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Condensed Cardiology-Heart Failure



The ESC guidelines recommend a holistic and multidisciplinary management programme, patient monitoring and paliative care  for HF with reduced and preserved ejection fraction. There is no specific recommendation regarding the followup of patients after discharge for an acute episode of decompensation  by the cardiologist or primary care physician.(1)

The American HF guidelines are more specific in this regard,  recomending a follow-up interval between 7 and 14 days or a phone call after 3 days following discharge. (2) Currently there are some initiatives from the national societies trying to setup a coordinated plan to follow up the hospitalised HF patients in order to reduce their high mortality and readmission rate.

Because HFPEF stil represents a big challange for cardiology practice concerning both   diagnosis and treatment, the trial PROMIS-HFpEF Microvascular dysfunction in heart failure with preserved ejection fraction (HFpEF)  was very helpful in understanding the mechanisms of myocardial dysfunction. (3)

Its purpose was to investigate the prevalence of coronary microvascular dysfunction and its association with systemic endotelial dysfunction, HF severity and myocardial dysfunction in a well defined HFPEF population using comprehensive functional imaging approach

The patients included in the trial had diagnosed HFPEF and a recent hospitalisation for HF and the centers were from Sweden, US, Finland and Singapore. The patients were evaluated for coronary flow reserve, systemic microvascular function and myocardial function. Coronary microvascular dysfunction was highly prevalent, 75%, among the HFPEF patients. This trial brings a new light in the mechanisms of HFPEF. The demonstration of mycrovascular dysfunction may be a promising composite risk  marker and a terapeutic target in HFPEF.

Another importand field of research in HF management is remote patient monitoring. TIM-HF2 trial investigated the impact of remote patient monitoring (RPM) on mortality, morbidity and quality of life in a population recently hospitalised for HF. (4) Another end-point was assessing the regional differences, rural versus urban, in the outcome. It was a pospective, randomised  controlled, open, parallel-group, multi-centre trial and included 1538 patients, recruited between Aug 2013 and May 2017 (765 RPM, 773 Usual Care). The results showed that   remote monitoring of hospitalised patients after discharge for 12 month reduces cv hospitalisations, total mortality and HF hospitalisations. It was also an effective approach to overcome regional differences in HF management.

With regards to new medication in HF patients in sinus rhythm and coronary artery disease the long awaited results from the Commander trial were a litte dissapointing.(5) The aim of the trial was  to test the hypothesis that rivaroxaban 2.5mg twice daily added to background therapy compared to placebo will reduce CV death and events in patients with HF reduced EF, coronary artery disease and no atrial fibrillation. 5000 patients were included, after 21 days from the index event they were randomised for either rivaroxaban or placebo on top of standard care. The results showed that there was no difference in primary efficacy outcome between rivaroxaban arm and placebo arm in terms of intention to treat, all-cause mortality, myocardial infarction or stroke. So adding rivaroxaban to standard therapy does not improve the composite end point of all cause mortality, myocardial infarction or stroke nor does it reduce HF rehospitalisation.

Nevertheless continuous efforts will further be made  to discover new treatments, pharmacologic or nonpharmacologic in the attempt to reduce the high mortality of HF. A new proof of the bad outcome of HF patients was recently published in the European Heart Journal confirming that despite advances in HF, the condition remains malignant as some forms of common cancers. (6)

The Study on Heart failure Awareness and Perception Europe and EuroHeart Failure Survey brought the first insight of what happens in the real world regarding HF. The recent published Core needs assesment survey is even more intresting. It was done over 3 continents and over different medical systems.(7)

Only 50% of HF symptoms were assessed by the majority of physicians. Symptoms like forgetfulness, confusion or sputum were frequently missed. Primary care physicians do not consider eco, ECG or lab tests to be essential for diagnosis. The cardiologists identify better HFREF and have difficulties with HFPEF. Primary care physicians identify atrial fibrillation but have difficulties with HFREF and HFPEF and providing patient education. The main HF medication is largely used, slightly lower mineralocorticoid receptor antagonists(MRA). The doses are lower than guideline recomandations and nonpharmacological interventions are done less and their utility is not clear. Less than half of  physicians do not monitor the patiens after dose titration and during followup. 75% of cardiologists and slightly more than half of primary care physicians monitor the serum electrolytes in patients prescribed MRAs but less in patients prescribed ACEI. The comorbidities in patients with HF are less screened. There are substantial gaps in patient education. The referal process is problemematic for both cardiologist and primary care physicians. The nurses are still confused regarding their role in the assessment of patients with HF. In general, nurses' involvement with patient monitoring was lower than that of physicians at all stages of HF management. Cardiac nurses were more involved than primary care nurses, particularly after each dose increment and at the end of medication. Cardiac nurses were significantly less likely than primary care nurses to report not being involved in patient monitoring at all.

Conclusion

The survey concluded that there is was need for further education, reinforcing evidence‐based dosing, titration, indications, and sequencing of HF medications, with an emphasis on diuretics, MRAs, ACE inhibitors, angiotensin receptor blockers, and beta‐blockers.

Clinicians would benefit from detailed guidance on identifying appropriate HF patients for non‐pharmacological interventions.

Nurses may benefit from an educational intervention that models effective patient education around basic HF treatment options.

References

  1. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure Eur J Heart Fail, 2016;18 (8), 891-975.
  2. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013 Oct 15;128(16):1810-52
  3. Shah SJ, Lam CSP, Svedlund S, Saraste A, Hage C, Tan RS, Beussink-Nelson L, Fermer ML, Broberg MA, Gan LM, Lund LH. Prevalence and correlates of coronary microvascular dysfunction in heart failure with preserved ejection fraction: PROMIS-HFpEF. Eur Heart J. 2018 Aug 27:[Epub ahead of print]
  4. Koehler F, Koehler K, Deckwart O, et al. Efficacy of Telemedical Interventional Management in Patients With Heart Failure (TIM-HF2): A Randomised, Controlled, Parallel-Group, Unmasked Trial. Lancet 2018;Aug 25:[Epub ahead of print]
  5. Zannad F1, Anker SD1, Byra WM1, Cleland JGF1, Fu M1, Gheorghiade M1, Lam CSP1, Mehra MR1, Neaton JD1, Nessel CC1, Spiro TE1, van Veldhuisen DJ1, Greenberg B1; COMMANDER HF Investigators. Rivaroxaban in patients with heart failure, sinus rhythm and coronary disease. N Engl J Med. 2018 Aug 27. [Epub ahead of print]
  6. Mamas A. M, Sperrin M, Watson M C. , Coutts A, Wilde K, Burton C, Kadam U T. , Shing Kwok C, Clark A B, Murchie P, Buchan I, Hannaford P C , Myint P K. Do patients have a worse outcome with heart failure than cancer? A primary care based cohort study with 10-year follow-up in Scotland. Eur J Heart Fail, 19 (9). 1095–1104
  7. Howlett J , Comin‐Colet J, Dickstein K, Fuat A, Pölzl G, Delaney S Clinical practices and attitudes regarding the disgnosis and management of heart failure: findings from the CORE Needs Assessment Survey. Eur J Heart Fail. 2018 Feb; 5(1): 172–183