iranian translation of the CDS (I-CDS) was administered to 261 individuals in Iran, concurrently with the Beck Depression Inventory. The factor structure of the I-CDS was examined using exploratory factor analysis procedures to enable comparison with previous psychometric evaluation of the CDS. Receiver operating characteristic curves were used to examine the ability of the I-CDS to discriminate between categories of depression., Results: First-order exploratory factor analysis uncovered two robust factors, consistent with the second-order dimensions originally reported by the developers of this instrument. Cronbach's alpha was .88 for the total 26-item I-CDS, indicating satisfactory internal consistency of the I-CDS. Intercorrelation between the total scores for the I-CDS and BDI was .62 (p<.001). For the I-CDS cut-off of 90, the sensitivity was 85%, and specificity was 61% with a computed area under the curve (AUC) of 0.81 (95% CI, 0.76-0.87). For the I-CDS cut-off of 100, the sensitivity was 81%, and specificity was 63% with a computed AUC of 0.81 (95% CI, 0.76-0.87)., Conclusion: This validation study of the Iranian version of the CDS demonstrated that it is an acceptable, reliable, and valid measure of depression in people with heart disease.

Chronic heart failure (CHF) is a complex syndrome characterised by progressive decline in left ventricular function, low exercise tolerance and raised mortality and morbidity. Regular exercise participation has been shown to be a safe and effective treatment modality in the majority of CHF patients, partially reversing some of the maladaptations evident in myocardial and skeletal muscle function, and resulting in improvements in physical fitness and quality of life, and perhaps reduced mortality. The volume and intensity of exercise that is recommended depends on the syndrome severity, however in most patients it should consist of a combination of low-to-moderate intensity aerobic (endurance) exercise on most days of the week and individually prescribed low-to-moderate intensity resistance (strength) training at least twice per week. Additionally, all patients should be closely monitored prior to and during exercise for contraindications by an appropriately trained health professional. The purpose of this statement is to inform and guide exercise practitioners and health professionals in the safe and effective prescription and supervision of exercise for patients with CHF., (2010. Published by Elsevier Ltd.)

Background: We aimed to determine the role of skeletal muscle mitochondrial ATP production rate (MAPR) in relation to exercise tolerance after resistance training (RT) in chronic heart failure (CHF)., Methods and Results: Thirteen CHF patients (New York Heart Association functional class 2.3 +/- 0.5; Left ventricular ejection fraction 26 +/- 8%; age 70 +/- 8 years) underwent testing for peak total body oxygen consumption (VO(2peak)), and resting vastus lateralis muscle biopsy. Patients were then randomly allocated to 11 weeks of RT (n = 7), or continuance of usual care (C; n = 6), after which testing was repeated. Muscle samples were analyzed for MAPR, metabolic enzyme activity, and capillary density. VO(2peak) and MAPR in the presence of the pyruvate and malate (P+M) substrate combination, representing carbohydrate metabolism, increased in RT (P < .05) and decreased in C (P < .05), with a significant difference between groups (VO(2peak), P = .005; MAPR, P = .03). There was a strong correlation between the change in MAPR and the change in peak total body oxygen consumption (VO(2peak)) over the study (r = 0.875; P < .0001), the change in MAPR accounting for 70% of the change in VO(2peak)., Conclusions: These findings suggest that mitochondrial ATP production is a major determinant of aerobic capacity in CHF patients and can be favorably altered by muscle strengthening exercise.

