Diastolic dysfunction

Although the annual mortality rate for diastolic heart failure is better than that for systolic heart failure, it is still greater than that for age-matched controls. Five-year mortality rates are about 50% for patients with systolic heart failure and are about 25% for patients with diastolic heart failure. In elderly patients (over 65 years of age), the outcome with systolic and diastolic dysfunction may be more comparable. In contrast to systolic heart failure, the effect of therapy in patients with diastolic heart failure has not been evaluated in large clinical controlled trials. Guidelines for managing heart failure with preserved systolic function broadly suggest the direction for management, but specific treatments are currently based on expert consensus, clinical experience, and scientific elucidation of diastolic mechanics. Although evidence-based guidelines are not available for all aspects of management of diastolic heart failure, future research will increase the knowledge of this disorder and improve treatment strategies.     

Critical review and recommendations for nesiritide use in the emergency department

Heart failure is a disease of epidemic proportions. Almost five million Americans suffer from heart failure and over 400,000 patients are newly diagnosed with heart failure each year. Indeed, heart failure is now the only cardiovascular disease that is increasing in incidence and prevalence. Costs related to heart failure are $18.8 billion per year and are steadily increasing. Although the outpatient management of these patients has seen substantial improvement in the last two decades, emergency department (ED) treatment of acute decompensated heart failure has remained largely unchanged since the late 1970s. Current ED therapy consists of diuretics, intravenous vasodilatators, and inotropes. Recently, the outcomes of several high-profile clinical trials evaluating intravenous nesiritide (human B-type natriuretic peptide) have suggested a benefit in select hospitalized patients. Such a therapy has potential to provide a therapeutic addition or alternative for emergency heart failure management. We discuss these trials' results, suggest their relationship to the ED population, and provide recommendations for appropriate ED use.     

Impact of point-of-care B-type natriuretic peptide (BNP) measurement on medical decision-making for older emergency department patients with dyspnea

Measurement of B-type natriuretic peptide (BNP) has been shown to aid in the Emergency Department (ED) diagnosis of heart failure. We sought to determine how point-of-care BNP measurement influences real-world medical decision-making. Using a commercially available, point-of-care assay, BNP levels were measured in a convenience sample of ED patients over the age of 55 years who complained of dyspnea. Blinded to BNP results, emergency physicians were asked to formulate a differential diagnosis and management plan for each patient. Immediately thereafter, BNP results were disclosed and the physicians were asked what (if any) decisions they would change. With physicians blinded to BNP results, 24 of 88 patients (27%) were given a primary diagnosis of heart failure, and 18 patients (20%) were given a secondary or alternative diagnosis of heart failure. For the former group, disclosure of BNP results resulted in no changes in diagnosis or management. For the latter group, disclosure of BNP results caused heart failure to become the primary diagnosis in 4 patients (22%), and led to five changes in medical management. For the 46 patients initially given neither a primary nor secondary diagnosis of heart failure, disclosure of BNP results caused heart failure to become the primary diagnosis in one patient (2%) and a secondary diagnosis in 4 patients (9%), and led to five changes in medical management. Thus, for ED patients with a primary clinical diagnosis of heart failure, BNP testing had no impact on medical decision-making. However, for other patients with dyspnea, elevated BNP levels did influence medical decision-making, particularly when heart failure was in the differential diagnosis.     

New therapies for heart failure: is thalidomide the answer?

The syndrome of advanced heart failure is associated with considerable morbidity and mortality. Ideas about the reasons for the progressive nature of the heart failure syndrome have changed over the years, with the initial view that progression was principally due to pump failure (the 'haemodynamic' hypothesis), giving way to more modern views, which implicate neuro-endocrine activation (including catecholamine excess, renin-angiotensin system activation, etc.). More recently, an excess of inflammatory cytokines has been found in advanced heart failure and implicated in the progression of the disease. Amongst the cytokines found, TNF-alpha seems to be particularly important. The principle therapeutic action of thalidomide appears to be reduction of TNF-alpha levels. We therefore suggest that there may be a role for thalidomide, or its derivatives, in the management of advanced heart failure.     

