Combined effects of repeated sauna therapy and exercise training on cardiac function and physical activity in patients with chronic heart failure

Purpose: We investigated the combined effects of repeated sauna therapy and exercise training on subjective symptoms, cardiac function, daily activities and ambulation capacity in patients with chronic heart failure. Methods: Fifty four patients including 26 patients with repeated sauna therapy and exercise training (combined therapy group) and 28 patients with repeated sauna therapy (monotherapy group) participated in the study. Repeated sauna therapy and exercise training were performed once a day, 5 days a week. Clinical symptoms, brain natriuretic peptide concentration, cardiac functions evaluated by echocardiography, cardiac size on chest radiography, Barthel Index (BI) and ambulation capacity were examined and compared between the time of hospital admission and the time of discharge. Results: Both the groups showed significantly improved New York Heart Association functional class, cardiothoracic ratio, brain natriuretic peptide concentration, left ventricular ejection fraction, BI score and ambulation capacity grade. The changes of New York Heart Association functional class, BI score and ambulation capacity in the combined therapy group were a higher level of statistical significance than those in monotherapy group. Notably, significant between group difference was observed in the changes of BI score. Conclusions: The addition of exercise training programs to repeated sauna therapy may be efficient and effective for improvement of cardiac function and daily activities for patients with chronic heart failure.

• Implications of Rehabilitation

• Repeated sauna therapy is an effective means of improving cardiac, vascular function and mental health in CHF patients.

• Exercise training is an effective means of improving exercise capacity, thus improving ADL.

• Combination of repeated sauna therapy and exercise training may be recommended as a comprehensive treatment to improve cardiac function, ambulation capacity, and ADL in CHF patients.

     

Limited value of NT-proBNP as a prognostic marker of all-cause mortality in patients with heart failure with preserved and mid-range ejection fraction in primary care: A report from the swedish heart failure register

Abstract

Aim: The prognostic value of natriuretic peptides in the management of heart failure (HF) patients with ejection fraction (EF) <40% is well established, but is less known for those with EF ≥40% managed in primary care (PC). Therefore, the aim of this study is to describe the prognostic significance of plasma NT-proBNP in such patients managed in PC.

Subjects: We included 924 HF patients (48% women) with EF ≥40% and NT-proBNP registered in the Swedish Heart Failure Registry. Follow-up was 1100?±?687?days.

Results: One-, three- and five-year mortality rates were 8.1%, 23.9% and 44.7% in patients with EF 40–50% (HFmrEF) and 7.3%, 23.6% and 37.2% in patients with EF ≥50% (HFpEF) (p?=?0.26). Patients with the highest mean values of NT-proBNP had the highest all-cause mortality but wide standard deviations (SDs). In univariate regression analysis, there was an association only between NT-proBNP quartiles and all-cause mortality. In HFmrEF patients, hazard ratio (HR) was 1.96 (95% CI 1.60–2.39) p?<?0.0001) and in HFpEF patients, HR was 1.72 (95% CI 1.49–1.98) p?<?0.0001). In a multivariate Cox proportional hazard regression analysis, adjusted for age, NYHA class, atrial fibrillation and GFR class, this association remained regarding NT-proBNP quartiles [HR 1.83 (95% CI 1.38–2.44), p?<?0.0001] and [HR 1.48 (95% CI 1.16–1.90), p?=?0.0001], HFmrEF and HFpEF, respectively.

Conclusion: NT-proBNP has a prognostic value in patients with HF and EF ≥40% managed in PC. However, its clinical utility is limited due to high SDs and the fact that it is not independent in this population which is characterized by high age and much comorbidity.

• Key points

• It is uncertain whether NT-proBNP predicts risk in heart failure with preserved ejection fraction (EF?>?40%, HFpEF) managed in primary care.

• We show that high NT-proBNP predicts increased all-cause mortality in HFpEF-patients managed in primary care.

• The clinical use is however limited due to large standard deviations, many co-morbidities and high age.

• Many of these co-morbidities contribute to all-cause mortality and management of these patients should also focus on these co-morbidities.