Background: We sought to determine whether skeletal muscle oxidative capacity, fiber type proportions, and fiber size, capillary density or muscle mass might explain the impaired exercise tolerance in chronic heart failure (CHF). Previous studies are equivocal regarding the maladaptations that occur in the skeletal muscle of patients with CHF and their role in the observed exercise intolerance. Methods and results Total body O(2) uptake (VO(2peak)) was determined in 14 CHF patients and 8 healthy sedentary similar-age controls. Muscle samples were analyzed for mitochondrial adenosine triphosphate (ATP) production rate (MAPR), oxidative and glycolytic enzyme activity, fiber size and type, and capillary density. CHF patients demonstrated a lower VO(2peak) (15.1+/-1.1 versus 28.1+/-2.3 mL.kg(-1).min(-1), P<.001) and capillary to fiber ratio (1.09+/-0.05 versus 1.40+/-0.04; P<.001) when compared with controls. However, there was no difference in capillary density (capillaries per square millimeter) across any of the fiber types. Measurements of MAPR and oxidative enzyme activity suggested no difference in muscle oxidative capacity between the groups., Conclusions: Neither reductions in muscle oxidative capacity nor capillary density appear to be the cause of exercise limitation in this cohort of patients. Therefore, we hypothesize that the low VO(2peak) observed in CHF patients may be the result of fiber atrophy and possibly impaired activation of oxidative phosphorylation.

Background: Resistance exercise training was applied to patients with chronic heart failure (CHF) on the basis that it may partly reverse deficiencies in skeletal muscle strength and endurance, aerobic power (VO(2peak)), heart rate variability (HRV), and forearm blood flow (FBF) that are all putative factors in the syndrome., Methods and Results: Thirty-nine CHF patients (New York Heart Association Functional Class=2.3+/-0.5; left ventricular ejection fraction 28%+/-7%; age 65+/-11 years; 33:6 male:female) underwent 2 identical series of tests, 1 week apart, for strength and endurance of the knee and elbow extensors and flexors, VO(2peak), HRV, FBF at rest, and FBF activated by forearm exercise or limb ischemia. Patients were then randomized to 3 months of resistance training (EX, n=19), consisting of mainly isokinetic (hydraulic) ergometry, interspersed with rest intervals, or continuance with usual care (CON, n=20), after which they underwent repeat endpoint testing. Combining all 4 movement patterns, strength increased for EX by 21+/-30% (mean+/-SD, P<.01) after training, whereas endurance improved 21+/-21% (P<.01). Corresponding data for CON remained almost unchanged (strength P<.005, endurance P<.003 EX versus CON). VO(2peak) improved in EX by 11+/-15% (P<.01), whereas it decreased by 10+/-18% (P<.05) in CON (P<.001 EX versus CON). The ratio of low-frequency to high-frequency spectral power fell after resistance training in EX by 44+/-53% (P<.01), but was unchanged in CON (P<.05 EX versus CON). FBF increased at rest by 20+/-32% (P<.01), and when stimulated by submaximal exercise (24+/-32%, P<.01) or limb ischemia (26+/-45%, P<.01) in EX, but not in CON (P<.01 EX versus CON)., Conclusions: Moderate-intensity resistance exercise training in CHF patients produced favorable changes to skeletal muscle strength and endurance, VO(2peak), FBF, and HRV.

Purpose: The objective of this study was to assess the reliability of testing skeletal muscle strength and peak aerobic power in a clinical population of patients with chronic heart failure (CHF)., Methods: Thirty-three patients with CHF (New York Heart Association (NYHA) Functional Class 2.3 +/- 0.5; left ventricular ejection fraction 27% +/- 7%; age 65 +/- 9 years; 28:5 male-female ratio) underwent two identical series of tests (T1 and T2), 1 week apart, for strength and endurance of the muscle groups responsible for knee extension/flexion and elbow extension/flexion. The patients also underwent two graded exercise tests on a bicycle ergometer to measure peak oxygen consumption (VO(2peak)). Three months later, 18 of the patients underwent a third test (T3) for each of the measures. Means were compared using MANOVA with repeated measures for strength and endurance, and ANOVA with repeated measures for VO(2peak)., Results: Combining data for all four movement patterns, the expression of strength increased from T1 to T2 by 12% +/- 25% (P <.001; intraclass correlation coefficient [ICC] = 0.89). Correspondingly, endurance increased by 13% +/- 23% (P =.004; ICC = 0.87). Peak oxygen consumption was not significantly different (16.2 +/- 0.8 and 16.1 +/- 0.8 mL.kg(-1).min(-1) for T1 and T2, respectively; P =.686; ICC = 0.91). There were no significant differences between T2 and T3 for strength (2% +/- 17%; P =.736; ICC = 0.92) or muscle endurance (-1% +/- 15%; P =.812; ICC = 0.96), but VO(2peak) decreased from 16.7 +/- 1.2 to 14.9 +/- 0.9 mL.kg(-1).min(-1) (-10% +/- 18%; P =.021; ICC = 0.89)., Conclusions: These data suggest that in a population of patients with CHF, a familiarization trial for skeletal muscle strength testing is necessary. Although familiarization is not required for assessing oxygen consumption as a single measurement, VO(2peak) declined markedly in the 3-month period for which these patients were followed. Internal consistency within patients was high for the second and third strength trials and the first and second tests of VO(2peak).

