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.

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.

Bakgrund: Hjärtsvikt är en kronisk sjukdom som blir allt vanligare i västvärlden, underliggande hjärt- och kärlsjukdomar är ofta bidragande orsaker till att hjärtsvikt uppstår. Sjukdomen har en allvarlig påverkan på kroppen och gör att personers hälsa sätts ur balans. Syfte: Syftet var att belysa upplevelser av att leva med diagnostiserad hjärtsvikt med minst NYHA II. Metod: En litteraturstudie har gjorts och baserats på 13 vetenskapliga artiklar. Resultat: Personer med hjärtsvikt upplever fysisk, social och psykisk påverkan på livet på grund av sjukdomen. Det väcker känslor av ilska, frustration och ångest. Personerna har ofta behov av att göra livstilsförändringar som påverkar deras sociala nätverk negativt och skapar känslor av ensamhet och sorg. Många funderar mycket på framtiden och hur familjesituationen kan komma att förändras. Diskussion: Fynden som diskuteras är den fysiska påverkan, osäkerheten inför framtiden och hur familj- och närståenderelationerna kan förändras. Slutord: Som sjuksköterska och andra yrkesgrupper inom vården  är det viktigt att  ha förståelse för vilka känslor som personer med hjärtsvikt har och upplever. Genom att förstå vilka fysiska begränsningar personerna har och vilka upplevelser det skapar, kan omvårdnadsarbetet underlättas. / Background: Heart failure is a chronic disease that is becoming increasingly more common in the Western civilization, where the underlying cardiovascular diseases often are contributing factors to the occurrence of heart failure. The disease has a serious impact on the body and makes health out of balance. Aim: The aim was to highlight experiences of living with diagnosed heart failure graded at least as NYHA II. Methods: A literature review has been made based on 13 scientific articles. Results: People’s experiences of living with heart failure are physical, social and psychological impact on life due to the disease. It arouses feelings of anger, frustration and anxiety. People often need to make lifestyle changes that affect their social networks negatively and this creates feelings of loneliness and sadness. Many think a lot about the future and how the family situation may change. Discussion: The findings which have been discussed are the physical impact, uncertainty about the future and how family and close relationships can change.Conclusion: As a nurse and other professionals in health care it´s important to understand the feelings that people with heart failure have. By understanding the physical limitations and the experiences it creates, nursing work might become easier.

Thesis (M.S.)--Auburn University, 2008. / Abstract. Includes bibliographical references (p. 118-127).

Thesis (Ph. D.)--University of Wisconsin-Madison, 2002. / Includes bibliographical references (p. 240-252). Also available on the Internet.

It has been known that anthracycline-based chemotherapy has the potential to cause cardiac dysfunction in breast cancer patients; however, recently evidence has shown that the addition of trastuzumab increases this risk. The study objective was to compare the cost-effectiveness of monitoring for cardiotoxicity with B-type natriuretic peptide (BNP), multi-gated acquisition scanning (MUGA), echocardiography (ECHO) or no monitoring from a payer’s prospective. Cost-effectiveness was compared between alternatives using an incremental cost-effectiveness ratio with outcomes of 1) quality-adjusted life-years and 2) percentage of patients diagnosed with each monitoring strategy. Costs estimates (in 2010 U.S. Dollars) of each strategy (obtained from the Center for Medicare and Medicaid Services website [www.cms.gov]) included the cost of the test, cost of treating heart failure once discovered (which includes medications, routine office visits, medication management) and the cost of potential acute care (which includes emergency department visits and hospitalizations). Estimates for the probabilities of heart failure development, disease progression, need for acute care, and mortality, as well as utility estimates for all disease stages were obtained from published literature. A 15-year time-frame was used with a 3% discount rate for both costs and QALYs. In the base-case analysis, the average costs and QALYs for monitoring patients were $10,062/ 6.92 QALY, $13,627/4.22 QALY, $14,739/ 6.61 QALY and $15,656/ 6.49 QALY for BNP, No Monitoring, ECHO and MUGA respectively. When comparing all alternatives to BNP, the ICER values were negative, indicating that BNP was the dominant monitoring strategy. Percent detection was similar between the three monitoring methods [21-22 % for HER-2(-) and 30-31% for HER-2(+) patients]. Again BNP was dominant over the other monitoring strategies. Sensitivity analyses were robust to changes in discount rate, probability of patients testing HER-2 (+), probability of patients being diagnosed in an asymptomatic stage, incidence of cardiac dysfunction in patients receiving anthracycline therapy ± trastuzumab and estimate of disutility associated with additional testing. A probabilistic sensitivity analysis conducted via Monte Carlo simulation led to the same conclusion as the base-case analysis; BNP was the dominant strategy over all monitoring alternatives. / text