     

Thoracic endovascular aortic repair versus open chest surgical repair for patients with type B aortic dissection: a systematic review and meta-analysis

Abstract

Aim: This meta-analysis study aimed to compare the efficacy and safety of TEVAR versus OCSR for TBAD patients.

Methods: We systematically searched PubMed, EmBase, and the Cochrane library to identify studies compared the effectiveness of TEVAR and OCSR in TBAD patients from the inception up to July 2019. The summary results were calculated using a random-effects model.

Results: The electronic search identified 1,894 studies, and 18 studies with 9,664 TBAD patients were included. We noted patients received TEVAR were associated with a reduced risk of in-hospital mortality, acute renal failure, respiratory failure, and bleeding as compared with OCSR, whereas no significant differences between groups for the risk of stroke, myocardial infarction, paraplegia, mesenteric ischaemia/infarction, reinterventions, sepsis, and spinal cord ischaemia.

Conclusions: The findings of this meta-analysis study suggested that TEVAR resulted in more short-term survival benefits. Moreover, the reduced risk of acute renal failure, respiratory failure and bleeding was detected in TEVAR group. The treatment effects of TEVAR versus OCSR on specific complications should be further verified by a study with high-level of evidence.

• Key message

• Comprehensive collected studies investigated the treatment effectiveness between TEVAR and OCSR for TBAD patients

• TEVAR resulted in more survival benefits, in addition to lower risk of acute renal failure, respiratory failure and bleeding

• The results of stratified analyses according to patients’ characteristics were conducted

     

To be on sick-leave due to heart failure: a qualitative perspective

Abstract

Purpose: The aim of the present study was to explore and describe meanings of being on sick leave due to heart failure. Methods: The study was conducted in Sweden during 2011–2012. Five men and one woman, aged 46 to 62, were interviewed. A reflective life-world research approach based on phenomenological philosophy was used. The result of the analysis is presented in three themes. Results: To be on sick leave due to heart failure implies a life situation characterized by anxiety, insecurity and uncertainty. When rehabilitation professionals do not take on their professional responsibility, sick listed people with heart failure perceive they are dismissed and abandoned. If rehabilitation professionals take on their professional responsibility it can be experienced as supportive. Conclusions: People who are on sick leave due to heart failure are abandoned by rehabilitation professionals and they lack opportunities to participate in their own sick leave/rehabilitation processes. Rehabilitation professionals need to take more responsibility and allow the patients to participate by connecting and recognizing patients as equal human beings. The present results can be used by rehabilitation professionals to reflect on and discuss the needs of people on sick leave due to heart failure.

• Implications for Rehabilitation

• Heart failure is a chronic condition implying a complicated life-situation.

• People with heart failure experience abandonment by rehabilitation professionals and lack participation in their own rehabilitation process.

• In order to support people on sick leave due to heart failure collaboration and coordination between rehabilitation professionals are needed.

     

Cardiac Troponin - diagnostic problems and impact on cardiovascular disease

Abstract

The definition of a high-sensitivity cardiac Troponin (cTn) assay describes the ability to quantify a cardiac biomarker level in at least 50% of healthy individuals. This advance in analytic sensitivity has come with a perceived loss of specificity in the most classic application – chest pain triage and the diagnosis of acute myocardial infarction (AMI). As cardiac Troponin can no longer be used as a dichotomous test, the medical field is increasingly moving towards a more granular interpretation. However, rapid rule-out/rule-in algorithms for AMI still rely on concrete thresholds for efficient triage, irrespective of the patient’s comorbidities. Owing to a slightly elevated cTn value, evermore patients appear to fall into an indeterminate risk zone of diagnostic uncertainty. The reasons are manifold, spanning biological variation, analytical issues, increased plasma membrane permeability and the potential cytosolic release of cTn. This review provides a contemporary overview of the literature concerning the use of cardiac Troponin in chronic and acute cardiovascular care.

• Key messages

• High-sensitivity cardiac Troponin assays have transformed the assessment of cardiovascular disease.

• Rapid rule-out algorithms for chest pain triage have become increasingly complicated, but enable safe rule-out.

