慢性心衰患者电话干预的随机试验：DIAL试验

目的:明确集中的电话干预能否降低慢性心衰门诊患者死亡或因心衰加重而住院的发生率。设计:多中心、随机对照试验。地点:阿根廷的51个中心(包括公立、私立的医院及流动设施)。参与者:1518例患有稳定的慢性心衰且已接受最佳药物治疗方案治疗的门诊患者,由心脏科主治医师分层后随机分为电话干预组和常规治疗组。干预:在常规治疗的基础上,由一个中心通过护士频繁的电话随访对患者进行教育、辅导和监督。主要观察指标:全因死亡或由于心衰加重而住院。结果:99.5%的患者完成了全部随访。常规治疗组758例患者中由于心衰加重而住院或死亡的比例(235…     

Impact of a Standardized Titration Protocol with Carvedilol in Heart Failure: Safety,Tolerability, and Efficacy—A Report from the GESICA Registry

Grupo de Estudio de la Sobrevida en la Insuficiencia Cardiaca en Argentina (GESICA) studied whether a standardized protocol for the initiation and titration of the β-blocker carvedilol in a multicenter, open-label program would optimize β-blocker use in heart failure (HF) patients. The program included: (1) the carvedilol initiation and titration period, and (2) long-term follow-up at 6 and 12 months. Of 1299 patients in the registry, 504 were excluded due to current therapy; of the remaining 795 eligible patients, 293 were excluded due to contraindications. Of the included patients with follow-up data (n = 316), 93.3% tolerated carvedilol initiation and 47.7% of the patients reached the target dose of 50 mg/day for a mean dose of 39 mg/day. Rates were comparable in the elderly (n = 83), of which 53% achieved a target dose for a mean dose of 43.08 mg/day. This protocol improved therapy rates and achieved target doses quickly (average of 4 visits). Concomitant medications did not have to be adjusted and there were low withdrawal rates (10%) and hospital admissions (7.2%) for HF. Patients were able to maintain carvedilol therapy at 6 and 12 months. These results indicate that a standardized titration protocol, as used in GESICA, for the initiation and titration of β-blockers is well tolerated and may improve β-blocker use in carefully selected heart failure patients.The study authors are members of the GESICA Steering Committee and Subcommittees     

Disease management programs in heart failure. Findings of the DIAL study

Despite significant advances in the treatment of heart failure, patients' quality of life and prognosis are still poor. Hospitalization for decompensated heart failure or due to other causes is frequent in these patients and places a heavy financial burden on the healthcare system. The shortcomings of ambulatory treatment have led to the implementation of disease management programs whose aim is to optimize quality of care and treatment adherence, thereby improving clinical outcome and prognosis, and reducing healthcare costs. The multicenter randomized DIAL study compared treatment administered by means of a centralized telephone intervention by trained nurses with usual care in 1518 ambulatory patients with stable chronic heart failure who were receiving appropriate medical treatment and were being followed up by a cardiologist. This intervention proved effective in increasing treatment adherence, in reducing hospitalization due to heart failure or any cause, in improving quality of life, and in reducing costs. The findings of the DIAL study add to existing evidence that disease management programs have clinical benefits in patients with chronic heart failure and support their use as part of the strategy for ambulatory care in this population.     

Seasonal variation and trends in heart failure morbidity and mortality in a South American community hospital

Circannual variation in cardiovascular events is well-known. Seasonal variation (SV) in heart failure (HF) has been described in the Northern Hemisphere, but there is scarcity of data in South America. The goals of the present study were to (1) describe the SV of admissions and deaths for HF, and (2) describe trends in HF morbidity and mortality in a community hospital in Argentina from 1992 to 1999. The study sample included 6369 admissions. During this period, the number of HF admissions rose by 188% and the rate HF admissions/all admissions increased from 3.28% to 7.84%. In-hospital mortality decreased from 21% to 13%. HF admissions followed a seasonal pattern with a winter-spring predominance. Male and very old patients were the subgroups with the highest SV. The authors identified clear SV in HF deaths and admissions, which raises a different hypothesis about the rationale of HF admissions and provides information for the organization of care and resource allocation.     

Randomized Trial of Telephone Intervention in Chronic Heart Failure (DIAL): study design and preliminary observations

BACKGROUND: In the last few years different approaches based on comprehensive patient care and close surveillance by multidisciplinary teams have shown promising results in heart failure. However, current evidence mainly derives from small and often nonrandomized studies performed at a single center, with selected populations, using dissimilar and complex strategies. We designed a large randomized study to test the hypothesis that a single program, based on a centralized telephone intervention performed by trained nurses, could reduce morbidity and mortality in chronic heart failure. METHODS: The Randomized Trial of Telephone Intervention in Chronic Heart Failure (DIAL) is a randomized, controlled, open trial designed to compare frequent telephone follow-up intervention versus control. We enrolled 1518 patients with stable chronic heart failure and optimal treatment from 51 centers in Argentina. DIAL trial intervention strategy is based on frequent telephone follow-up provided by nurses trained in heart failure and performed from a single surveillance center, assuring a homogeneous and high quality intervention. The primary objective is to determine the effect of the intervention as compared with the usual follow-up on the combined endpoint of all-cause mortality or hospitalization for worsening heart failure. The objectives of the intervention are education, counseling, and monitoring to enhance self-control mechanisms, timely medical visits, diet, and drug therapy compliance. Telephone call frequency was determined according to preestablished criteria of clinical status severity assessed at each phone contact. The study ended in August 2002. CONCLUSION: The results of this study may provide information about mortality, hospitalizations, and quality of life contributing to set standards for management programs in the current treatment of chronic heart failure.