The prevalence of heart failure became a major and growing public health problem globally, with rising mortality numbers causing a great financial burden. In Mongolia, the hospitalization for cardiovascular diseases makes up 55% of all hospitalizations, and mortality rate of circulatory diseases was the highest nationwide, accounting for 36.7% of all deaths (S.Ariuntuya et al., 2011). However, there is still no formal research addressing the prevalence of heart failure in Mongolia. Therefore, this paper is meant to bring awareness of the problem of hidden heart failure in Mongolia, which might be contributing significantly to the cardiovascular disease mortality and health care costs. This paper describes the Mongolian health care structure and the high incidence of heart failure risk factors is identified. Moreover, this paper proposes to develop and adapt a heart failure disease management program, as well as the heart failure patient education program in Mongolia. It is important that Mongolian health care providers and health policy makers acknowledge that if a proper disease management plan is not adapted soon, the prevalence of heart failure will continue to increase along with health care costs. Mongolia needs more public health and clinical researchers addressing heart failure.

Aims : Patients with mild heart failure (HF) who are clinically compensated may have normal left ventricular (LV) stroke volume (SV). Despite this, altered intra-ventricular flow patterns have been recognized in these subjects. We hypothesized that, compared with normal LVs, flow in myopathic LVs would demonstrate a smaller proportion of inflow volume passing directly to ejection and diminished the end-diastolic preservation of the inflow kinetic energy (KE). Methods and results : In 10 patients with dilated cardiomyopathy (DCM) (49 ± 14 years, six females) and 10 healthy subjects (44 ± 17 years, four females), four-dimensional MRI velocity and morphological data were acquired. A previously validated method was used to separate the LV end-diastolic volume (EDV) into four flow components based on the blood's locations at the beginning and end of the cardiac cycle. KE was calculated over the cardiac cycle for each component. The EDV was larger (P = 0.021) and the ejection fraction smaller (P < 0.001) in DCM compared with healthy subjects; the SV was equivalent (DCM: 77 ± 19, healthy: 79 ± 16 mL). The proportion of the total LV inflow that passed directly to ejection was smaller in DCM (P = 0.000), but the end-diastolic KE/mL of the direct flow was not different in the two groups (NS). Conclusion : Despite equivalent LVSVs, HF patients with mild LV remodelling demonstrate altered diastolic flow routes through the LV and impaired preservation of inflow KE at pre-systole compared with healthy subjects. These unique flow-specific changes in the flow route and energetics are detectable despite clinical compensation, and may prove useful as subclinical markers of LV dysfunction.

Patienter med hjärtsvikt är en stor patientgrupp som har ökat i antal då hjärtsjukvården förbättrats samt att medellivslängden har ökat i Sverige. Hjärtsvikt karaktäriseras av påfrestande symtom och påverkar både patient och anhöriga i deras vardag. För att individen ska kunna hantera sin livssituation behövs stöd ifrån både omgivningen och vården. Syftet med studien var att belysa betydelsen av stöd till patienter med hjärtsvikt. Metoden var en litteraturstudie innehållande totalt 13 vetenskapliga artiklar. Artiklarna var både av kvalitativ och kvantitativ ansats. Två övergripande teman framkom i resultatet, Stöd gav kontroll och trygghet och Stöd gav förbättrat självförtroende och egenvård. Hjärtsvikt medförde känslor som ångest och osäkerhet. Stöd i form av information gav bättre kontroll och känsla av trygghet. Stöd från anhöriga och vänner gav ett förbättrat självförtroende och en förbättrad egenvård. Slutsatsen är att stöd från hälso- och sjukvårdspersonal, anhöriga och vänner har stor betydelse för att patienter med hjärtsvikt ska kunna hantera sin livssituation och kunna uppleva trygghet och säkerhet trots livet med en oförutsägbar sjukdom. Mer forskning behövs för att få fram fler stödjande omvårdnadsåtgärder som kan användas i den praktiska vårdverksamheten. För att främja en god omvårdnad som ger trygghet och säkerhet bör även stöd belysas mer i sjuksköterskeutbildningen. / Patients with heart failure is a large group of patients which has increased in numbers as cardiac care has improved and the average life has increased in Sweden. Heart failure is characterized by distressing symptoms and influence the daily life of both the patient and their family. For the individual to manage their life, support is needed from both the environment and the health care. The aim of the study was to illuminate the support for patients with heart failure. The method was a literature review containing a total of 13 scientific papers. The articles were of both qualitative and quantitative method. Two main themes were found, Support gave control and safety and Support gave improved self- confidence and self- care. Heart failure caused feelings of anxiety and uncertainty. Support in form of evident information led to better control and feelings of security. Support from family members and friends showed improved self- confidence and self-care. The conclusion is that support from health- care providers, family and friends is of great importance in patients with heart failure to manage their lives and be able to experience safety and security despite life with an unpredictable disease. More research is needed to develop more supportive care measures that can be used in practice. In order to provide good care that provides safety and security, support should be highlighted more in the nurse education.