New directions in heart failure management

Approximately 4.8 million Americans are afflicted with heart failure; this accounts for 800,000 to 900,000 hospital admissions annually. Astute management in the primary care setting is essential for decreasing mortality and minimizing the risk for hospitalization. Although heart failure was initially viewed as a hemodynamic disorder, current evidence overwhelmingly supports that neurohormones, such as angiotensin II and aldosterone, contribute significantly to disease progression. The benefits of angiotensin-converting enzyme inhibitors and other drugs that block these substances are well established. This article discusses current management options that retard left ventricular remodeling to improve systolic function over time.     

心力衰竭患者容量管理的研究进展

容量超负荷是急、慢性心力衰竭发展过程中重要的病理生理改变,容量管理是心力衰竭管理过程中十分重要的组成部分。本文从心力衰竭与容量管理之间的关系入手,从容量评估的方法、容量管理常用的护理干预措施进行综述,旨在强调心力衰竭患者容量管理的重要性、必要性,为临床护士提供容量评估方向以及制定相应护理措施提供依据。     

New advances and novel treatments in heart failure

As briefly summarized in this report, the prevalence of heart failure is high and it will continue to rise as the population ages. There will be over 1 million hospitalizations for acutely decompensated heart failure this year. The goals of treatment for patients with acutely decompensated heart failure are to lower cardiac filling pressures, remove fluids and improve symptoms of dyspnea, decrease vascular resistance, and increase cardiac output without activating the RAAS. There are few guidelines for the treatment of individuals with acutely decompensated heart failure and many different agents have been used in patients with this disease. Many of these drugs are not completely effective and may lead to serious adverse events. BNP is a natural protein produced by myocardial cells in response to ventricular distension, and its level is dramatically increased in patients with heart failure. The results of several recent clinical trials have shown that administration of nesiritide is safe and highly effective for the initial treatment of patients with acutely decompensated heart failure and can help physicians and nurses meet treatment goals for the management of patients with this serious condition.     

Heart failure: it's not just for men

Heart failure is end-stage cardiac disease, developing in 46% of women within 6 years of having a myocardial infarction, and is the leading cause of all hospitalizations and readmissions in women over the age of 65 years. Since women present with atypical symptoms leading to inaccurate diagnosing of heart disease, education becomes a key component in increasing women's ability to self-manage heart failure symptoms and to become proactive in health-promoting behaviors. Health care providers are responsible for communicating discharge education including risk factors, causes, classification and staging, clinical presentation, diagnostic testing, and management of heart failure to assist women in managing this terminal disease and improving their quality of life.     

持续非卧床腹膜透析患者心衰发生的危险因素分析

目的：探讨持续非卧床腹膜透析（ CAPD ）患者心衰发生的危险因素。方法采用CAPD患者容量管理量表、纽约心脏协会（ NYHA）的心功能分级及生化指标等调查分析影响CAPD患者心衰发生的独立危险因素。探讨不同营养状态下,容量管理水平与心衰发生的关系。结果共发放调查问卷114份,收回114份,有效回收率为100％。容量管理水平、血清前白蛋白、尿素氮是引起CAPD患者发生心衰的独立危险因素（ r值分别为-1．290,-0．006,0．085;P＜0．05）。前白蛋白正常组患者中,容量管理水平与心衰发生率呈负相关（χ2＝10．542,P＜0．05）。结论提高CAPD患者容量管理水平及透析充分性,重视营养状态的评估,可为预防心衰的发生提供依据。     

N-terminal proBNP: a novel biomarker for the diagnosis, risk stratification and management of congestive heart failure

Congestive heart failure is a leading cause of morbidity and mortality throughout the world and is now the leading cause of hospitalizations in adults over 65 years of age with an estimated annual expenditure in excess of USD 20 billion. In addition, it is the only cardiovascular disorder that continues to increase in both incidence and prevalence, and as the population continues to age, it is expected that the prevalence of this disease will continue to rise. Ironically, the armamentarium of medications that decrease mortality due to congestive heart failure also continues to grow; however, the relative number of eligible patients with congestive heart failure (or at risk for congestive heart failure) that receive these important therapies remains low. Thus, better tools to aid the early diagnosis and management of this disease are needed. Testing for natriuretic peptide markers, such as B-type natriuretic peptide or its amino-terminal fragment, has emerged as an important tool to assist in the optimal diagnosis and risk stratification of patients with congestive heart failure and may also play a valuable role in guiding therapy.     