Background: There is a high prevalence of depression in patients with heart failure (HF) that is associated with worsening prognosis. The value of using a reliable and valid instrument to measure depression in this population is therefore essential. We validated the Cardiac Depression Scale (CDS) in heart failure patients using a model of ordinal unidimensional measurement known as Mokken scaling. Findings: We administered in face-to-face interviews the CDS to 603 patients with HF. Data were analysed using Mokken scale analysis. Items of the CDS formed a statistically significant unidimensional Mokken scale of low strength (H<0.40) and high reliability (Rho>0.8). Conclusions: The CDS has a hierarchy of items which can be interpreted in terms of the increasingly serious effects of depression occurring as a result of HF. Identifying an appropriate instrument to measure depression in patients with HF allows for early identification and better medical management. [ABSTRACT FROM AUTHOR]

Reduced exercise tolerance is an independent predictor of hospital readmission and mortality in patients with heart failure (HF). Exercise training for HF patients is well established as an adjunct therapy, and there is sufficient evidence to support the favorable role of exercise training programs for HF patients over and above the optimal medical therapy. Some of the documented benefits include improved functional capacity, quality of life (QoL), fatigue, and dyspnea. Major trials to assess exercise training in HF have, however, focused on heart failure with reduced ejection fraction (HFREF). At least half of the patients presenting with HF have heart failure with preserved ejection fraction (HFPEF) and experience similar symptoms of exercise intolerance, dyspnea, and early fatigue, and similar mortality risk and rehospitalization rates. he role of exercise training in the management of HFPEF remains less clear. his article provides a brief overview of pathophysiology of reduced exercise tolerance in HFREF and heart failure with preserved ejection fraction (HFPEF), and summarizes the evidence and mechanisms by which exercise training can improve symptoms and HF. Clinical and practical aspects of exercise training prescription are also discussed. [ABSTRACT FROM AUTHOR]

INTRODUCTION: This study will examine the effects of combined aerobic and resistance training on left ventricular remodeling in diabetic patients with diastolic dysfunction. This is the first randomized controlled trial to look for effects of combined strength training and aerobic exercise on myocardial function as well as other clinical, functional, or psychological parameters in diabetic patients with isolated diastolic dysfunction, and will provide important insights into the potential management strategies for heart failure with preserved ejection fraction. METHODS AND ANALYSIS: This is a prospective, randomized controlled investigator initiated single center trial. Diabetic patients with LV diastolic dysfunction suitable for exercise training intervention will be randomized to three months of a supervised combination of aerobic and strength training exercises, or supervised light stretching (control arm). Pre and post intervention assessment will include stress echocardiography, peak aerobic power with 12-lead ECG, dual-energy X-ray absorptiometry, muscle strength, the capacity to perform activities of daily living (ADLs), and questionnaires to assess self-perceived quality of life and symptoms of depression. The primary endpoint is to compare any change in tissue Doppler-derived LV systolic and early diastolic velocities. ETHICS AND DISSEMINATION: The current trial protocol has been approved by the Human Research Ethics Committee of Austin Health and the University of Melbourne, Melbourne. The study will be performed in accordance with the Declaration of Helsinki. The investigator, regardless of the outcome, will publish the results of the study. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12610000943044. [ABSTRACT FROM AUTHOR]