Background: Symptomatic heart failure is a chronic and disabling condition that affects over 350 000 Canadians and is characterized by inevitable progression. Historically, research on the ways to increase survival has focused on biomedical factors. However, the continued poor prognosis of heart failure has prompted the search for other ways to improve the lives of these patients. Research in other chronic conditions demonstrates that social circumstances, described collectively as individual social interactions (e.g. social support, social participation) and community social factors (e.g. social capital, social norms), can influence health outcomes. Purpose: The purpose of this research was to describe and assess the impact of selected social circumstances potentially related to heart failure outcomes. Methods: Two literature reviews and one empirical study were performed. Conceptual models were proposed to describe the hypothesized pathways between selected social circumstances and heart failure outcomes. The first review was a systematic review of quantitative studies evaluating the relationship between social support and both rehospitalization and death. The review included a critical analysis of the methods employed by previous studies. The second review integrated the qualitative and quantitative literature describing the relationship between individual social interactions (including support, roles and participation) and the quality of life of patients or experience of living with heart failure. A narrative summary was provided and an integration of findings from both qualitative and quantitative study designs was performed. In the empirical study, patients‘ demographic and clinical information was examined simultaneously with selected community factors in a multilevel analysis. Outcomes of interest included rehospitalization or death of heart failure patients. Results: The systematic review shows that previous quantitative research has linked social support to reduced rehospitalization, but there is little evidence to link it with prolonged survival. The critique of the methods describes an inadequate conceptualization and inconsistent measurement of social support. A conceptual model showing how social support can influence rehospitalization is proposed. The integrative review presents qualitative research that identified the following social interactions as important components of the heart failure experience: social support, social participation and role fulfillment. However, no quantitative relationship between social support and quality of life was found. The potential reasons for the discrepant findings between the qualitative and quantitative studies include: the focus on social support as the only component of social interactions assessed in the quantitative literature; and the inconsistent measurement of social support. A conceptual model is presented to describe the multiple components of social interactions and the theoretical basis for their effects. The multilevel analysis demonstrates that individual factors exerted the strongest effect on heart failure outcomes in most models. Community characteristics had little influence on rehospitalization or death. Study design and analysis issues are proposed to explain these findings. Conclusion: The literature reviews and the empirical study provide a contribution to the population health literature, offering a broad approach to assessing the determinants of disease progression in heart failure patients. This thesis research advances the discussion about which social circumstances may influence heart failure outcomes and their pathways. The use of the proposed conceptual models in future research will help clarify the role of social circumstances in the prognosis of heart failure.

Cardiotoxicity associated with many cancer drugs is a critical issue facing physicians these days and a huge hurdle that must be overcome for a side effects-free cancer therapy. Survival of cardiac myocytes is compromised upon the exposure to certain chemotherapeutic drugs. Unfortunately, the mechanisms implicated in cardiac toxicity and the pathways governing myocyte survival are poorly understood. The following thesis addresses the mechanisms underlying the cardiotoxicity of two anticancer drugs, doxorubicin (DOX) and Imatinib mesylate (Gleevec). Transcription factor GATA-4, has recently emerged as an indispensable factor in the adult heart adaptive response and cardiomyocyte survival. Therefore, the specific aim of this project was to determine the role of GATA-4, its upstream regulators, as well as partners in survival. A combination of cell and molecular techniques done on in vivo, and ex vivo models were utilized to tackle these issues. In this study, we confirmed the cardiotoxicity of the anticancer drug, Imatinib mesylate and found to be age dependent. GATA-4, already known to be implicated in DOX-induced toxicity, was confirmed as an Imatinib target. At the molecular level, we identified IGF-1 and AKT as upstream regulators of GATA-4. Moreover, we confirmed ZFP260 (PEX-1), a key regulator of the cardiac hypertrophic response, as a GATA-4 collaborator in common prosurvival pathways. Collectively, these results provide new insights on the mechanisms underlying drug-induced cardiotoxicity and raise the exciting possibility that cancer drugs are negatively affecting the same prosurvival pathway(s), in which GATA-4 is a critical component. Therapeutic interventions aimed at enhancing GATA-4 activity may be interesting to consider in the context of treatments with anticancer drugs.

