Age and quality of in-hospital care of patients with heart failure

BACKGROUND: Elderly patients may be at risk of suboptimal care. Thus, the relationship between age and quality of care for patients hospitalized for heart failure was examined. METHODS: A cross-sectional study based on retrospective chart review was performed among a random sample of patients hospitalized between 1996 and 1998 in the general internal medicine wards, with a principal diagnosis of congestive heart failure, and discharged alive. Explicit criteria of quality of care, grouped into three scores, were used: admission work-up (admission score); evaluation and treatment during the stay (evaluation and treatment score); and readiness for discharge (discharge score). The associations between age and quality of care scores were analysed using linear regression models. RESULTS: Charts of 371 patients were reviewed. Mean age was 75.7 (+/-11.1) years and 52% were men. There was no relationship between age and admission or readiness for discharge scores. The evaluation and treatment score decreased with age: compared with patients less than 70 years old, the score was lower by -2.6% (95% CI: -7.1 to 1.9) for patients aged 70 to 79, by -8.7% (95% CI: -13.0 to -4.3) for patients aged 80 to 89, and by -19.0% (95% CI: -26.6 to -11.5) for patients aged 90 and over. After adjustment for possible confounders, this relationship was not significantly modified. CONCLUSIONS: In patients hospitalized for congestive heart failure, older age was not associated with lower quality of care scores except for evaluation and treatment. Whether this is detrimental to elderly patients remains to be evaluated.     

Value of basic and intensive management of patients with heart failure; results of a randomised controlled clinical trial

OBJECTIVE: To determine the efficacy of 2 nurse-directed programmes of different intensity for the counselling and follow-up of patients hospitalised for heart failure, compared with standard care by a cardiologist. DESIGN: Multicentre randomised clinical trial (www.trialregister.nl: NCT 98675639). METHOD: A total of 1023 patients were randomized after hospitalisation for heart failure to 1 of 3 treatment strategies: standard care provided by a cardiologist, follow-up care from a cardiologist with basic counselling and support by a nurse specialising in heart failure, or follow-up care from a cardiologist with intensive counselling and support by a nurse specialising in heart failure. Primary end points were the time to rehospitalisation due to heart failure or death and the number of days lost to rehospitalisation or death during the 18-month study period. Data were analysed on an intent-to-treat basis. RESULTS: Mean patient age was 71 years, 38% were women, 50% had mild heart failure and 50% had severe heart failure. During the study, 411 patients (40%) were rehospitalised due to heart failure or died from any cause: 42% in the control group, and 41% and 38% in the basic and intensive support groups, respectively (differences not significant). The time to rehospitalisation or death was similar in the 3 groups: hazard ratios for the basic and intensive support groups versus the control group were 0.96 (95% CI: 0.76-1.21; p = 0.73) and 0.93 (95% CI: 0.73-1.17; p = 0.53), respectively. The number of days lost to rehospitalisation or death was 39,960 in the control group; this number was 15% less in the intervention groups, but the difference was not significant. However, there was a trend toward lower mortality in the intervention groups. In all 3 groups, more visits occurred than planned, which may have had a considerable effect on care, notably in the control group. CONCLUSION: The results of this study indicated that the provision of additional counselling and support by a nurse specialising in heart failure as an adjuvant to intensive follow-up care provided by a cardiologist does not always lead to a reduction in rehospitalisation frequency.     

Psychosocial risk factors and heart failure hospitalization: a prospective cohort study

Prospective studies on the role of psychosocial factors in heart failure development are virtually nonexistent. The authors aimed to address the effect of psychosocial factors on the risk of heart failure hospitalization in men and women free of cardiovascular disease. In 1991-1993, the 8,670 participants of the Copenhagen City Heart Study (Denmark) were asked comprehensive questions on major life events, work-related stress, social network, vital exhaustion, and sleep medication and were followed in nationwide registries until 2007, with less than 0.2% loss to follow-up. Almost one-fourth of the population reported some degree of vital exhaustion. The vital exhaustion score was associated with a higher risk of heart failure in a dose-response manner (P < 0.002), with high vital exhaustion being associated with a 2-fold higher risk of heart failure in both men (hazard ratio = 1.93, 95% confidence interval: 1.20, 3.10) and women (hazard ratio = 2.56, 95% confidence interval: 1.80, 3.65). Contrary to expectation, major life events, social network, and sleeping medication did not play an individual role for heart failure hospitalization. Because of the high prevalence of vital exhaustion in the population, even a modestly higher risk of heart failure associated with vital exhaustion may be of importance in the planning of future preventive strategies for heart failure.     

