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Background: Diagnosing heart failure (HF) is difficult, relying on medical history, symptoms, and signs only. Clinical guidelines recommend natriuretic peptides (NPs) as an additional diagnostic test, notably to exclude HF in suspected patients. NP testing has been available since 2003 for primary care in the Netherlands, but little is known about its uptake. Aim: To evaluate the trend in ordering and appropriateness of NP testing in primary care. Design & setting: An observational study was performed between January 2005 and December 2013. Nine Dutch general practices participated, with 21 000 registered people (approximately 4300 aged ≥65 years). Method: The total number of patients undergoing NP testing each year was calculated per 1000 patient years (PY) based on the total practice population. NP levels were used to assess whether NP testing was applied to exclude or confirm HF. Results: The number of NP testing increased from 2.5 per 1000 PY in 2005 to 14.0 per 1000 PY in 2013, with a peak in 2009 of 15.6 per 1000 PY. The proportion of participants with N-terminal B-type natriuretic peptide (NTproBNP) below 125 pg/ml (the exclusionary threshold recommended by the European Society of Cardiology [ESC] guidelines on HF) was on average 30%, and highest in the first year (47%). Conclusion: After a rapid uptake of NP testing in primary care from 2005 onwards, the use of it seemed to stabilise after 2009, thus leaving patients who are prone to HF without an optimal diagnostic work-up.

• Home telemonitoring may partly substitute face-to-face contacts in stable outpatients with heart failure. • Stable heart failure patients receiving a non-invasive e-health adjusted care pathway had similar reduction in NT-proBNP values than those receiving usual care with on average four face-to-face contacts a year. • More studies are needed to evaluate substitution of face-to-face contacts by e-health. Home telemonitoring in heart failure (HF) patients may reduce workload of HF nurses by reducing face-to-face contacts. The aim of this study is to assess whether telemonitoring as a substitution could have negative effects as expressed by less reduction in circulating natriuretic peptide levels between baseline and one-year of follow up compared to usual care. A post-hoc analysis of the e-Vita HF trial, a three-arm parallel randomized trial conducted in stable HF patients. Patients were randomized into three arms: (i) usual HF outpatient care, (ii) usual care combined with the use of the website heartfailurematters.org, and (iii) telemonitoring (e-Vita HF platform) instead of face-to-face consultations. Mixed linear model analyses were applied to assess differences in the N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels between the three arms over a year. A total of 223 participants could be included (mean age 67.1 ± 10.1 years, 27% women, New York Heart Association class I–IV; 39%, 38%, 14%, and 9%). The mean left ventricular ejection fraction was 35 ± 10%. The median of routine face-to-face contacts over a year was 1.0 lower (2.0 vs. 3.0) in the third arm compared with usual care. Median NT-proBNP levels did not significantly differ between the three arms. In stable and optimally treated HF patients, telemonitoring causing a reduction of routine face-to-face contacts seems not to negatively affect hemodynamic status as measured by NT-proBNP levels over time. [Display omitted] [ABSTRACT FROM AUTHOR]

Abstract: Background: Elderly heart failure (HF) patients frequently have multiple comorbidities. The prognostic impact of combined comorbidities is poorly quantified in these patients. We assessed the impact of comorbidities on 3-year mortality in geriatric outpatients with newly diagnosed HF. Methods and Results: Of 93 geriatric outpatients with HF (mean age 82.7 years, 36.6% men), 52 patients (55.9%) died within 3 years after HF was diagnosed. Comorbidity was measured with the Charlson Comorbidity Index (CCI). Age- and gender-adjusted hazard ratio (HR) for 3-year mortality was 1.6 (95% confidence interval [CI] 0.9–3.2) for patients with 3–4 CCI points and 3.2 (95% CI 1.5–6.8) for those with >4 CCI points, compared with 1–2 CCI points. After adjustment for age, gender, left ventricular ejection fraction (LVEF), and N-terminal pro–B-type natriuretic peptide, CCI remained predictive of death (CCI 3–4: HR 1.5 (95% CI 0.7–2.9); CCI >4: HR 4.0 (95% CI 1.9–8.8)). In addition to age and gender, the c-statistics for CCI and LVEF were similar (0.63 [95% CI 0.55–0.70] and 0.64 [95% CI 0.56–0.72], respectively). Conclusions: The majority of geriatric outpatients with new HF die within 3 years. Comorbidity, summarized in the CCI, is the strongest independent predictor of mortality. [Copyright &y& Elsevier]