• Cardiac Troponin tracks mid- to long-term risk in patients with hyperlipidaemia, heart failure and renal dysfunction.

     

Contact with primary health care physicians before an acute hospitalisation

Abstract

Objectives: To assess contacts with general practitioners (GPs), both regular GPs and out-of-hours GP services (OOH) during the year before an emergency hospital admission.

Design: Longitudinal design with register-based information on somatic health care contacts and use of municipality health care services.

Setting: Four municipalities in central Norway, 2012–2013.

Subjects: Inhabitants aged 50 and older admitted to hospital for acute myocardial infarction, hip fracture, stroke, heart failure, or pneumonia.

Main outcome measures: GP contact during the year and month before an emergency hospital admission.

Results: Among 66,952 identified participants, 720 were admitted to hospital for acute myocardial infarction, 645 for hip fracture, 740 for stroke, 399 for heart failure, and 853 for pneumonia in the two-year study period. The majority of these acutely admitted patients had contact with general practitioners each month before the emergency hospital admission, especially contacts with a regular GP. A general increase in GP contact was observed towards the time of hospital admission, but development differed between the patient groups. Patients admitted with heart failure had the steepest increase of monthly GP contact. A sizable percentage did not contact the regular GP or OOH services the last month before admission, in particular men aged 50–64 admitted with myocardial infarction or stroke.

Conclusion: The majority of patients acutely admitted to hospital for different common severe emergency diagnoses have been in contact with GPs during the month and year before the admission. This points towards general practitioners having an important role in these patients’ health care.

• KEY MESSAGES

• There is scarce knowledge about primary health care contact before an emergency hospital admission.

• The percentage of patients with contacts differed between patient groups, and increased towards hospital admission for most diagnoses, particularly heart failure.

• More than 50% having monthly general practitioner contact before admission underscores the general practitioners’ role in these patients’ health care.

• Our results underscore the need to consider medical diagnosis when talking about the role of general practitioners in preventing emergency hospital admissions.

     

Genetic and ethnic modulation of cardiovascular toxicity of vascular endothelial growth factor inhibitors

Vascular endothelial growth factor (VEGF) inhibitors, including monoclonal antibodies and tyrosine kinase inhibitors (TKIs), are important as anticancer treatments through curbing tumour angiogenesis and growth. VEGF inhibitors have significant cardiovascular effects. By blocking VEGF receptors, ligands, or signal pathways, VEGF inhibitors disturb the balance between vasodilation and vasoconstriction, undermine endothelial cell integrity, and activate cardiomyocyte apoptosis. VEGF inhibitors increase risks of hypertension, heart failure, thromboembolism and arrhythmia. Genetic and geographic studies showed that genetic polymorphisms likely play significant predictive or prognostic roles in cardiovascular toxicity associated with VEGF inhibitors. This review updates current understandings of VEGF inhibitors on cardiovascular toxicity, explores potential mechanisms, and clarifies whether genetic or ethnic factors contribute to their adverse effects.

• Key Messages

• VEGF inhibitors disturb the balance between vasodilation and vasoconstriction, undermine endothelial cell integrity and activate cardiomyocyte apoptosis.

• VEGF inhibitors increase risks of hypertension, heart failure, thromboembolism and arrhythmia.

• Genetic and geographic studies showed that genetic polymorphisms likely play significant predictive or prognostic roles in cardiovascular toxicity associated with VEGF inhibitors.

     

Complex relationship of obesity and obesity paradox in heart failure – higher risk of developing heart failure and better outcomes in established heart failure

Heart failure (HF) and obesity are major public health problems. Studies have shown that obesity may increase the risk of developing new HF but after patients have developed HF, obesity may be associated with improved outcomes. This paradoxical association of obesity with HF remains poorly understood. It is believed that the obesity paradox may in part be due to the inherent limitations of body mass index (BMI) as a measure of obesity. BMI may not appropriately measure important components of body mass like body fat, fat distribution, lean body mass, and body fluid content and may not be ideal for examining the relationship of body composition with health outcomes. Differentiating between body fat and lean body mass may explain some of the paradoxical association between higher BMI and better prognosis in patients with HF. Paradoxical outcomes in HF may also be due to phenotypes of obesity. Future studies need to develop and test metrics that may better measure body composition and may serve as a better tool for the estimation of the true association of obesity and outcomes in HF and determine whether the association may vary by obesity phenotypes.