Levosimendan: first in a new class of inodilator for acute and chronic severe heart failure

Heart failure is the most common malignant disease in the developed world. Levosimendan (Simdax) is a novel intravenous agent that exerts inotropic effects through sensitization of myofilaments to calcium and vasodilator effects by opening ATP-dependent potassium channels on vascular smooth muscle. Infusion of levosimendan increases cardiac output due to an increase in stroke volume and heart rate, with a fall in pulmonary capillary wedge pressure. It has an active metabolite with a half-life of about 80 h, therefore infusions of 6 to 24 h result in hemodynamic effects that persist for 7 to 10 days. Preliminary observations suggest that a single infusion of levosimendan lasting 6 to 24 h in patients with severe heart failure due to left ventricular systolic dysfunction results in hemodynamic changes, symptomatic benefit and a reduction in morbidity and mortality over the following 2 to 4 weeks compared with placebo in one study and with dobutamine in another. Long-term follow-up suggests no loss of this early benefit over 6 months. Levosimendan is licensed for the treatment of decompensated heart failure in many countries but not in North America. Further large trials are being conducted comparing levosimendan with placebo and with dobutamine in patients with severe heart failure and left ventricular systolic dysfunction. If these studies confirm the benefits of levosimendan, then it may become routine therapy for the management of severe heart failure.     

Imaging Heart Failure in 2010

Heart failure is a common and serious public health problem in industrialized countries. The epidemics of diabetes, obesity, hypertension, and coronary disease are contributing to the increasing prevalence of heart failure. The diagnosis of heart failure is based on a detailed history and a thorough physical examination. Echocardiography plays a central role in aiding in the diagnosis and characterization of heart failure and in directing its management. This review highlights recent advances in echocardiography in relation to heart failure. Three-dimensional echocardiography, tissue Doppler imaging, and speckle tracking echocardiography represent recent developments in echocardiography relevant to heart failure and as such are emphasized in this review. Advanced cardiac imaging includes nuclear cardiac imaging, cardiac CT, and cardiac MRI, and they also play an important role in heart failure management; in this review we emphasize their application in heart failure secondary to ischemic heart disease.     

Levosimendan: first in a new class of inodilator for acute and chronic severe heart failure

Heart failure is the most common malignant disease in the developed world. Levosimendan (Simdax®) is a novel intravenous agent that exerts inotropic effects through sensitization of myofilaments to calcium and vasodilator effects by opening ATP-dependent potassium channels on vascular smooth muscle. Infusion of levosimendan increases cardiac output due to an increase in stroke volume and heart rate, with a fall in pulmonary capillary wedge pressure. It has an active metabolite with a half-life of about 80 h, therefore infusions of 6 to 24 h result in hemodynamic effects that persist for 7 to 10 days. Preliminary observations suggest that a single infusion of levosimendan lasting 6 to 24 h in patients with severe heart failure due to left ventricular systolic dysfunction results in hemodynamic changes, symptomatic benefit and a reduction in morbidity and mortality over the following 2 to 4 weeks compared with placebo in one study and with dobutamine in another. Long-term follow-up suggests no loss of this early benefit over 6 months. Levosimendan is licensed for the treatment of decompensated heart failure in many countries but not in North America. Further large trials are being conducted comparing levosimendan with placebo and with dobutamine in patients with severe heart failure and left ventricular systolic dysfunction. If these studies confirm the benefits of levosimendan, then it may become routine therapy for the management of severe heart failure.     

血压与心力衰竭的关系：研究现状与挑战

血压与心力衰竭（简称心衰）的关系密切且复杂。高血压不仅是导致心衰的重要危险因素,血压管理也贯穿了心衰患者治疗和预后改善的全过程。如何对心衰患者进行血压管理,心衰患者血压控制最佳靶目标值是多少,不同类型心衰间是否存在差异,目前尚有争议和不确定性,尚缺乏充分循证证据指导的血压管理方案。本文就血压与心衰之间关系的研究现状与进展、存在问题与挑战进行综述。     

N-terminal proBNP: a novel biomarker for the diagnosis,risk stratification and management of congestive heart failure

Congestive heart failure is a leading cause of morbidity and mortality throughout the world and is now the leading cause of hospitalizations in adults over 65 years of age with an estimated annual expenditure in excess of US$20 billion . In addition, it is the only cardiovascular disorder that continues to increase in both incidence and prevalence , and as the population continues to age, it is expected that the prevalence of this disease will continue to rise. Ironically, the armamentarium of medications that decrease mortality due to congestive heart failure also continues to grow [3–5]; however, the relative number of eligible patients with congestive heart failure (or at risk for congestive heart failure) that receive these important therapies remains low. Thus, better tools to aid the early diagnosis and management of this disease are needed. Testing for natriuretic peptide markers, such as B-type natriuretic peptide or its amino-terminal fragment, has emerged as an important tool to assist in the optimal diagnosis and risk stratification of patients with congestive heart failure and may also play a valuable role in guiding therapy.     

