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Article 1 Read 0 Citations Rückenschmerz: kein Benefit durch Kombinationstherapie Published: 08 April 2016
Journal Club Schmerzmedizin, doi: 10.1055/s-0042-102516
Akute Schmerzen zwischen Rippen und Steißbein gehören zu den häufigsten Gründen für die Vorstellung in einer Notaufnahme. Die meisten Patienten mit einer nicht traumatischen Lumbalgie erhalten nicht-steroidale Antiphlogistika, die mit Muskelrelaxanzien und Morphinen kombiniert werden können. Die amerikanische Arbeitsgruppe aus Ärzten und Pharmazeuten verglich die kurz- und mittelfristigen Behandlungsergebnisse der Mono- und Kombinationstherapien.
Article 2 Reads 0 Citations 36 High prevalence of asymptomatic left ventricular dysfunction despite excellent risk factor control in a diabetic coho... Published: 01 September 2015
Heart, doi: 10.1136/heartjnl-2015-308621.36
Introduction Diabetes mellitus is an established cause of left ventricular dysfunction and a strong independent predictor of new onset heart failure. The STOP-HF Midlands project is a screening programme utilising NT-proBNP and collaborative care to detect left ventricular dysfunction in an asymptomatic diabetic cohort. Method 612 diabetic patients attending the STOP-HF Midlands were included in this analysis. The demographic characteristics and biomarkers of traditional risk factor control in diabetics were recorded, including NT-proBNP. Doppler-echocardiography was performed if the NT-proBNP was >250 pg/mL. Left ventricular systolic dysfunction (LVSD) was defined as left ventricular ejection fraction of 34 ml/m2 with lateral E´ 34 ml/m2 with lateral E <10 cm/s. Conclusion These data demonstrate a high prevalence of significant asymptomatic left ventricular dysfunction in a community diabetic cohort despite excellent control of risk factors. Wider use of RAAS modifying therapy in this cohort might reduce the burden of this problem and slow the development to heart failure. The observations indicate that this population should be a focus of efforts to prevent heart failure.
Article 1 Read 0 Citations 37 Clinical workload in a DMP in the first three months post discharge and comparison of hfref and HFpEF Published: 01 September 2015
Heart, doi: 10.1136/heartjnl-2015-308621.37
Background Continuing high event rates post discharge following management of acute decompensated heart failure (HF) may reflect the lack of uniform application of proven benefit of disease management programmes (DMP). Compromising the application may be the workload associated with this approach, which has not been adequately described. Methods All patients admitted with a primary diagnosis of HF were enrolled in a comprehensive DMP encompassing in-patient and out-patient care. Workload was viewed through an assessment of post discharge clinic visits (scheduled and unscheduled), telephonic contact and medication changes. Outcomes measured were mortality and emergency hospitalisations. Results 1292 patients were enrolled (male 58.7%; 74.5 yrs; HFrEF 68%). Mortality at one and three months post discharge was 0.3% and 3.8% respectively, with HF readmission of 2.5% and 7.3% respectively. Over the three-month programme duration, there were 5046 clinical visits, with a mean of 3.9 visits/patient, and 0.47 unscheduled visits/patient. Almost 30% of patients required at least one unscheduled visit, most frequently in the first week post discharge. Those with HFrEF had more frequent visits than the HFpEF cohort (4.0 vs. 3.7 visits/patient), which likely reflects increased number of medication titrations. There was a mean of 12.7 calls/patient with outbound calls being dominant. 25.8% of patients had 1 inbound call and 45.7% of patients had >1 during this three-month period. There no differences in frequency of inbound and outbound calls in those with HFrEF vs. those with HFpEF. At discharge, 92.5% of patients were prescribed diuretics. Mean diuretic dose at discharge was 58.7 mg frusemide eq. Mean diuretic dose at three months being 63.1 mg. Alteration of diuretic dose (at least one increase or decrease) occurred in 44.7% of patients with 25.8% having one dose change and 18.9% having >1 dose changes during the three-month programme duration. There was no significant difference in diuretic dose between those with HFrEF vs. HFpEF at either discharge or three months. At discharge 73.7% of the patients were prescribed ACEi with at least one dose alteration in ACEI / ARB occurring in 31.9% during the programme. Dose changes in ACEi/ARB were less common in the HFpEF group but still occurred in approximately 20% of those on an ACEi. At discharge, 67.7% were prescribed beta-blockers, with doses unchanged at 3 months in 57.2%. Epleronone as prescribed in 8.8% on discharge, and in 12.4% at three months, with a mean dose of 24.1 mg. Conclusion The workload associated with an intensive cardiology-led DMP in the immediate period post discharge, while significant, reflecting clinical instability and complexity of care, is similar for those with both HFrEF and HFpEF. Given the rapid growth in this patient population, this data should be used to inform appropriate resource organisation for establishing or evolving DMP structures.