Background: Correction of functional mitral regurgitation in ischaemic heart disease, with a better risk:benefit ratio is an unmet need. A new methodology of external approach of correcting the annulus (BACE: basal annuloplasty of the cardia externally) to repair and stabilise the mitral valve without entering the heart was used in this prospective study. This study was conducted to assess the efficacy and safety of the concept BACE device in patients with moderate functional mitral valve regurgitation as a result of symptomatic coronary artery disease and heart failure. Methods: The study involved a group of patients who had complex cardiac surgery between January 2000 and December 2001 at the University of Melbourne Campus Hospitals, Melbourne, Australia. Twelve patients with ischaemic heart disease, congestive heart failure, and moderate functional mitral regurgitation (MR) (minimum 2+) underwent the BACE procedure along with coronary artery bypass grafting and/or left ventricular reconstruction. Results: No peri-operative complications or deaths related to surgical procedures occurred in the study group. There were no clinically significant problems related to the BACE implantation procedure. Mean MR grade was significantly improved in BACE Group from baseline to post BACE implant (2.8 pre- and 0.3 post-surgery; P <0.05). Mean left ventricular ejection fraction (LVEF) was significantly improved (P <0.05) and maintained at 6, 12, and 18 months post BACE implant compared to pre-operative baseline, with a mean improvement of 20% (24% at baseline to 44% at 18 months post-operatively) (P <0.05). In addition to that the patients also had a significant improvement (P <0.05) in mean New York Heart Association (NYHA) functional status from pre-operative baseline to 6 and 18 months post procedure with BACE. Conclusions: External stabilisation of the cardiac base with BACE was associated with significant improvement in mitral valve function with no significant intra-operative or post-operative problems in patients with moderate functional MR. These findings support further study of BACE in functional MR. [Copyright &y& Elsevier]

Jeremy A. Patterson, Steve E. Selig, Deidre Toia, Voramont Bamroongsuk, David L. Hare. Forearm Blood Flow In Individuals With CHF And Age-Matched Healthy Volunteers: A Study And Historical Review. JEPonline 2007;10(5):1-15. This study examined forearm blood flow (FBF) in individuals with chronic heart failure (CHF) at rest, moderate exercise, and following limb occlusion. FBF was measured by venous occlusion plethysmography in CHF patients (n = 43) and healthy age-matched volunteers (n = 8) at rest and during exercise consisting of intermittent isometric hand squeezing at 15, 30, and 45% of maximum voluntary contraction (MVC). Peak vasodilatory capacity was also determined following the release of an occluding arm cuff. FBF was lower in CHF patients during exercise and during peak reactive hyperemia (PRH) compared to healthy volunteers, but there was no significant difference between groups at rest. Peak vasodilatory capacity was significantly higher in healthy volunteers than the CHF group ((30.6 ± 8.6 ml⋅100 mL-1⋅min-1 and 18.3 ± 6.9 ml⋅100 mL-1⋅min-1, respectively). Local blood flow stimulation in response to exercise or limb occlusion is reduced in individuals with CHF, however, there was no difference in resting flows between the two groups, suggesting vasodilatory medication may restore resting blood flow to healthy values. [ABSTRACT FROM AUTHOR]

