Optimisation du traitement de l'insuffisance cardiaque à l'institut de cardiologie d'Abidjan

Do T.N., Do Q.H., Cowie M.R., Ha N.B., Do V.D., Do T.H., Nguyen T.T., Tran T.L., Nguyen T.N., Nguyen T.M., Chau T.T., Nguyen T.T., Nguyen C.T., Tran K.D., Nguyen T.N., et. al.

The Ho-Chi-Minh-city Heart Institute in Vietnam took part in the Optimize Heart Failure (OHF) Care Program, designed to improve outcomes following heart failure (HF) hospitalization by increasing patient awareness and optimizing HF treatment.HF patients hospitalized with left ventricular ejection-fraction (LVEF)

Bivigou E.A., Allognon M.C., Ndoume F., Mipinda J.B., Nzengue E.E.

Lin A.H., Chin J.C., Sicignano N.M., Evans A.M.

Heart failure (HF) affects more than 5.1 million Americans and is projected to increase. Understanding the relationship between hospitalization and mortality can help to guide clinical management. The aim of the study is to evaluate the impact of repeat HF hospitalizations on all-cause mortality and to determine risk variables related to patient mortality.Using administrative data from the Military Health System, a cohort of patients with an index admission for HF between 2007 and 2011 was identified. HF hospitalizations were defined as any hospital claim with an International Classification of Diseases, Ninth Revision diagnosis of 428.xx in the primary diagnosis field over the 7-year study period (2007-2013). Patients were subsequently categorized based on total number of HF hospitalizations. A multivariate Cox regression model, adjusting for age, sex, and comorbidities, was used to estimate hazard ratios. Kaplan-Meier survival curves were constructed based on the frequency of HF hospitalizations.Of the 51,286 patients admitted for HF, 54.7% were male with a mean (SD) age of 76.3 (10.8) years, and 29,714 died during 135,211 person-years of follow-up. Mean survival time was 2.6, 1.8, 1.5, and 1.3 years after the first, second, third, and fourth hospitalization, respectively. The mortality rate of patients at 30 days and 1 year postindex HF hospitalization was 7.4% and 27.3%, respectively. A history of dementia and chronic kidney disease without dialysis decreased overall survival.Repeat HF hospitalizations remain a strong predictor of mortality for existing patients with HF. As a result, clinicians and patients can individualize the optimal treatment strategy and resources on the basis of the suspected prognosis.

Cowie M.R., Lopatin Y.M., Saldarriaga C., Fonseca C., Sim D., Magaña J.A., Albuquerque D., Trivi M., Moncada G., González Castillo B.A., Sánchez M.O., Chung E.

Hospitalization for heart failure (HF) places a major burden on healthcare services worldwide, and is a strong predictor of increased mortality especially in the first three months after discharge. Though undesirable, hospitalization is an opportunity to optimize HF therapy and advise clinicians and patients about the importance of continued adherence to HF medication and regular monitoring. The Optimize Heart Failure Care Program (www.optimize-hf.com), which has been implemented in 45 countries, is designed to improve outcomes following HF hospitalization through inexpensive initiatives to improve prescription of appropriate drug therapies, patient education and engagement, and post-discharge planning. It includes best practice clinical protocols for local adaptation, pre- and post-discharge checklists, and 'My HF Passport', a printed and smart phone application to improve patient understanding of HF and encourage involvement in care and treatment adherence. Early experience of the Program suggests that factors leading to successful implementation include support from HF specialists or 'local leaders', regular educational meetings for participating healthcare professionals, multidisciplinary collaboration, and full integration of pre- and post-hospital discharge checklists across care services. The Program is helping to raise awareness of HF and generate useful data on current practice. It is showing how good evidence-based care can be achieved through the use of simple clinician and patient-focused tools. Preliminary results suggest that optimization of HF pharmacological therapy is achievable through the Program, with little new investment. Further data collection will lead to a greater understanding of the impact of the Program on HF care and key indicators of success.