Digoxin increases mortality among women with congestive heart failure

Digoxin increases mortality in women with congestive heart failure, compared with men; however, the clinical significance of this is unknown since gender is a nonmodifiable risk factor. More importantly, there is a suggestion of harm when looking at women treated with digoxin versus placebo. Since there are other therapies with definite benefit in congestive heart failure (angiotensin-converting enzyme inhibitors, beta-blockers, spironolactone), it is prudent to reconsider the use of digoxin in women with ejection fractions less than 45%.     

双心护理模式在慢性心衰合并抑郁症中的效果

目的 观察双心护理模式在慢性心力衰竭合并抑郁症患者护理中的应用效果.方法 选择高唐县人民医院2018年9月-2019年10月收治的慢性心力衰竭合并抑郁症患者96例进行调查研究,随机分为观察组和对照组,每组各48例.对照组采用常规护理方式,观察组采用双心护理模式.比较两组护理满意度、抑郁自评量表(SDS)和生活质量评分....     

Prediction of coronary heart disease mortality in Busselton, Western Australia: an evaluation of the Framingham, national health epidemiologic follow up study, and WHO ERICA risk scores.

STUDY OBJECTIVES: To evaluate the performance of the Framingham, national health epidemiologic follow up study, and the WHO ERICA risk scores in predicting death from coronary heart disease (CHD) in an Australian population. DESIGN: Cohort follow up study. SETTING AND PARTICIPANTS: The cohort consisted of 1923 men and 1968 women who participated in health surveys in the town of Busselton in Western Australia over the period 1966-81. Baseline assessment included cardiovascular risk factor measurement. Mortality follow up to 31 December 1994 was used. MAIN RESULTS: Risk scores for death from CHD within 10 years based on age, systolic blood pressure, cholesterol, smoking, and BMI were derived from the Busselton study data using logistic regression analysis. Similar risk scores developed from the Framingham, the national health epidemiologic follow up study, and the WHO ERICA cohorts were found to perform just as well in Busselton as the Busselton-derived scores, both before and after controlling the effect of age. There was considerable overlap across the different risk scores in the identification of individuals in the highest quintile of risk. Those in the top 20% of scores included about 41% of deaths from CHD among men and about 63% of deaths from CHD among women. CONCLUSION: Although there is variation in risk score coefficients across the studies, the relative risk predictive performance of the scores is similar. The use of Framingham and other similar risk scores will not be misleading in white Australian populations.     

Clinical characteristics of nursing home residents hospitalized with heart failure

OBJECTIVE: The purpose of this retrospective study was to describe the clinical characteristics of heart failure among nursing home residents hospitalized with heart failure and determine the validity of dyspnea at rest in the diagnosis of heart failure. METHODS: Subjects were nursing home residents hospitalized with a diagnosis of heart failure. Data on demographic and various admission characteristics were collected by chart abstraction. Proportions of patients presenting with various symptoms and signs of heart failure have been described. The diagnosis of heart failure was confirmed using modified Framingham criteria. The sensitivity, specificity, and positive predictive value of the symptom of dyspnea at rest in the diagnosis of heart failure in nursing home residents hospitalized with heart failure were then estimated. RESULTS: Patients (N = 98) were elderly, predominantly female and about one-fifth African-American. Dyspnea at rest was the presenting symptom of 85 (87%) patients. Sixty-eight (69%) patients met modified Framingham criteria for the diagnosis of heart failure. Dyspnea at rest had a sensitivity of 91%, specificity of 23%, and predictive value positive of 73% for diagnosis of heart failure. CONCLUSION: Dyspnea at rest was the most common symptom among this cohort of nursing home residents hospitalized with heart failure and has a potential to play a useful role in the diagnosis of heart failure in these patients.     