A series of seven experiments were conducted to evaluate the risk of acute (sudden death syndrome; SDS) or chronic (congestive heart failure; CHF) heart failure associated with dietary over-supplementation of vitamin A, vitamin D3, vitamin E, vitamin C or cardiotoxic factors present in meat meal. The risk of heart failure associated with the above mentioned dietary factors was tested followed by gross, microscopic, ultrastructural and biochemical investigation for mechanisms associated with mentioned risk factors. Simultaneously, the molecular mechanisms underlying the deterioration of heart function in fast-growing commercial broilers were studied. Each compound was tested separately at a concentration higher than the recommended levels. The basic experimental unit comprised groups of 40 to 50 day old male broiler chickens at the start of experiment. Lowered thermal brooding temperature protocol, an approach resulting in clinical manifestation of heart failure in practically all broilers predisposed to heart disease, was used.<p> Broilers fed the vitamin D3 enriched diet were 2.5 fold more likely to succumb to acute heart failure (p<0.05). Simulated stress challenge with epinephrine revealed that broilers fed excess of vitamin D3 were more susceptible to ventricular arrhythmia. The risk of CHF was higher (P<0.05) in broilers fed the vitamin D3, vitamin A and methanol soluble extract from meat meal enriched diets as compared to groups fed the control diet. The incidence of CHF in broilers fed the diet fortified with vitamin E was not significantly different as compared to the control group, whereas supplementation of vitamin C in the diet tended (p=0.10) to reduce the incidence of CHF. The level of malondialdehyde equivalents, an indicator of lipid peroxidation, was significantly higher (p<0.05) in myocardium of broilers developing CHF irrespective of dietary factors. Antioxidant vitamins (E and C) did not prevent lipid peroxidation in broilers developing CHF. <p>In conclusion, the present findings indicate that over-supplementation of vitamin A and D3 increases the risk of heart failure in broilers. Meat meal contains some unknown cardiotoxic factors, capable of precipitating heart conditions in susceptible broilers. Oxidative stress is involved in the pathogenesis of heart failure in broilers, but supplementation of antioxidant vitamins did not prevent oxidative damage in broilers that developed CHF. The oversupplementation of vitamins (A and D3) should not be encouraged in broilers diet as they may increase the economic losses to broilers industry subsequent to heart related mortalities/morbidities.

This thesis examines the retention of best practices by clinicians after the implementation of an integrated care pathway for patients with congestive heart failure. While the literature suggests there are many reasons why the implementation of best practices is difficult, there is little information on the sustainability of best practices once implemented.<p>Using a qualitative research design guided by Rogers theory of Diffusion of Innovations the researcher interviewed seven clinicians who participated in the implementation of the pathway. A thematic analysis revealed several themes that ran throughout participants responses. <p>While the participants indicated they see value in best practices, they also identified barriers to getting that knowledge into practice and keeping it there. A spectrum of factors, including individual autonomy, time, resources, organizational support and the organization of the system all played a role.<p>In the end, participants revealed that although small pieces of the pathway remain in practice, the pathway itself is no longer used by clinicians to manage patients with congestive heart failure.

Methods to improve self-care and clinical management of heart failure are required, especially in light of the anticipated increase in heart failure prevalence and associated high costs. Remote patient monitoring (RPM) has been shown to improve heart failure outcomes, but the feasibility and efficacy of mobile phone-based RPM systems are still unknown. The main objectives of this research were to investigate the optimal design of a mobile phone-based RPM system, and to determine the effects of the system on self-care, clinical management, and health outcomes. A mobile phone-based RPM system was first developed using a user-centric design process. It was then evaluated with a six-month randomized controlled trial consisting of 100 patients attending a heart function clinic. The quality of life improved only for the intervention group, but both intervention and control groups improved with respect to self-care, heart function, and heart failure prognosis. The clinic was determined to be a confounder. Patients who were enrolled into the clinic for less than six months showed significantly greater improvements (six months is required for patients to stabilize from medication optimization). Therefore, a subgroup analysis using data from the 63 patients who were enrolled into the clinic for over six months at time of recruitment was performed. The results from the subgroup analysis indicated that the RPM system improved self-care, heart function, and heart failure prognosis at statistically significant and clinically meaningful levels. These improvements were found to be a result of enhanced self-care knowledge and practices, as well as enhanced clinical management enabled by the system. No differences in mortality or hospital admissions were found between groups, but the trial was underpowered to detect changes in these outcome measures. In summary, mobile phone-based RPM was found to be a feasible and effective tool to help improve heart failure management and outcomes.