Sargento L., Simões A.V., Longo S., Lousada N., dos Reis R.P.

Heart failure with reduced ejection fraction (HFrEF) is a disease of older people, but the target doses of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) are unknown. To evaluate the association of ACEI/ARB dose level with long-term survival in stable older patients (aged >70 years) and octogenarian outpatients with HFrEF. A total of 138 outpatients aged >70 years (35.5 % > 80 years), with an LVEF <40 % and who were clinically stable on optimal therapy were followed up for 3 years. The ACEI/ARB doses were categorized as: none (0), low (1–50 % target dose), and high (50–100 % target dose). The Cox regression survival model was adjusted for age, ischemic etiology, and renal function. ACEIs/ARBs were prescribed to 91.3 % of patients, and 52.9 % received the high dose. Survival improved with increasing ACEI/ARB dose level in the total population (Hazard Ratio [HR] = 0.67; 95 % confidence interval [CI] 0.55–0.82; p < 0.001), older patients aged >70 years (HR = 0.65; 95 % CI 0.51–0.83; p < 0.001), and octogenarians (HR = 0.71; 95 % CI 0.51–0.99; p = 0.045). The low (HR = 0.35; 95 % CI 0.16–0.76; p = 0.008) and high doses (HR = 0.13; 95 % CI 0.06–0.32; p < 0.001) improved survival compared with not receiving ACEIs/ARBs. The high dose was associated with a better survival than the low dose in the total population (HR = 0.35; 95 % CI 0.19–0.67; p = 0.001) and in a propensity score-matched cohort (HR = 0.41; 95 % CI 0.16–1.02; p = 0.056). In octogenarians, all dose levels were associated with improved survival compared with not receiving ACEIs/ARBs, but there was no difference between ACEI/ARB doses. The achieved optimal dose of ACEIs/ARBs in ambulatory older people with HFrEF is associated with long-term survival.

Crespo‐Leiro M.G., Anker S.D., Maggioni A.P., Coats A.J., Filippatos G., Ruschitzka F., Ferrari R., Piepoli M.F., Delgado Jimenez J.F., Metra M., Fonseca C., Hradec J., Amir O., Logeart D., Dahlström U., et. al.

Ponikowski P., Voors A.A., Anker S.D., Bueno H., Cleland J.G., Coats A.J., Falk V., González-Juanatey J.R., Harjola V., Jankowska E.A., Jessup M., Linde C., Nihoyannopoulos P., Parissis J.T., Pieske B., et. al.

Tuppin P., Cuerq A., de Peretti C., Fagot-Campagna A., Danchin N., Juillière Y., Alla F., Allemand H., Bauters C., Drici M., Hagège A., Jondeau G., Jourdain P., Leizorovicz A., Paccaud F.