ABCs of Heart Failure Management: A Guide for Nurse Practitioners

Heart failure management can be challenging for nurse practitioners due to abundance of pharmacologic options. Pharmacotherapy is crucial in the management of heart failure and the associated pathophysiologic changes. This report provides an easy-to-recall mnemonic guide for nurse practitioners when making therapeutic decisions for patients with heart failure with reduced ejection fraction. We believe that our approach of using a 7-letter alphabetic mnemonic to manage heart failure with reduced ejection fraction has the potential to improve its clinical outcomes.     

Guideline for the management of heart failure caused by systolic dysfunction: part II. Treatment

Several large clinical trials conducted over the past decade have shown that pharmacologic interventions can dramatically reduce the morbidity and mortality associated with heart failure. These trials have modified and enhanced the therapeutic paradigm for heart failure and extended treatment goals beyond limiting congestive symptoms of volume overload. Part II of this two-part article presents treatment recommendations for patients with left ventricular systolic dysfunction. The authors recommend that, if tolerated and not contraindicated, the following agents be used in patients with left ventricular systolic dysfunction: an angiotensin-converting enzyme inhibitor in all patients; a beta blocker in all patients except those who have symptoms at rest; and spironolactone in patients who have symptoms at rest or who have had such symptoms within the past six months. Diuretics and digoxin should be reserved, as needed, for symptomatic management of heart failure. Other treatments or treatment programs may be necessary in individual patients.     

Learning for heart failure patients (The L‐HF patient study)

Aim and objective. To investigate the learning style and preferences for information delivery of heart failure patients for the purpose of informing the design of educational resources. Background. Patient education is a vital component of heart failure management programmes however the content and delivery of education varies in each programme. Traditionally education programmes for patients have focussed on educational needs as identified by health care providers however research has shown there are discrepancies between patients’ and nurses’ perceptions of the learning needs of heart failure patients. There is no evidence that educational programmes for heart failure patients are based on identification of patients learning needs or their preferred learning style. Design. Qualitative. Method. A purposive sample of 12 participants, diagnosed with heart failure and enrolled in a heart failure management programme, participated in semi‐structured interviews. Results. Four themes emerged: knowledge quest (L‐loading), barriers to learning (L‐inhibitors), facilitators for learning (L‐agonists), and meeting educational needs (L‐titration). Integral to these themes was the participant’s relationship with health care professionals. Conclusion. This study provides unique information regarding the preferred learning modality of heart failure patients and, as such, serves to inform the development of appropriate education resources specifically tailored for this population. Relevance to clinical practice. The development of effective modes of education is likely to further enhance heart failure management programmes service organisation and delivery and improve health outcomes for heart failure patients.     

心力衰竭患者液体管理的研究进展

液体管理目的在于预防和控制心力衰竭患者的液体潴留,从而降低心力衰竭患者的再入院率与病死率,提高患者的生活质量.该文综述了液体管理的具体内容与开展形式,并指出目前液体管理方面存在的缺陷及改进的方向,旨在引起护士对心力衰竭患者液体管理的重视,探寻适合心力衰竭患者的液体管理模式.     

Recent advances in point-of-care testing for natriuretic peptides: potential impact on heart failure diagnosis and management

Heart failure is a leading cause of morbidity and mortality worldwide. The presenting symptoms of heart failure are often nonspecific. The diagnosis of heart failure has traditionally relied heavily upon clinical exam findings, which are often subjective and have low sensitivity. Efficient and rapid diagnosis of heart failure in the emergency room setting can reduce health care costs, hospital admission and ER visits, and improve patient care. Natriuretic peptides are objective biomarkers that can help with diagnosis, prognosis and management of heart failure. The most extensively studied and clinically utilized natriuretic peptides include brain natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP). Point-of-care testing in the emergency room setting can result in faster triage times. Point-of-care testing can also be utilized in the outpatient setting for real-time management of patients with heart failure.