全身运动细化评估的脑瘫预警评分的建立

目的 通过高危儿全身运动细化评估的研究,建立扭动运动阶段的脑性瘫痪预警评分。方法 抽取2016年1月-2017年1月徐州市儿童医院康复科建立档案的高危儿为研究对象。分别在纠正年龄4~6周行全身运动评估及全身运动细化评分,纠正年龄4~8周内测试0~1岁52项神经运动检查,在12月龄(纠正年龄44~52周)时,按照脑瘫诊断标准,确定不同发育结局。按照卫生统计学的研究方法,建立扭动运动阶段全身运动细化评估的脑瘫预警评分。结果 扭动运动阶段的全身运动细化评分,在正常组、单调性运动组和痉挛同步性运动组中差异无统计学意义(F=208.186,P<0.001);与52项运动相关评分呈正相关(r=0.968,P<0.001)。本研究的脑瘫预警评分,运动发育正常组(“绿色区”)的范围为27~42分;轻度异常组(“黄色区”)的范围为18~26分;而重度异常组(“红色区”) 的范围则为5~17分,预测效度为92.11%,敏感度为100%,特异度为90.00%,阳性预测值为72.73%,阴性预测值为100%,假阳性率10%,假阴性率为0。结论 建立的脑瘫预警评分,具有较高的敏感性及特异性,较低的假阳性率及假阴性率,可供同行在临床实践中应用。     

Reversal of heart failure remodeling in women

Epidemiological studies suggest that women with heart failure differ from men with heart failure in that their survival is better. Therapeutic trials have not clearly demonstrated a survival benefit for women. This study was to determine the tolerance for high doses of angiotensin-converting enzyme (ACE) inhibitor-nitrates in women versus men and to compare their symptomatic response, exercise tolerance, and ventricular functional improvement over 1 year. Eighty-eight sequential patients with heart failure, 54 men and 34 women with left ventricular ejection fraction < or = 35%, were prospectively followed for 1 year. For all patients, ACE inhibitor-nitrate therapy was intensified. Each patient had three 6-monthly echocardiograms at baseline, at 6 months, and at 1 year, and metabolic stress testing. Patients were 57.3 +/- 12.3 years old, with New York Heart Association (NYHA) class severity 2.6 +/- 1.0. Lisinopril dosages were raised from 14 +/- 14 mg/day to 57 +/- 26 mg/day, isosorbide mononitrate from 15 +/- 27 mg/day to 126 +/- 72 mg/day, and carvedilol (n = 34) to 17 +/- 16 mg/day. Women and men were epidemiologically comparable, with similar baseline echocardiographic parameters (left ventricular ejection fraction 19% +/- 7% versus 17% +/- 6%, respectively). Both tolerated up-titration in medical therapy. Final 12-month ejection fractions were equivalent for women and men at 34% +/- 17% and 34% +/- 13%, respectively, with similar improvements in left ventricular diameters. At 1 year, women had higher resting heart rates and remained more symptomatic with lower exercise capacity. However, the relative changes in NYHA status and aerobic capacity were similar for women and men. Thus, both women and men tolerated uptitrated ACE inhibitor-nitrate medical therapy, with comparable reversal of heart failure remodeling. Although women continued to be more symptomatic than men, relative improvements in symptomatic status, in exercise capacity, and in hospitalization rate were equivalent.     