• KEY MESSAGES

• Obesity predisposes to heart failure in all age groups. But obesity in heart failure is an area of controversy, because of obesity paradox, the apparent protective effect of overweight and mild obesity on mortality after development of heart failure.

• Traditional markers of obesity do not measure different components of body weight like muscle mass, fat, water, and skeletal weight. Body Mass Index in heart failure subjects does not measure accurately body fat or fluid retention. So new markers of obesity like visceral adiposity index, body composition analysis, sarcopenic status assessment may be helpful in the assessment of heart failure outcomes.

• Different phenotypes of obesity may be responsible for the different morbidity, mortality as well as therapeutic outcomes in heart failure.

     

Overuse of organ biopsies in immunoglobulin light chain amyloidosis (AL): the consequence of failure of early recognition

Introduction: The diagnosis of amyloidosis requires histological confirmation of Congo-red (CR) deposits. The tissue source is preferably fat aspiration and/or bone marrow (BM) biopsy, but at times organ biopsy is required.

Methods: We studied 612 patients with systemic immunoglobulin light chain amyloidosis to characterise the tissues used to establish the diagnosis.

Results: The median number of tissue samples was 3. About 95% of BM biopsies were stained for CR, while 79% of patients had fat aspiration CR-stained. CR stain sensitivity was 69% in BM, 75% in fat aspiration and 89% for both sources combined. In comparison, CR sensitivity was 97–100% for heart, renal and liver biopsies. About 42% of patients with renal involvement, 21% of patients with liver involvement and 13% of patients with heart involvement underwent organ biopsy, when a less invasive biopsy would have established the diagnosis. Predictors for the requirement for organ biopsy were male sex, limited organ involvement and lack of fat aspiration.

Discussion: Fat aspiration is underutilised for histologic confirmation of amyloidosis. A high rate of organ biopsies represents a failure to recognise the disease. Early awareness of amyloidosis in patients with organ dysfunction may lead to more judicious use of organ biopsies in this disease.

• Key messages

• Fat pad aspiration is underutilised to establish the diagnosis of amyloidosis.

• Bone marrow and fat pad aspiration obviates the need for invasive biopsies.

• The excessive use of organ biopsy in AL amyloidosis reflects failure to recognise the disease early in its course.

     

Associations between socio-demographic factors,encounters with healthcare professionals and perceived ability to return to work in people sick-listed due to heart failure in Sweden: a cross-sectional study

Purpose: The aim of this study was to investigate associations between socio-demographic factors, experiences of positive/negative encounters with healthcare professionals, and the encounters' impact on the ability to return to work in a population of people on sick leave due to heart failure. Methods: This was a cross-sectional study. Data were collected from two official registries in Sweden and from a postal questionnaire. In all, 590 people with heart failure responded to the questionnaire. Associations between variables were calculated with bivariate correlation analyses and logistic regression analyses. Results: For people on sick leave due to heart failure, positive encounters with healthcare professionals are associated with being Swedish-born, female gender, and high income. People with high income are more likely to be supported back to work by positive encounters with healthcare professionals. To perceive that healthcare professionals believe in person's ability to return to work can be facilitating. Conclusions: Women, people who are not foreign-born, and people with high income are more likely to perceive encounters with healthcare professionals as positive. Healthcare professionals who work with rehabilitation for people with heart failure need to be aware of social inequalities and that being on sick leave is a process of change.

• Implications for Rehabilitation

• A failing heart limits everyday life implying risk for long-term sick leave. Even though there are rehabilitation programs for people with heart failure, vocational rehabilitation is often over-looked. The knowledge about factors associated with sick leave due to heart failure is scarce.

• Experiences of positive encounters with healthcare professionals were associated with being Swedish-born, female gender, and high income. People with high income were more likely to be supported back to work by positive encounters with healthcare professionals.

