mangement of chronic heart failure

Management of chronic heart failure

93432

1


The Effect of Cardiac Resynchronization on Morbidity and Mortality in Heart Failure

Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L, Tavazzi L, Cardiac

Resynchronization-Heart Failure (CARE-HF) Study Investigators. The effect of cardiac

resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005 Apr 14;352(15):1539-

49.

For patients with cognitive heart failure due to dyssnchrony, cardiac resynchronization can improve left

ventricular function. In this context the authors in their experimental research attempt to ascertain the

effects of cardiac resynchronization on morbidity and mortality of the patients because in the opinion of

the authors the after effects of cardiac resynchronization posed a risk of complications which often

resulted in deaths.

In a randomized trial, 'Cardiac Resynchronization-Heart Failure' which was funded by Medtronic

Corporation heart failure patients, who were 18 years of age and above and suffered for at least six weeks

with heart failure were in New York Heart Association, were enrolled and were given a InSync

III device, to provide atrial-based, biventricular stimulation and they were kept under observation

overnight. All patients were evaluated for 18 months. The primary end point was time of death for any

cause and the secondary end point was death by any cause.

Hospitalization due to serious procedure related event was taken as primary end point. A composite of

death by unplanned hospitalization with heart failure was taken as secondary end point. By using the

mixed models including baseline variables, all data was analyzed as random effects.

Out of 813 patients undergoing cardiac resynchronization process, end point arrived was 159 including

one device related death, compared to the 229 patients undergoing medical-therapy. In the cardiac

resynchronization group 82 died while in the medical therapy, 120 deaths were reported. This proved that

cardiac resynchronization worked better by improving symptoms of overall cardiac condition.

Cardiac resynchronization improved patients condition proved to improve symptoms as well as life

quality and reduced morbidity and mortality rate among heart failure patients as well as was more

economical.

2


Collaborative Group on ACE Inhibitor Trials

Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality

and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. JAMA 1995

May 10;273(18):1450-6.

This research provides a thorough examination of the major roles of angiotensin-converting enzyme

(ACE) inhibitors on mortality and morbidity congestive heart failure patients. The author discusses

relevant experimental evidence, patterns of treatment and previous research from where all the data were

obtained and were related to ACE inhibitors and were helpful in determination of mortality and treatment.

Data was obtained by corresponding with the chief investigator of each pharma company. The data thus

collected were collected by the use of Yusuf-Peto adaptation of the Mantel-Haenszel method.

It was observed by the data, which were largely based on enalapril maleate, captopril, ramipril, quinapril

hydrochloride, and lisinopril, that a condiserable reduction in mortality rate was evident as well as in the

combined end point. With ACE inhibitors various benefits were evident. The groups and the subgroups

were examined according to New York Heart Association class. Although benefits started to appear in the

first three months, lowest ejection fraction patients have had the greatest benefits which also become

greater by further treatment. So it showed that symptoms of congestive heart failure reduced remarkably

by ACE inhibitors.

Various disease management interventions for the patients with cognitive heart failure are although

proposed and this study points out that whether significant or not, but further treatment of CHF patients

proved to be beneficial in the long run with proper and consistent nursing care.

3


Clinical service organisation for heart failure

Takeda A, Taylor SJ, Taylor RS et al. Clinical service organisation for heart failure. Cochrane Database

Syst Rev 2012;(9):CD002752.

This research offers update the previously published research about cognitive heart failure. For this

purpose the researchers used a number of databases on Randomized controlled trials, which are:

CENTRAL, (the Cochrane Central Register of Controlled Trials) and DARE, on The Cochrane Library,

( Issue 1 2009); MEDLINE (1950-January 2009); EMBASE (1980-January 2009); CINAHL (1982-

January 2009); AMED (1985-January 2009). For the original review (but not the update) we had also

searched: Science Citation Index Expanded (1981-2001); SIGLE (1980-2003); National Research

Register (2003) and NHS Economic Evaluations Database (2001).