Comanagement of patients with congestive heart failure by family physicians and cardiologists: frequency, timing, and patient characteristics

BACKGROUND: Many patients with congestive heart failure (CHF) receive care solely from a primary care physician, while some receive care from both a primary care physician and a cardiologist. Patients in the latter type of care relationships have not been described. The principal objectives of our study were to determine what percentage of patients with CHF are comanaged, the characteristics of comanaged CHF patients, and when in the natural history of CHF this relationship is initiated. METHODS: A retrospective record review was conducted of all patients who met the modified Framingham criteria for the diagnosis of CHF in a large community-based family practice office. Comanagement was defined as an ongoing relationship with a cardiologist characterized by a minimum of one visit to the cardiologist's office in the year of evaluation. We divided the natural history of CHF into 4 stages to describe the timing of the initial referral to the cardiologist: I Prediagnosis; II Diagnosis; III Progression; and IV Terminal. RESULTS: Of 151 patients identified with CHF, 36% of the patients were comanaged by a primary care physician and a cardiologist. The comanagement relationship often began early in the development of CHF, 20% at stage I and 54% at stage II. The patients who were comanaged were younger, predominately men, had a greater frequency of myocardial infarction, were more likely to have decreased systolic function, were on more cardiac medications, and had fewer hospitalizations for CHF exacerbations compared with CHF patients managed solely by family physicians. CONCLUSIONS: Comanagement of patients with CHF is a common occurrence, and comanaged CHF patients have distinct characteristics from those managed solely by family physicians. These results have implications for the quality and cost of caring for patients with CHF and suggest that more detailed study is required.     

早期连续性肾脏替代治疗严重脓毒症合并急性左心衰患者的疗效

目的探究早期连续性肾脏替代(Early continuous renal replacement,CRRT)治疗严重脓毒症合并急性左心衰患者的临床疗效及对机体心肌肌钙蛋白(Cardiac troponin I,cTnI)、N端前脑钠肽(N terminal pro brain natriuretic peptide,NT-proBNP)、中性粒细胞/淋巴细胞比值(Neutrophil to lymphocyte ratio,NLR)水平的影响。方法选取胜利油田中心医院2016年1月-2017年12月收治的严重脓毒症合并急性左心衰竭患者79例,按随机数字法分为对照组39例和治疗组40例,对照组患者采用常规治疗,治疗组患者在常规治疗的基础上采用CRRT治疗,比较治疗前后两组患者的急性生理学与慢性健康状况评价系统Ⅱ(Acute physiology and chronic health assessment system II,APACHEⅡ)评分、序贯器官衰竭估计(Sequential organ failure assessment,SOFA)评分、氧合指数及左室射血分数(Left ventricular ejection fraction,LVEF),判断CRRT治疗的疗效,比较治疗前后两组患者的CRP、cTnI、NT-proBNP及NLR水平,分析治疗前后两组患者免疫功能指标(CD4^+、CD8^+、CD4^+/CD8^+、IgA、IgG和IgM)情况。结果治疗前,两组患者APACHEⅡ评分及SOFA评分比较差异无统计学意义;治疗后,两组患者APACHEⅡ评分及SOFA评分均降低,且治疗组各指标水平优于对照组,差异均有统计学意义(P<0.05);治疗后,两组患者氧合指数、LVEF、CD4^+、CD4^+/CD8^+、IgA、IgG和IgM均上升,CD8^+水平下降,且治疗组各指标水平优于对照组,差异均有统计学意义(P<0.05)。结论CRRT治疗可有效改善严重脓毒症合并急性左心衰患者的机体免疫情况,减轻炎症反应,对于患者的预后情况有改善作用。     

Validity of coronary heart diseases and heart failure based on hospital discharge and mortality data in the Netherlands using the cardiovascular registry Maastricht cohort study

Incidence rates of cardiovascular diseases are often estimated by linkage to hospital discharge and mortality registries. The validity depends on the quality of the registries and the linkage. Therefore, we validated incidence rates of coronary heart disease (CHD), acute myocardial infarction, unstable angina pectoris, and heart failure, estimated by this method, against the disease registry of the cardiovascular registry Maastricht cohort study. The cohort consists of 21,148 persons, born between 1927 and 1977, who were randomly sampled from Maastricht and surrounding communities in 1987–1997. Incident cases were identified by linkage to the Netherlands causes of death registry and either the hospital discharge registry (HDR) or the cardiology information system (CIS) of the University Hospital Maastricht. Sensitivities and positive predictive values were calculated using the CIS-based registry as gold standard. Relatively high sensitivities and positive predictive values were found for CHD (72 and 91%, respectively) and acute myocardial infarction (84 and 97%, respectively). These values were considerably lower for unstable angina pectoris (53 and 78%, respectively) and heart failure (43 and 80%, respectively). A substantial number of cases (14–47%) were found only in the CIS-based registry, because they were missed or miscoded in the HDR-based registry. As a consequence, the incidence rates in the HDR-based registry were considerably lower than in the CIS-based registry, especially for unstable angina pectoris and heart failure. Incidence rates based on hospital discharge and mortality data may underestimate the true incidence rates, especially for unstable angina pectoris and heart failure.     