• Healthcare professionals who work with rehabilitation for people with heart failure can support patients with heart failure by showing them confidence and trust. However, they need to be aware that sick leave implies a process of change.

     

Plasma bilirubin values on admission and ventricular remodeling after a first anterior ST-segment elevation acute myocardial infarction

Introduction: Bilirubin may elicit cardiovascular protection and heme oxygenase-1 overexpression attenuated post-infarction ventricular remodeling in experimental animals, but the association between bilirubin levels and post-infarction remodeling is unknown.

Materials and methods: In 145 patients with a first anterior ST-segment elevation acute myocardial infarction (STEMI), we assessed whether plasma bilirubin on admission predicted adverse remodeling (left ventricular end-diastolic volume [LVEDV] increase?≥20% between discharge and 6 months, estimated by magnetic resonance imaging).

Results: Patients’ baseline characteristics and management were comparable among bilirubin tertiles. LVEDV increased at 6 months (P?Conclusions: Admission bilirubin values are not related to LVEDV or ejection fraction progression after a first anterior STEMI and do not predict adverse ventricular remodeling.

• Key messages

• Bilirubin levels are inversely related to cardiovascular disease, and overexpression of heme oxygenase-1 (the enzyme that determines bilirubin production) has prevented post-infarction ventricular remodeling in experimental animals, but the association between bilirubin levels and the progression of ventricular volumes and function in patients with acute myocardial infarction remained unexplored.

• In this cohort of patients with a first acute anterior ST-segment elevation myocardial infarction receiving contemporary management, bilirubin levels on admission were not predictive of the changes in left ventricular volumes or ejection fraction at 6 months measured by serial cardiac magnetic resonance imaging.

• The data are contrary to a significant protective effect of bilirubin against post-infarction ventricular remodeling.

     

Diabetic Retinopathy –Incidence And Risk Factors In A Community Setting- A Longitudinal Study

Aim: To evaluate the natural history of diabetic retinopathy (DR) in diabetic patients and to assess long term risk for other chronic diseases associated with DR.

Methods: Retrospective, community-based study. Diabetics who underwent their first fundoscopic examination during 2000–2002, and had at least one follow- up examination by the end of 2007 were included. The primary outcome was the development of DR (proliferative diabetic retinopathy (PDR), non PDR (NPDR) or macular edema.

Patients were followed for another 9 years for documentation of new diagnosis of related diseases.

Results: 516 patients' (1,032 eyes) records were included and were followed first for an average of 4.15?±?1.27 years. During follow-up, 28 (2.7%) of the total 1,032 eyes examined were diagnosed with PDR. An additional 194 (18.8%) eyes were diagnosed with new NPDR. The cumulative incidence of NPDR was 310/1,032 (30.0%). All the patients who developed PDR had prior NDPR. By the end of the 9 years extended follow up, patients with NPDR had a greater risk for developing chronic renal failure HR?=?1.71 (1.14–2.56), ischemic heart disease HR?=?1.57 (1.17–2.09), and had an increased mortality rate HR?=?1.26 (1.02–1.57)

Conclusion: DR is associated with a higher rate of diabetes complications. Patients with DR should be followed more closely.

• Key points

• During a mean follow-up of 4.5 years, the cumulative incidence of diabetic retinopathy in a community cohort was 18.8%.

• NDPR (non-proliferative diabetic retinopathy) is a predictor of PDR (proliferative diabetic retinopathy).

• In a real life setting NPDR is a marker of a poorer prognosis.

• Patients with NDPR should be monitored more closely.

     

Increasing prevalence of thalassemia in America: Implications for primary care

Abstract

Thalassemia, once a rarity in the United States, is increasingly encountered in clinical practice due to shifts in immigration. Early carrier screening in at-risk populations can help clinicians implement genetic counseling and prevent new cases. Chronic transfusions are the mainstay of therapy for patients with severe thalassemia (beta thalassemia major), and are used intermittently in individuals with milder forms of thalassemia (Hb H/H Constant Spring disease and beta thalassemia intermedia). Iron overload is a major source of morbidity and mortality in individuals with transfusion and non-transfusion-dependent thalassemia, necessitating iron chelation therapy. Iron overload contributes to increased risk of cirrhosis, heart failure, and endocrinopathies, while ineffective erythropoiesis and hemolysis contribute to multiple complications, including splenomegaly, extramedullary hematopoiesis, pulmonary hypertension, and thrombosis. An understanding of the importance of carrier screening, complications, monitoring, and management strategies, coupled with collaboration with a hematologist with thalassemia expertise, is essential to reduce the morbidity and mortality in patients with thalassemia.