Impedance has been used as a tool for cardiac research since the early 1940’s. Recently there have been many advances in this field in the diagnosis of human heart failure through the measurement of pacemaker and ICD coupled impedance detection to determine the state of pulmonary edema in patients through drops in lung impedance. These new detection methods are far downstream of the initial changes in physiology, which signify heart failure risk, namely, an increased left ventricular (LV) end-diastolic volume (also known as preload). This dissertation presents the first formal validation of the complex admittance technique for more accurate blood volume measurement in vivo in mice. It aims to determine a new configuration of admittance measurement in a large scale animal model (pigs). It also aims to prove that “piggybacking” an admittance measurement system onto previously implanted AICD and bi-ventricular pacemakers is a feasible and practical measurement that will serve as an early warning system for impending heart failure through the measurement of LV preload, which appears before the currently measured drop in lung impedance using previous techniques. / text

Ο ρόλος της εξωκυττάριας ουσίας στην καρδιακή ανεπάρκεια. / The functional role of extracellular matrix in heart failure.

Background: Patients with heart failure (HF) are characterized by exercise intolerance, breathlessness, fatigue and excessive neurohormonal activation associated with premature mortality. Recently, inflammatory activation has been described as an important factor in the progression of HF. Increased levels of certain pro-inflammatory cytokines (e.g., TNF-ɑ, IL-6) have been related to increased severity of left ventricular dysfunction, the activation of the sympathetic and renin-angiotensin systems and the catabolism of skeletal muscle. Although exercise training is important in the management of HF, acute bouts of exercise may lead to increases in proinflammatory cytokines. It is believed that the skeletal muscle abnormalities associated with HF may increase the risk of damage to skeletal muscle, (i.e., exercise-induced muscle injury (EIMI) with associated inflammatory activation) especially following unaccustomed exercise training. Recently, several training methods have been proposed for patients with HF that challenge the traditional “steady-state” (SS) training model, including interval training (IT). Interval training methods employ greater muscular loading than SS and therefore may increase the risk of inflammatory system activation EIMI, and/or reduced muscle function. There is no study that has examined the effects of IT on EIMI, muscle function and/or inflammatory markers. Material and Methods: Fourteen male participants with HF (mean age: 59 +/- 7.8 yrs; mean VO2 peak: 13.64 +/- 4.5 ml/kg/m-1; EF < 45%) were matched (for body mass and aerobic fitness) and randomized into SS or IT for 20 minutes. The IT involved 2 minute work:recovery phases of 90% and 40% of heart rate reserve, respectively. The SS involved continuous exercise at 65% of heart rate reserve. Biochemical markers of muscle damage and acute inflammation, concentric and eccentric isokinetic muscle torque, and subjective indicators of delayed onset muscle soreness (DOMS) and lower extremity function were evaluated at baseline, and then immediately following the training bout, and at 6, 24, and 48 hours post. Results: There were no significant differences between the IT and the SS training group for markers of skeletal muscle injury or inflammatory activation. Conclusions: The findings from the present study suggest that IT or SS do not result in excessive inflammatory system activation or skeletal muscle injury. These results have important implications for clinicians prescribing exercise regimes for HF patients who may be starting back into activity after a prolonged sedentary period. Additionally, results from this study indicate that there is a need for future research looking at the actual and perceived effect of even a single about of exercise on lower extremity function.

ABSTRACT The Benefits of Yoga Therapy for Heart Failure Patients by Paula R. Pullen STATEMENT OF THE PROBLEM The number of patients living with heart failure (HF) is on the rise. Yoga has been found to improve physical and psychological parameters amongst healthy individuals. The effects of yoga on HF patients are unknown. The purpose of this study was to examine the effects of yoga on cardio-vascular endurance [functional capacity (FC)], flexibility, inflammatory markers, and quality of life (QoL) on medically stable HF patients. METHOD Forty HF patients with compensated systolic or diastolic HF participated in the study. A randomized control design created two groups, yoga (N=21). and control (N=19).The treatment intervention consisted of 16-yoga sessions conducted bi-weekly (YG) vs. standard medical care (control- CG) for two months. All participants were asked to follow a home walk program. Pre- and post-study measurements included a treadmill stress test to peak exertion, flexibility (FLEX), girth, interleukin-6 (IL-6), c- reactive protein (CRP), and extra-cellular dismutase (EC-SOD). Quality of life was assessed by the Minnesota Living with Heart Failure Questionnaire (MLwHFQ). RESULTS Forty patients were randomized to YG (N=21) or CG (N=19). The results were significant for favorable changes in the YG as compared to the CG for flexibility (P=0.012), treadmill time (P=0.002), ~VO2peak (P=0.003), and all biomarkers (IL-6, CRP, and EC-SOD) of inflammation. Within the YG, pre- to post- test scores for the total and physical sub- scale of the MLwHFQ were significant (P=0.02 and P<0.001). CONCLUSIONS Yoga therapy offered additional benefits to the standard medical care of HF patients by improving QoL, exercise capacity, FLEX, and biomarkers of inflammation