Out of twenty five trials the classifications of intervention were: Case management which in round the

clock monitoring of patients it included home visits, clinic interventions and interventions of

multidisciplinary nature. These revealed little reduction in cases of mortality. Two studies also showed

that readmissions were apparently reduced. Therefore there is no remarkable evidence in support of

interventions which have follow up as major component. But nonetheless amongst CHF patients who

have previously been admitted to hospital for this condition there is now good evidence that case

management type interventions led by a heart failure specialist nurse reduces CHF related readmissions

4


Item Description

1. Abstract The research studies are randomized controlled as per the abstract of the studies.

2. Introduction Accurate explanations of medical background and description of the rationale.

Methods:

3. Participants Patient participation and their eligibility criteria are right stated.

4. Interventions Exact description of interventions proposed for each group is accurately detailed

5. Outcomes Primary and secondary ends are appropriately explained

6. Objectives Exact research question are defined

7. Sample size Full explanation on sample size and how it determined was is given.

8. Statistical methodsStatistical procedures utilized for comparison of groups for primary outcomes are appropriately described.

Results:

9. Participants flowPatient participants were randomly assigned, provided with planned treatment completing the research protocols then analyzed for outcomes, all are explained in detail.

10. Recruitment All important dates of recruitment of participants are described.

11. Baseline data Baseline demographic and clinical features of each participant group are accurately stated.

12. Outcomes and estimation For each end, the gist of treatment and their effects for each participant group is stated.

13. Adverse events Adverse events, technical failures and morbidity rates in each group are detailed.

Introduction

All authors are eminent medical professionals and academicians. The research studies were published in

The New England Journal of Medicine which is a weekly general medical journal, The Journal of the

American Medical Association and Medscape-which consists of the online databases of systematic

reviews.

Cognitive heart failure is the impairment of any functional or structural of the heart and is very complex.

A study of previous history of patient with this disease is crucial to understand the root of problems.

5


Besides chest radiograph, electrocardiogram, and echocardiography is essential to understand the

problem.

In the case of reduced cardiac output and heart failure, there are two mechanisms, the systolic and

diastolic dysfunction. Usual causes of systolic dysfunction are ischemic heart disease, idiopathic dilated

cardiomyopathy, hypertension, and valvular heart disease. Diastolic dysfunction, it is more prevalent

especially women and more specifically at the later stage of life. Many patients who have symptoms

suggestive of heart failure which includes, shortness of breath, peripheral edema, paroxysmal nocturnal

dyspnea

This study reviewed the three research studies by eminent medical professionals, about the

pathophysiology, diagnosis, and treatment of CHF, with specific discussion of cardio resynchronization

process, including ACE inhibitors and interventions of multidisciplinary nature. The selection of three

studies was on the basis of their relevancy as well as the scope of benefits that these research studies

revealed and which were crucial for understanding the morbidity and mortality in CHF patients and

recommended means of treatment that enhanced the quality of life.

PICOT

The PICOT format is a helpful approach for summarizing research questions that explore the effect of

therapy hence it is mentioned as follows:

Study Design:

6


The research studies were a prospective, co -relational/predictive study as well as cross investigations of

other research data. Cross-sectional and longitudinal data were collected from individuals with CHF

which is becoming rampant due to the following factors:

Obesity - people who are both obese and have diabetes type 2

Smoking - people who smoke regularly have high blood pressure

Patients with heart disease often suffer from with depression

Problems addressed in the study:

Research has shown that in patients of CHF mortality and morbidity can be reduced by cardio

resynchronization and ACE inhibitors including proper and consistent nursing care for long duration of

time.

Research questions:

Can mortality and morbidity rate in CHF patients be reduced significantly?

Independent variables and their operational definitions:

Independent variable included:

• Age

• Gender

• Race – defined as Caucasian, African American, Hispanic or other race

• Impairment – defined as cognitive heart failure

Research studies from other data obtained for this study confirms that there are various factors that

affected CHF patients, the lack of knowledge, negligence after acknowledging the symptoms, self

treatments, addiction to alcohol, chain smoking and emotional and mental anxieties are all related to the

CHF patients. The researchers should revisit their original hypotheses in future as more studies are crucial

to understand the correct diagnosis and treatment of CHF patients. In doing so, they may find a better and

more accurate predictor.

7


Cardio resynchronization has proved to be efficacious for selected patients with heart failure, but it

remains a very costly therapy, its being economical is questionable as it reveals uncertainty in the higher

cost per life year. The determination of whether cardio resynchronization has acceptable value for money

in order to warrant its broader use today is questionable. This contradicts ACE inhibitors for patients with

advanced heart failure.

8

mangement of chronic heart failure

Health & Medicine