The Framingham Disability Study: relationship of various coronary heart disease manifestations to disability in older persons living in the community.

The relation between coronary heart disease and disability was examined in 2,576 community-dwelling women and men ages 55-88 years. These Framingham Study participants were originally recruited in 1948-51 for an examination of cardiovascular disease. Twenty-seven years later, remaining members of the cohort were interviewed to ascertain physical abilities, and a score on a disability scale was assigned. Multivariate logistic analyses examined disability in relation to uncomplicated angina pectoris (AP), complicated AP, and coronary heart disease other than AP, controlling for possible confounders. In younger and older women and men, uncomplicated and complicated AP were associated with disability. Coronary heart disease other than AP was associated with disability only in the younger men. Congestive heart failure predicted disability only in the women. These results suggest that onset of AP should be recognized as a critical point in the development of disability and that AP is a better predictor of disability than is myocardial infarction or coronary insufficiency.     

Prevention of heart disease in general practice: the use of a risk score

Between 1987 and 1988 seven general practices took part in a pilot study of a predictive risk score for ischaemic heart disease in men aged 40-59 years. The aim was to assess the feasibility and usefulness of this score as part of a coronary prevention programme. The score was generally well received by practice nurses and general practitioners, and found to be helpful as a method of focusing preventive activity. Most chose to reveal the score to the patient, although there was some concern that this could lead to false reassurance being perceived by those with a low score but remediable risk factors. Practitioners were able to use the score as a method for identifying a priority group for intervention, and it is concluded that the risk score is a useful component of health checks.     

Review of death certificate diagnosis of coronary heart disease and heart failure in Japan

Vital statistics for coronary heart disease (CHD) were dramatically influenced by the tenth revision of the International Classification of Diseases (ICD-10) in 1995. To better understand the accuracy of death certificate diagnosis of CHD and heart failure, validation studies in Japan were reviewed. Positive predictive values and sensitivity, calculated as validation measures, varied widely between studies, differing with regard to autopsy rates, amount of information on medical records, and period investigated. However, heart failure, which has been frequently assigned on death certificates in Japan, was validated in some studies. Half of these were evaluated to be sudden deaths, including coronary deaths. Because autopsy-based studies on sudden deaths indicated that 30-50% of these were accounted for by CHD deaths, deaths assigned to heart failure should be taken into consideration in order to determine the actual number of CHD deaths in Japan. Focusing on changes in vital statistics after the 1995 ICD revision, the Oita Cardiac Death Surveys (OCDS) allowed interpretation of its effects on CHD and heart failure. Much of the increase in CHD deaths on vital statistics reflects more false positive cases, particularly for out-of-hospital deaths. Considering the Japanese features of vital statistics for CHD, further epidemiological validation studies are needed in order to confirm the accuracy of CHD death certificate diagnoses and to monitor actual CHD trends in Japan.     