• Key Messages

• Thalassemia is becoming more prevalent in the United States due to immigration of people from affected regions, with an approximately 7.5% increase over the last five decades.

• Newborn screening, antenatal screening, prenatal diagnosis, and counseling are key to early diagnosis and prevention of thalassemia.

• Chronic transfusions are the mainstay of therapy for patients with severe thalassemia and milder forms of thalassemia in some cases, but can lead to iron overload, which has numerous clinical consequences.

• Iron overload can be effectively monitored by blood tests and magnetic resonance imaging, and be managed with iron chelation to reduce adverse effects on target organs and improve survival.

     

Leptin predicts short-term major adverse cardiac events in patients with coronary artery disease

Introduction: Leptin is an adipose tissue-derived hormone associated with cardiovascular risk factors. We examined whether leptin predicts major adverse cardiac events (MACE) in coronary artery disease (CAD) patients.

Methods: Fasting plasma leptin levels were measured in 1327 male and 619 female CAD patients. The patients were followed up for two years. The primary endpoint (MACE) was the composite of a hospitalisation for congestive heart failure (CHF) or a cardiac death. The secondary endpoint was the composite of an acute coronary syndrome (ACS) or a stroke.

Results: In regression analysis including established risk variables, high leptin levels were associated with a significantly increased risk of MACE (HR 3.37; 95%CI 1.64–6.90; p?=?0.001) and ACS or stroke (HR 1.95; 95%CI 1.29–2.96; p?=?0.002). Adding leptin to the risk model for MACE increased the C-index from 0.78 (95%CI 0.71–0.85) to 0.81 (0.74–0.88) and improved classification (NRI 0.36; 95%CI 0.13–0.60; p?=?0.002) and discrimination of the patients (IDI 0.016; 95%CI 0.001–0.030; p?=?0.031).

Conclusions: High plasma leptin levels predict short-term occurrence of CHF or cardiac death and ACS or stroke in patients with CAD independently of established risk factors. The possible harmful effects of leptin should be thoroughly investigated.

• Key messages

• Leptin is a peptide hormone secreted mainly by adipose tissue. It has been associated with several cardiovascular risk factors.

• High leptin levels predict the short-term occurrence of congestive heart failure or cardiac death and ACS or stroke in patients with CAD independently of established risk factors.

• The possible detrimental effects of leptin on the cardiovascular system should be thoroughly investigated.

     

Mechanical dispersion is associated with poor outcome in heart failure with a severely depressed left ventricular function and bundle branch blocks

Objectives: Bundle branch blocks (BBB)-related mechanical dyssynchrony and dispersion may improve patient selection for device therapy, but their effect on the natural history of this patient population is unknown.

Methods: A total of 155 patients with LVEF?≤?35% and BBB, not treated with device therapy, were included. Mechanical dyssynchrony was defined as the presence of either septal flash or apical rocking. Contraction duration was assessed as time interval from the electrocardiographic R-(Q-)wave to peak longitudinal strain in each of 17 left ventricular segments. Mechanical dispersion was defined as either the standard deviation of all time intervals (dispersion_SD) or as the difference between the longest and shortest time intervals (dispersion_delta). Patients were followed for cardiac mortality during a median period of 33 months.

Results: Mechanical dyssynchrony was not associated with survival. More pronounced mechanical dispersion_delta was found in patients with dyssynchrony than in those without. In the multivariate regression analysis, patients’ functional class, diabetes mellitus and dispersion_delta were independently associated with mortality.

Conclusions: Mechanical dispersion, but not dyssynchrony, was independently associated with mortality and it may be useful for risk stratification of patients with heart failure (HF) and BBB.