This study examined the accuracy of current recommended guidelines for prescribing exercise intensity using the methods of percentage of heart rate reserve (%HRR), percentage of VO2 peak (%VO2peak) and percentage of VO2 reserve (%VO2R) in a clinical population of chronic heart failure (CHF) patients. The precision of prescription of exercise intensity for 45 patients with stable CHF (39:6 M:F, 65±9 yrs (mean±SD)) was investigated. VO2peak testing is relatively common among patients with cardiac disease, but the assessment of VO2rest is not common practice and the accepted standard value of 3.5 mL/kg/min is assumed in the application of %VO2R (%VO2R3.5). In this study, VO2rest was recorded for 3 min prior to the start of a symptom-limited exercise test on a cycle ergometer. Target exercise intensities were calculated using the VO2 corresponding to 50 or 80 %HRR, VO2peak and VO2R. The VO2 values were then converted into prescribed speeds on a treadmill in km/hr at 1 %grade using ACSM's metabolic equation for walking. Target intensities and prescribed treadmill speeds were also calculated with the %VO2R method using the mean VO2rest value of participants (3.9 mL/kg/min) (%VO2R3.9). This was then compared to the exercise intensities and prescribed treadmill speeds using patient's measured VO2rest. Error in prescription correlates the difference between %VO2R3.5 and %VO2R3.9 compared to %VO2R with measured VO2rest. Prescription of exercise intensity through the %HRR method is imprecise for patients on medications that blunt the HR response to exercise. %VO2R method offers a significant improvement in exercise prescription compared to %VO2peak. However, a disparity of 10 % still exists in the %VO2R method using the standard 3.5 mL/kg/min for VO2rest in the %VO2R equation. The mean measured VO2rest in the 45 CHF patients was 11 % higher (3.9±0.8 mL/kg/min) than the standard value provided by ACSM. Applying the mean measured VO2rest value of 3.9 mL/kg/min rather than the standard assumed value of 3.5 mL/kg/min proved to be closer to the prescribed intensity determined by the actual measured resting VO2. These results suggest that the %HRR method should not be used to prescribe exercise intensity for CHF patients. Instead, VO2 should be used to prescribe exercise intensity and be expressed as %VO2R with measured variables (VO2rest and VO2peak). [ABSTRACT FROM AUTHOR]

Background: Telemedicine and digital health technologies hold great promise for improving clinical care of heart failure. However, inconsistent and contradictory findings from randomized controlled trials have so far discouraged widespread adoption of digital health in routine clinical practice. We undertook this review study to summarize the study outcomes of the use of exploring the evidence for telemedicine in the clinical care of patients with heart failure and readmissions. Methods: We inspected the references of guidelines and searched PubMed for randomized controlled trials published over the past 10 years on the use of telemedicine for reducing readmission in heart failure. We utilized a modified realist review approach to identify the underlying contextual mechanisms for the intervention(s) in each randomized controlled trial, evaluating outcomes of the intervention and understanding how and under what conditions they worked. To provide uniformity, all extracted data were synthesized using adapted domains from the taxonomy for disease management created by the Disease Management Taxonomy Writing Group. Results: A total of 12 papers were eligible, 6 of them supporting and 6 others undermining the use of telemedicine for improving heart failure readmission. In general terms, those studies not supporting the use of telemedicine were multicentre, publicly funded, with large amount of participants, and long duration. The patients had also better rates of treatment with angiotensin-converting enzyme inhibitors/angiotensin II receptor blocker and beta-blockers, and telemonitoring and automatic transmission of vital signs were less utilized, in comparison with the studies in which telemedicine use was supported. The analysis of the environment, intensity, content of interventions, method of communication, quality of the underlying model of care and the ability, capability, and interest from health workers can help us to envisage probabilities of success of telemedicine use. Conclusions: A realist lens may aid to understand whom and in which circumstances the use of telemedicine can add any substantial value to traditional models of care. Wider outcome criteria beyond major adverse cardiovascular events, for example, cost efficacy, should also be considered as appropriate for effecting guidelines on care delivery when robust prognostic therapeutics already exist. [ABSTRACT FROM AUTHOR]