Methods to improve self-care and clinical management of heart failure are required, especially in light of the anticipated increase in heart failure prevalence and associated high costs. Remote patient monitoring (RPM) has been shown to improve heart failure outcomes, but the feasibility and efficacy of mobile phone-based RPM systems are still unknown. The main objectives of this research were to investigate the optimal design of a mobile phone-based RPM system, and to determine the effects of the system on self-care, clinical management, and health outcomes. A mobile phone-based RPM system was first developed using a user-centric design process. It was then evaluated with a six-month randomized controlled trial consisting of 100 patients attending a heart function clinic. The quality of life improved only for the intervention group, but both intervention and control groups improved with respect to self-care, heart function, and heart failure prognosis. The clinic was determined to be a confounder. Patients who were enrolled into the clinic for less than six months showed significantly greater improvements (six months is required for patients to stabilize from medication optimization). Therefore, a subgroup analysis using data from the 63 patients who were enrolled into the clinic for over six months at time of recruitment was performed. The results from the subgroup analysis indicated that the RPM system improved self-care, heart function, and heart failure prognosis at statistically significant and clinically meaningful levels. These improvements were found to be a result of enhanced self-care knowledge and practices, as well as enhanced clinical management enabled by the system. No differences in mortality or hospital admissions were found between groups, but the trial was underpowered to detect changes in these outcome measures. In summary, mobile phone-based RPM was found to be a feasible and effective tool to help improve heart failure management and outcomes.

Background: Symptomatic heart failure is a chronic and disabling condition that affects over 350 000 Canadians and is characterized by inevitable progression. Historically, research on the ways to increase survival has focused on biomedical factors. However, the continued poor prognosis of heart failure has prompted the search for other ways to improve the lives of these patients. Research in other chronic conditions demonstrates that social circumstances, described collectively as individual social interactions (e.g. social support, social participation) and community social factors (e.g. social capital, social norms), can influence health outcomes. Purpose: The purpose of this research was to describe and assess the impact of selected social circumstances potentially related to heart failure outcomes. Methods: Two literature reviews and one empirical study were performed. Conceptual models were proposed to describe the hypothesized pathways between selected social circumstances and heart failure outcomes. The first review was a systematic review of quantitative studies evaluating the relationship between social support and both rehospitalization and death. The review included a critical analysis of the methods employed by previous studies. The second review integrated the qualitative and quantitative literature describing the relationship between individual social interactions (including support, roles and participation) and the quality of life of patients or experience of living with heart failure. A narrative summary was provided and an integration of findings from both qualitative and quantitative study designs was performed. In the empirical study, patients‘ demographic and clinical information was examined simultaneously with selected community factors in a multilevel analysis. Outcomes of interest included rehospitalization or death of heart failure patients. Results: The systematic review shows that previous quantitative research has linked social support to reduced rehospitalization, but there is little evidence to link it with prolonged survival. The critique of the methods describes an inadequate conceptualization and inconsistent measurement of social support. A conceptual model showing how social support can influence rehospitalization is proposed. The integrative review presents qualitative research that identified the following social interactions as important components of the heart failure experience: social support, social participation and role fulfillment. However, no quantitative relationship between social support and quality of life was found. The potential reasons for the discrepant findings between the qualitative and quantitative studies include: the focus on social support as the only component of social interactions assessed in the quantitative literature; and the inconsistent measurement of social support. A conceptual model is presented to describe the multiple components of social interactions and the theoretical basis for their effects. The multilevel analysis demonstrates that individual factors exerted the strongest effect on heart failure outcomes in most models. Community characteristics had little influence on rehospitalization or death. Study design and analysis issues are proposed to explain these findings. Conclusion: The literature reviews and the empirical study provide a contribution to the population health literature, offering a broad approach to assessing the determinants of disease progression in heart failure patients. This thesis research advances the discussion about which social circumstances may influence heart failure outcomes and their pathways. The use of the proposed conceptual models in future research will help clarify the role of social circumstances in the prognosis of heart failure.