Article 1 Read 0 Citations 22 Role of 12-lead electrocardiography in predicting heart failure in the community Published: 01 September 2015
Heart, doi: 10.1136/heartjnl-2015-308621.22
Purpose Many patients attending their primary care physician with symptoms suggestive of new onset heart failure, have a 12 lead electrocardiogram (ECG) as part of an initial triage work up. However, the role of ECG in predicting heart failure in the community is not yet defined. We thus examined the ability of ECG to predict heart failure in this patient population. Method All 733 patients attending the rapid access clinic for possible heart failure in St Vincent’s University Hospital, Dublin, from the period of 2000 till 2012 were included in this study. 12-lead ECG was performed using the Agilent Page Writer 100 ECG machine and interpreted by independent cardiologists. The ECGs were analysed along side the diagnosis of heart failure. ROC curves were performed to assess the robustness of the ECG in predicting heart failure. Result Heart failure patients had significant prolonged QRS duration, prolonged QT duration, prolonged QTc and more rightward T wave axis compared to the non heart failure group. They also had significant ECG evidence of prior myocardial ischaemia, intraventricular conduction disorder, abnormal axis, ventricular hypertrophy and atrial fibrillation. Using the ECG evidence of myocardial ischaemia, intraventricular conduction disorder, atrioventricular disorder, abnormal axis, atrial enlargement, ventricular hypertrophy, ventricular arrhythmia and atrial fibrillation as a predictive model, the ROC analysis showed that the ECG model is a reasonable test (AUC = 0.81) to help predict heart failure in the community. Adding BNP to the model increased the robustness of the model in predicting heart failure (AUC = 0.88). Conclusion The utility of the 12-lead ECG in predicting heart failure in the community is under appreciated. This study showed that this simple test is useful and can offer primary care physicians the ability to expedite the diagnosis of heart failure in order to start relevant further investigation and treatment in the community. In conclusion, ECG is a useful test in predicting heart failure in the community, however addition of BNP into the model helped to increase the robustness of the test.
Article 2 Reads 0 Citations 30 Lack of specialist involvement in heart failure diagnosis leave concerning gaps in management: an all ireland analysi... Published: 01 September 2015
Heart, doi: 10.1136/heartjnl-2015-308621.30
Purpose Previous research has identified that patients with a diagnosis of heart failure in the community frequently have not had previous heart failure specialist assessment. This study sought to determine the characteristics of patients with a label of heart failure in the community without a record of previous specialist assessment in two different health systems. Methods Patients with a coded diagnosis of heart failure or on loop diuretics were identified in 13 general practice electronic health records in the Republic of Ireland and Northern Ireland. Records were reviewed and data was extracted on those patients who had no previous record of cardiology specialist assessment. Results 111 patients met the criteria for inclusion. The demographic details are outlined in Table 1. View this table:In this window In a new window 30 Table 1 Demographic details Patients with a diagnosis of heart failure in the community without previous specialist assessment tended to be older females with low levels of recent echocardiography. Use of natriuretic peptide testing was low in both healthcare systems. Loop diuretic use was high despite a low rate of echocardiography and lack of specialist assessment. Conclusion This All-Ireland cohort of patients with a diagnosis of heart failure in the community or who are on heart failure medication have not had specialist assessment. The use of loop diuretic is high with low rates of Echocardiography. The lack of echocardiography means it is not possible to determine if patients with heart failure have HF-REF or HF-PEF. Strategies to reach this patient group need to be developed to confirm diagnosis and implement appropriate medical and device management.
Article 1 Read 0 Citations 56 Comparison of morbidity, mortality and cost impact of stage B and stage C heart failure underline the clinical and ec... Published: 01 September 2015
Heart, doi: 10.1136/heartjnl-2015-308621.56
Introduction Heart failure (HF) has hit the epidemic proportion and is incurring significant cost to the health care system. Given the major morbidity, mortality and economic burden of this condition, a prevention strategy needs careful assessment to determine its role in the future health care policy. The STOP-HF project has underlined the clinical and cost effectiveness of a biomarker driven risk stratification and intervention strategy in those at risk for HF. Supportive data to establish the widespread application of this strategy would come from a comparative analysis of patients at risk for HF and those of a new community diagnosis of HF followed in a disease management programme. To assess the importance of HF prevention, we report the morbidity, mortality and economic costs of an at-risk cohort compared to established community HF. Method 1566 patients attending the HF prevention unit and rapid access clinic for possible new onset HF from 2002 up to end of 2012 were selected for this analysis. Using Doppler echocardiography, patients were categorised to stage A (risk factors for HF with no structural or functional impairment of the heart), stage B (asymptomatic LV systolic dysfunction [B-LVSD], or isolated LV diastolic dysfunction [B-LVDD]), and stage C (symptomatic HF with reduce LVEF [C-REF] or preserved LVEF [C-PEF]). Follow-up time for events was until the end of 2014. Hospitalisations were collected, confirmed by HIPE records and categorised as HF event, other cardiovascular (other-CV) event, non-cardiovascular (non-CV) event and death. In the pre-specified cost analysis, direct costs associated with emergency hospitalisations were analysed using a case-mix approach from the perspective of the healthcare provider. Result 1097 patients were in stage A, 173 stage B (112 B-LVDD and 61 B-LVSD), and 296 stage C (181 C-PEF and 115 C-REF). BNP increased through the stages at 19.1 pg/mL, 62.8 pg/mL, 67 pg/mL, 185 pg/mL and 384.5 pg/mL. Figure 1 showed that the HF events and death rate increased across the spectrum. The other-CV events are higher in B-LVDD group compare to the B-LVSD group. C-REF has more other-CV events compared to C-PEF, but the non-CV events are similar. In the costing sub-study of 1,025 patients for whom detailed costing data were available, emergency CV hospitalisation costs per patient per annum were €313 ± 1222, €350 ± 1095 and €899 ± 1228 for stages A to C respectively. The data also show that emergency non-CV hospitalisation costs per patient per annum were €422 ± 1078, €560 ± 1316 and €2739 ± 4769 for stages A to C respectively, underlining a dramatic 4-fold increase emergency hospitalisation costs between stage B and C. View larger version:In a new window Download as PowerPoint Slide 56 Figure 1 Burden of heart failure in the community Conclusion The clinical and costs impact of HF care escalate significantly with the development of the symptomatic phase of HF syndrome. These data along with the positive clinical and cost effectiveness analysis of the STOP-HF data underline the need for national activation of the STOP-HF strategy.