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Diss. (sammanfattning) Stockholm : Karol. inst., 2006. / Härtill 5 uppsatser.

Heart failure (HF) is a serious, life limiting chronic illness and is the most common cause of <30-day hospital readmission, which is costly both in its profound negative impact on patient mortality and quality of life, and in economics. Limited access to care in rural communities increases the prevalence of hospitalizations for heart disease in rural areas. The aims of this project using data mined from Arizona Health Sciences Center Clinical Research Data Warehouse, are to define clinical events (fever, pain, changes in respiratory status, change in level of consciousness, changes in output, bleeding, and suicide ideation) for patients with heart failure, and determine what assessment values are for chronically ill patients and compare to "normal" assessment values for non-chronically ill patients. A literature review was completed to determine how to define clinical events for chronically ill patients with HF, and how decision making is used at home to manage chronic illness. Assessment value data was mined from the clinical research data warehouse and compared to “normal” assessment values, with identification of associations between clinical events and action taken in the hospital. The project results support that there are differences in "normal" assessment values for fever, pain, and change in respiratory status between chronically ill patients with HF, and non-chronically ill patients; there was insufficient data to define bleeding, change in output, or suicide ideation. Impacts to care include earlier recognition of worsening HF symptoms that could result in an earlier call or visit to primary care provider forestalling the need for emergent care and hospital readmission. Application of the mined clinical may inform development of evidenced-based algorithm to guide decision-making at home, and it may also provide the foundation for the development of a tool for patient use to prevent <30-day hospital readmission.

Previous research on quality of life (QOL) and its relation to BNP levels in heart failure (HF) has been widely studied. However, the impact of physicians' knowledge of BNP levels at time of clinic visit on QOL and hospital length of stay (LOS) has yet to be fully investigated. The purpose of this study were to determine if physicians' knowledge of BNP levels affected a change in QOL scores at 90 days and reduce hospital length of stay among heart failure patients. QOL data from HF clinic patients (N = 108, 67.5 ± 12.3, 56% male, ejection fraction 26.5 ± 8.2) were analyzed. QOL was measured at time of clinic visit (T1) and at 90 days (T2) using the Minnesota Living with Heart Failure Questionnaire (MLHFQ). An independent t-test was utilized to compare the two groups. Findings: Both groups were comparable regarding demographic and baseline characteristics. There was no significant association observed between the experimental and control group at 90 days, although the data indicated a decrease in the mean QOL scores at 90 days (37.46 ± 28.67) as compared to the mean QOL scores at baseline (46.87 ± 29.63) for both groups. Because the QOL scale is reversed, this indicated that there was a positive change in QOL scores during the 90 day time interval. Hospital LOS was similar for both groups (mean=3 days). BNP levels were significantly correlated with both baseline QOL scores (r=.25, p=.01) and physical subscale scores (r=.24, p=.01). Mortality was higher in the control when compared to the experimental group (t=1.99, df=90, p=.04). Conclusion: While physicians' awareness of BNP levels had not shown a significant change in QOL at 90 days, patients' QOL might already have been quite positive. Chronic HF patients may have adapted to their disease and have adjusted their perception of their QOL. Therefore, QOL may be a stable construct at this time. Findings may have been different on newly diagnosed HF patients since they may not have adapted to their health condition.

