Pilot Randomized Controlled Trial to Reduce Readmission for Heart Failure Using Novel Tablet and Nurse Practitioner Education

Background

Heart failure education programs are not standardized. The best form of education is unclear. We evaluated whether addition of a novel tablet application to nurse practitioner (NP) education was superior to NP education alone in reducing 30-day readmission after heart failure hospitalization.

Dissociation between ACE activity and autonomic response to ACE inhibition in patients with heart failure

BACKGROUND: Administration of angiotensin-converting enzyme (ACE) inhibitors to patients with congestive heart failure has been shown to increase parasympathetic tone as indicated by increases in high-frequency heart rate variability. The mechanism for this effect, including its relation to changes in baroreflex activity, blood pressure variability, and suppression of ACE activity, remains undefined. This study was designed to test the relation of these variables, which may govern changes in autonomic activity, to the previously described increase in parasympathetic tone. METHODS: Seven patients with heart failure received a 3-hour infusion of the ACE inhibitor enalaprilat. Hemodynamic variables and parameters of heart rate and blood pressure variability, baroreflex gain derived from the interaction of heart rate and blood pressure variability, and serum ACE activity were measured during and after the infusion. Measures of heart rate and blood pressure variability were also compared against a historic control group. RESULTS: Serum ACE activity was significantly suppressed throughout and after enalaprilat infusion. Hemodynamic measures did not change other than a small decline in right atrial and pulmonary capillary wedge pressures. Parasympathetic tone showed an initial significant increase with a peak at 2 hours but then declined below baseline 8 hours after initiation of enalaprilat infusion. Sympathetically influenced low-frequency heart rate variability was significantly increased above baseline in the enalaprilat treatment group 8 hours after initiation of the infusion. Baroreflex gain showed a significant trend to an increase with the maximum value coinciding with the peak in parasympathetic tone. There was no change in blood pressure variability in the enalaprilat group and no change in baroreflex gain, heart rate variability, or blood pressure variability in the control group. CONCLUSIONS: Parasympathetic tone and baroreflex gain increased with parenteral administration of an ACE inhibitor but subsequently decreased below baseline values despite continued suppression of serum ACE activity. The dissociation between ACE suppression and autonomic response to ACE inhibition indicates that enzyme systems not reflected by plasma ACE activity or independent from the classic pathways of angiotensin formation contribute to the regulation of the autonomic response to ACE inhibition in patients with heart failure. The absence of significant change in hemodynamic variables or in blood pressure variability indicates that these autonomic changes are not an indirect reflex response to ACE inhibitor-induced vasodilation or hemodynamic baroreceptor stimulation.     

Psychological distress and cardiovascular disease: results from the 2002 National Health Interview Survey.

AIMS: The objective of this study was to examine the burden of psychological distress among individuals with different forms of heart disease in a large representative sample of adults. METHODS AND RESULTS: Data were obtained from the 2002 National Health Interview Survey, which is a large annual survey of the US non-institutionalized civilian population. Psychological distress was assessed with a standardized questionnaire (K6) and heart disease diagnoses were based on self-report. Among non-diseased individuals, the estimated prevalence of psychological distress was 2.8%, whereas the estimates were 10, 6.4, and 4.1% among those with congestive heart failure (CHF), myocardial infarction (MI), and coronary heart disease (CHD), respectively. Over 1 million individuals with one or more of these conditions are estimated to experience psychological distress. However, only 31-35% of the participants with heart disease and psychological distress have visited a mental health professional. The logistic regression model results indicate that MI (OR 2.0, 95% CI 1.4-3.0) and CHF (OR 3.1, 95% CI 1.8-5.1) are significantly associated with psychological distress. CONCLUSION: These findings imply that psychological distress is a significant comorbidity of cardiovascular disease. Other investigations have demonstrated a link between psychological distress and morbidity and mortality. Taken together, these findings provide the impetus for future investigations that assess the role that a medical and mental health care professional intervention may have in altering these outcomes when targeted at this distress.     

The detection and use of hemoglobin mutants in the direct analysis of human globin genes

Many human globin-chain mutants contain amino acid replacements that result from single base changes in the corresponding globin gene. Using recombinants, the coding sequences of each of the alpha-, beta-, Ggamma- , and Agamma-globin genes have now been determined. Those sequences of DNA that are cleaved by a number of specific restriction endonucleases have been identified and accurately positioned. Mutations at these sequences abolish the restriction site, and therefore, the pattern of DNA fragments containing hybridizing globin-gene sequences is altered compared to DNA from normal persons. This allows the identification of one of a pair of cross-hybridizing human globin-gene sequences, as is shown here for the two alpha-globin, the two gamma-globin, and the delta- and beta-globin genes.