Aims: We aimed to confirm the hypothesis that dysglycaemia including in the pre-diabetes range affects a majority of patients admitted with acute coronary syndrome (ACS) and is associated with worse outcomes.Methods: In this prospective observational cohort study, consecutive inpatients aged ≥ 54 years with ACS were uniformly tested and categorised into diabetes (prior diagnosis/ HbA1c ≥ 6.5%, ≥48 mmol/mol), pre-diabetes (HbA1c 5.7-6.4%, 39-47 mmol/mol) and no diabetes (HbA1c ≤ 5.6%, ≤38 mmol/mol) groups.Results: Over two years, 847 consecutive inpatients presented with ACS. 313 (37%) inpatients had diabetes, 312 (37%) had pre-diabetes and 222 (25%) had no diabetes. Diabetes, compared with no diabetes, was associated with higher odds of acute pulmonary oedema (APO, odds ratio, OR 2.60, p < 0.01), longer length of stay (LOS, incidence rate ratio, IRR 1.18, p = 0.02) and, 12-month ACS recurrence (OR 1.86, p = 0.046) after adjustment, while no significant associations were identified for pre-diabetes. Analysed as a continuous variable, every 1% (11 mmol/mol) increase in HbA1c was associated with increased odds of APO (OR 1.28, P = 0.002) and a longer LOS (IRR 1.05, P = 0.03).Conclusions: The high prevalence of dysglycaemia and association with poorer clinical outcomes justifies routine HbA1c testing to identify individuals who may benefit from cardioprotective anti-hyperglycaemic agents and, lifestyle modification to prevent progression of pre-diabetes. [ABSTRACT FROM AUTHOR]

This feature article for the thematic series on congestive heart failure (CHF) readmissions aims to outline important gaps in guidelines for patients with multiple comorbidities and the elderly. Congestive heart failure diagnosis manifests as a 3-phase journey between the hospital and community, during acute, chronic stable, and end-of-life (palliative) phases. This journey requires in variable intensities a combination of multidisciplinary care within tertiary hospital or ambulatory care from hospital outpatients or primary health services, within the general community. Management goals are uniform, ie, to achieve the lowest New York Heart Association class possible, with improvement in ejection fraction, by delivering gold standard therapies within a CHF program. Comorbidities are an important common denominator that influences outcomes. Comorbidities include diabetes mellitus, chronic obstructive airways disease, chronic renal impairment, hypertension, obesity, sleep apnea, and advancing age. Geriatric care includes the latter as well as syndromes such as frailty, falls, incontinence, and confusion. Many systems still fail to comprehensively achieve all aspects of such programs. This review explores these factors. [ABSTRACT FROM AUTHOR]

BACKGROUND: Beta-blockers (BBs) are the mainstay prognostic medication for all stages of chronic heart failure (CHF). There are many classes of BBs, each of which has varying levels of evidence to support its efficacy in CHF. However, most CHF patients have one or more comorbid conditions such as diabetes, renal impairment, and/or atrial fibrillation. Patient enrollment to randomized controlled trials (RCTs) often excludes those with certain comorbidities, particularly if the symptoms are severe. Consequently, the extent to which evidence drawn from RCTs is generalizable to CHF patients has not been well described. Clinical guidelines also underrepresent this point by providing generic advice for all patients. The aim of this review is to examine the evidence to support the use of BBs in CHF patients with common comorbid conditions. METHODS: We searched MEDLINE, PubMed, and the reference lists of reviews for RCTs, post hoc analyses, systematic reviews, and meta-analyses that report on use of BBs in CHF along with patient demographics and comorbidities. RESULTS: In total, 38 studies from 28 RCTs were identified, which provided data on six BBs against placebo or head to head with another BB agent in ischemic and nonischemic cardiomyopathies. Several studies explored BBs in older patients. Female patients and non-Caucasian race were underrepresented in trials. End points were cardiovascular hospitalization and mortality. Comorbid diabetes, renal impairment, or atrial fibrillation was detailed; however, no reference to disease spectrum or management goals as a focus could be seen in any of the studies. In this sense, enrollment may have limited more severe grades of these comorbidities. CONCLUSIONS: RCTs provide authoritative information for a spectrum of CHF presentations that support guidelines. RCTs may provide inadequate information for more heterogeneous CHF patient cohorts. Greater Phase IV research may be needed to fill this gap and inform guidelines for a more global patient population. [ABSTRACT FROM AUTHOR]