• Key Messages

• Mechanical dispersion, measured by strain echocardiography, is associated with poor outcome in heart failure with a severely depressed left ventricular function and bundle branch blocks.

• Mechanical dispersion may be useful for risk stratification of patients with heart failure and bundle branch blocks.

     

Six-minute walking test in children

• Implications for Rehabilitation

• Six-minute walking test.

• The six-minute walking test is safe and widely performed in the world because of its easy implementation and low cost.

• Many countries have established normal values to the six-minute walking test in healthy children.

• However, the applicability of this test also gains popularity among children with other disease conditions.

     

HDL therapy today: from atherosclerosis,to stent compatibility to heart failure

Abstract

Epidemiologically, high-density lipoprotein (HDL) cholesterol levels have been inversely associated to cardiovascular (CV) events, although a Mendelian Randomisation Study had failed to establish a clear causal role. Numerous atheroprotective mechanisms have been attributed to HDL, the main being the ability to promote cholesterol efflux from arterial walls; anti-inflammatory effects related to HDL ligands such as S1P (sphingosine-1-phosphate), resolvins and others have been recently identified. Experimental studies and early clinical investigations have indicated the potential of HDL to slow progression or induce regression of atherosclerosis. More recently, the availability of different HDL formulations, with different phospholipid moieties, has allowed to test other indications for HDL therapy. Positive reports have come from studies on coronary stent biocompatibility, where the use of HDL from different sources reduced arterial cell proliferation and thrombogenicity. The observation that low HDL-C levels may be associated with an enhanced risk of heart failure (HF) has also suggested that HDL therapy may be applied to this condition. HDL infusions or apoA-I gene transfer were able to reverse heart abnormalities, reduce diastolic resistance and improve cardiac metabolism. HDL therapy may be effective not only in atherosclerosis, but also in other conditions, of relevant impact on human health.

• Key messages

• High-density lipoproteins have as a major activity that of removing excess cholesterol from tissues (particularly arteries).

• Knowledge on the activity of high-density lipoproteins on health have however significantly widened.

• HDL-therapy may help to improve stent biocompatibility and to reduce peripheral arterial resistance in heart failure.

     

Appropriate and Safe Utilization of Helicopter Emergency Medical Services: A Joint Position Statement with Resource Document

Abstract

This position statement with accompanying resource document is the result of a collaborative effort of a writing group comprised of members of the Air Medical Physician Association (AMPA), the American College of Emergency Physicians (ACEP), the National Association of EMS Physicians (NAEMSP), and the American Academy of Emergency Medicine (AAEM). This document has been jointly approved by the boards of all four organizations.

Patients benefit from the appropriate utilization of helicopter emergency medical services (HEMS). EMS and regional health care systems must have and follow guidelines for HEMS utilization to facilitate proper patient selection and ensure clinical benefit. Clinical benefit can be provided by

• Meaningfully shortening the time to delivery of definitive care to patients with time-sensitive medical conditions

• Providing necessary specialized medical expertise or equipment to patients before and/or during transport

• Providing transport to patients inaccessible by other means of transport

The decision to use HEMS is a medical decision, separate from the aviation determination whether a transport can be completed safely.

• Physicians with specialized training and experience in EMS and air medical transport must be integral to HEMS utilization decisions, including guideline development and quality improvement activities.

• Safety management systems must be developed, adopted, and adhered to by air medical operators when making decisions to accept and continue every HEMS transport.

HEMS must be fully integrated within the local, regional, and state emergency health care systems.

• HEMS programs cannot operate independently of the surrounding health care environment.

• The EMS and health care systems must be involved in the determination of the number of HEMS assets necessary to provide appropriate coverage for their region. Excessive resources may lead to competitive practices that can affect utilization and negatively impact safety. Inadequate resources will delay receipt of definitive care.

National guidelines for appropriate utilization of HEMS must be developed. These guidelines should be national in scope yet allow local, regional, and state implementation.

A National HEMS Agenda for the Future should be developed to address HEMS utilization and availability and to identify and support a research strategy for ongoing, evidence-based refinement of utilization guidelines.