Introduction: Chronic kidney disease (CKD) and congestive heart failure (CHF) patients have higher serum B-type natriuretic peptide (BNP), which alters the test interpretation. We aim to define BNP cutoff levels to diagnose acute decompensated heart failure (ADHF) in CKD according to CHF subtype: heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). Material and methods: We reviewed 1,437 charts of consecutive patients who were admitted for dyspnea. We excluded patients with normal kidney function, without measured BNP, echocardiography, or history of CHF. BNP cutoff values to diagnose ADHF for CKD stages according to CHF subtype were obtained for the highest pair of sensitivity (Sn) and specificity (Sp). We calculated positive and negative likelihood ratios (LR+ and LR–, respectively), and diagnostic odds ratios (DOR), as well as the area under the receiver operating characteristic curves (AUC) for BNP. Results: We evaluated a cohort of 348 consecutive patients: 152 had ADHF, and 196 had stable CHF. In those with HFpEF with CKD stages 3–4, BNP < 155 pg/ml rules out ADHF (Sn90%, LR– = 0.26 and DOR = 5.75), and BNP > 670 pg/ml rules in ADHF (Sp90%, LR+ = 4 and DOR = 6), with an AUC = 0.79 (95% CI: 0.71–0.87). In contrast, in those with HFrEF with CKD stages 3–4, BNP < 412.5 pg/ml rules out ADHF (Sn90%, LR– = 0.19 and DOR = 9.37), and BNP > 1166.5 pg/ml rules in ADHF (Sp87%, LR+ = 3.9 and DOR = 6.97) with an AUC = 0.78 (95% CI: 0.69–0.86). All LRs and DOR were statistically significant. Conclusions: BNP cutoff values for the diagnosis of ADHF in HFrEF were higher than those in HFpEF across CKD stages 3–4, with moderate discriminatory diagnostic ability. / Revisión por pares

Background and aims: Heart failure (HF) is a life threatening condition and optimal handling is necessary to reduce risk of therapy failure. The aims of this thesis were: (Paper I) to examine whether BNP (B-type natriuretic peptide)-guided HF treatment improves morbidity and mortality when compared with HF therapy implemented by a treating physician at sites experienced in managing patients with HF according to guidelines; (Paper II) to investigate how to define a responder regarding optimal cut-off level of BNP to predict death, need for hospitalisation, and worsening HF and to determine the optimal time to apply the chosen cut-off value; (Paper III) to evaluate how Health-Related Quality of Life (HR-QoL) is influenced by natriuretic peptide guiding and to study how HR-QoL is affected in responders compared to non-responders; (Paper IV) to evaluate the impact of patient age on clinical outcomes, and to evaluate the impact of duration of the HF disease on outcomes and the impact of age and HF duration on BNP concentration. Methods: A randomized, parallel group, multi-centre study was undertaken on 279 patients with HF and who had experienced an episode of worsening HF with increased BNP concentration. The control group (n=132) was treated according to HF guidelines and in the BNP-guided group (n=147) the HF treatment algorithm goal was to reduce BNP concentration to &lt; 150 ng/L in patients &lt; 75 years and &lt;300 ng/L in patients &gt; 75 years (Paper I), and to define the optimal percentage decrease in BNP and at what point during the follow-up to apply the definition (Paper II). To compare the BNP-guided group with the conventional HF treated group (Paper I), and responders and non-responders (Paper II) regarding HR-QoL measured with Short Form 36 (SF-36) at study start and at study end (Paper III) and to evaluate if age or HF duration influenced the HF outcomes and the influence of BNP on age and HF duration (Paper IV). Results: The primary outcome (mortality, hospitalisation and worsening HF) was not improved by BNP-guided HF treatment compared to conventional HF treatment or in any of the secondary outcome variables (Paper I). Applying a BNP decrease of at least 40 percent in week 16 (compared to study start) and/or a BNP&lt;300 ng/L demonstrated the best risk reduction for cardiovascular mortality, by 78 percent and 89 percent respectively for HF mortality (Paper II). The HR-QoL improved in four domains in the BNP-guided group and in the control group in six of eight domains; however there were no significant differences between the groups (Paper III). For responders the within group analysis showed improvement in four domains compared to the non-responders that improved in one domain; however there were no significant differences between the two groups. There were improvements in HR-QoL in all four groups (Paper III). Age did not influence outcome but HF duration did. HF duration was divided into three groups: HF duration less than 1 year (group 1), 1-5 years (group 2) and &gt;5 years (group 3). A 1.65-fold increased risk could be demonstrated in those with HF duration of more than five years compared to patients with short HF duration. The BNP concentration was increased with increased age, and there was a better response regarding BNP decrease in NP-guiding in patients with short HF duration, independent of age (Paper IV). Conclusions: There were no significant differences between BNP-guided HF treatment group and the group with conventional HF treatment as regards mortality, hospitalisation or HR-QoL. The responders to HF treatment showed a significantly better outcome in mortality and hospitalisation compared to non-responders but no significant differences in HR-QoL. The duration of HF might be an important factor to consider in HF treatment by BNP-guiding in the future.

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