交通事故幸存者创伤后应激障碍的流行情况及预测因素分析

目的了解交通事故幸存者创伤后应激障碍(post traumatic stress disorder,PTSD)的流行情况,并分析相关的预测因素。方法选择2010年10月—2011年5月206例交通事故幸存者,其中,男168例,女38例,年龄(39.8±12.5)岁。采用17项PTSD检测表——特定事件版(PTSD checklist-specific stressor version,PCL-S)进行评估。结果 206例交通事故幸存者中共有51例为可能的PTSD患者,发生率为24.8%;PTSD症状比较女性较男性严重,男性PCL-S得分(26.90±7.70)分,女性(31.46±8.87)分,男女比较差异有统计学意义(P0.05),已婚者较单身者严重,已婚PCL-S得分(28.72±8.07)分,单身(23.00±5.47)分,二者比较差异有统计学意义(P0.05)。结论 PTSD在我国交通事故幸存者中是一种常见的心理疾患,其主要的预测因素包括:性别、年龄、婚姻状况、评估距离创伤时间间隔、躯体康复状况。     

A simple method of assessing the effect of dietary advice to reduce plasma cholesterol

A simple eight-item questionnaire was used to assess the saturated fat content of the diet of participants in a multifactorial trial of the prevention of coronary heart disease. The questionnaire was found to have good repeatability, and a score derived from it correlated significantly with a more lengthy dietary recall method (the 3-day diary) in assessing the amount of saturated fat in the diet: high scores reflected a low saturated fat intake. The score was higher among those advised to reduce their saturated fat intake (suggesting that they had taken the advice) than among those who had been given no advice. Men given personal counseling had higher scores than those who were only sent letters and leaflets containing essentially the same information by post. Among unadvised control men there was no correlation between the score and the plasma cholesterol level; but among the men given advice, the higher their score the greater was the fall in their plasma cholesterol. This highlights the paradox that an individual's current saturated fat intake cannot predict his plasma cholesterol level, yet a change in this level is readily predicted by even a crude assessment of change in dietary fat.     

Double-disease management or one care manager for two chronic conditions: pilot feasibility study of nurse telephonic disease management for depression and congestive heart failure.

This study assessed the feasibility of a telephonic nurse double-disease management program (DDMP) for patients with depression and congestive heart failure. Thirty-five patients with depression and congestive heart failure were entered into a novel DDMP modeled after Wagner's chronic illness care model and implemented as part of a 13-month Breakthrough Series Collaborative administered by the Institute of Healthcare Improvement. Twenty-four patients remained in the program long enough to complete at least one follow-up assessment (ie, 6 weeks or longer). Patients were entered into the program based on depression severity scores from either the interactive voice response (IVR) version of the Hospital Anxiety and Depression Scale (HADS) or the self-administered (or telephonic) Patient Health Questionnaire (PHQ). Because use of the IVR version of the HADS was eliminated after several weeks into the program (because of poor patient acceptance), 19 patients had both entry and follow-up scores on the same instrument (PHQ). Depression "response" was defined as a 50% improvement in PHQ score. Mixed models regression was used to test the statistical significance of change in PHQ scores over time. Patient and clinician reports were obtained to evaluate program acceptability and satisfaction. Eighty-two percent of patients (n = 11) with Major Depressive Disorder (MDD) responded, and 75% of patients (n = 8) with "other depression" (PHQ score < 10) responded. Mean change in PHQ scores for the sample as a whole improved significantly over the 24 weeks of the program (p < 0.0003), as well as for those with major depression and other depression considered separately (p < 0.01 for both). In some patients who refused medication, depression seemed to respond to self-management support interventions of the care manager. Based on patient acceptance and clinicians' reports, the program appeared feasible and possibly effective. DDMP appears feasible and possibly effective. Future clinical trials are warranted.     

综合营养评估工具在心衰患者中的应用价值

目的 对心衰患者所采用的综合营养评估工具及应用价值进行综述，为我国心衰患者的营养相关研究提供理论基础。方法 以“营养”、“心力衰竭”、“nutrition”、“heart failure”等为关键词，查询PubMed、Web of Science、知网等数据库相关文献，综述材料。结果 对心衰患者运用的综合营养评估工具种类较多，各量表信效度较高，营养风险和营养不良检出率较好，但均为普适量表，测评内容不能与心衰患者的临床特征完全相符，开发针对心衰患者的营养评估工具处于起步阶段。结论 综合营养评估工具对心衰患者的营养评估效果较好，未来需要加强针对心衰患者营养量表的研究。