National population-based management and outcome data for patients of all ages hospitalized for heart failure have rarely been reported. National population-based management and outcome of patients of all ages hospitalized for heart failure have rarely been reported. The present study reports these results, based on 77% of the French population, for patients hospitalized for the first time for heart failure in 2009. The study population comprised French national health insurance general scheme beneficiaries hospitalized in 2009 with a principal diagnosis of heart failure, after exclusion of those hospitalized for heart failure between 2006 and 2008 or with a chronic disease status for heart failure. Data were collected from the national health insurance information system (SNIIRAM). A total of 69,958 patients (mean age, 78 years; 48% men) were studied. The hospital mortality rate was 6.4%, with 1-month, 1-year and 2-year survival rates of 89%, 71% and 60%, respectively. Heart failure and all-cause readmission-free rates were 55% and 43% at 1 year and 27% and 17% at 2 years, respectively. Compared with a reference sample of 600,000 subjects, the age- and sex-standardized relative risk of death was 29 (95% confidence interval [CI] 28–29) at 2 years, 82 (95% CI 72–94) in subjects aged < 50 years and 3 (95% CI 3–3) in subjects aged ≥ 90 years. For subjects aged < 70 years who survived 1 month after discharge, factors associated with a reduction in the 2-year mortality rate were: female sex; age < 55 years; absence of co-morbidities; and use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta-blockers, lipid-lowering agents or oral anticoagulants during the month following discharge. Poor prognostic factors were treatment with a loop diuretic before or after hospitalization and readmission for heart failure within 1 month after discharge. This large population-based study confirms the severe prognosis of heart failure and the need to promote the use of effective medications and management designed to improve survival. La prise en charge et le devenir de patients hospitalisés pour insuffisance cardiaque (IC) à un niveau national et tous âges confondus, est rarement rapporté. C’est le cas de cette étude sur 77 % de la population française pour des patients avec une première hospitalisation pour IC en 2009. Parmi les bénéficiaires du régime général de l’Assurance maladie hospitalisés en 2009 avec un diagnostic principal d’IC ont été exclus ceux hospitalisés pour IC entre 2006 et 2008 ou avec une affection de longue durée pour IC. Les données utilisées étaient celles présentes dans le système d’information de l’Assurance maladie (SNIIRAM). Au total, 69 958 patients ont été inclus (âge moyen 78 ans, 48 % d’hommes). Leur taux de décès hospitalier était de 6,4 %. Leurs taux de survie étaient de 89 % à un mois, 71 % à un an et de 60 % à deux ans. Ceux sans réhospitalisation pour IC étaient de 55 % à un an et de 43 % à deux ans et sans réhospitalisation toutes causes respectivement de 27 % et 17 %. Comparativement à un échantillon permanent par tirage au sort de 600 000 assurés, leur risque relatif de décès à 2 ans, standardisé sur l’âge et le sexe, était de 29 (95 % CI 28–29) et chez les moins de 50 ans de 82 (95 % CI 72–94) et de 3 (95 % CI 3–3) chez ceux de 90 ans et plus. Pour les moins de 70 ans ayant survécu un mois après leur sortie, les facteurs positifs associés au décès à deux ans étaient le sexe féminin, l’âge inférieur à 55 ans, l’absence de comorbidités, une consommation le mois de sortie d’IEC-sartan, de bêtabloquant, d’hypolipémiant, d’anticoagulant oral. Parmi les facteurs péjoratifs, il était retrouvé un traitement par diurétique de l’anse avant ou après hospitalisation et une réhospitalisation pour IC le mois de sortie. Cette étude sur une large population confirme la sévérité du pronostic de l’IC, la nécessité de favoriser l’utilisation de médicaments bénéfiques et de prises en charge limitant les réhospitalisations.

McMurray J.J., Adamopoulos S., Anker S.D., Auricchio A., Bohm M., Dickstein K., Falk V., Filippatos G., Fonseca C., Gomez-Sanchez M.A., Jaarsma T., Kober L., Lip G.Y., Maggioni A.P., Parkhomenko A., et. al.

ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 : The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC

Mosterd A., Hoes A.W.

The aim of this paper is to review the clinical epidemiology of heart failure. The last paper comprehensively addressing the epidemiology of heart failure in Heart appeared in 2000.w1 Despite an increase in manuscripts describing epidemiological aspects of heart failure since the 1990s,1 additional information is still needed, as indicated by various editorials.w2 w3 The evaluation and management of heart failure is schematically depicted in fig 1. Following some methodological considerations, most issues indicated in fig 1 (risk factors, aetiology, prevalence, incidence, prognosis, prevention) will be discussed. Figure 1  The evaluation and management of heart failure. The therapeutic management of patients diagnosed with heart failure is beyond the scope of this paper, as is detailed information about the possible diagnostic tests and strategies to establish or rule out heart failure, although the prevailing definitions and categorisations of the syndrome will be discussed. The guidelines of the European Society of Cardiology and selected reviews provide up to date information on the diagnosis and therapeutic management of heart failure.2w4 w5 Heart failure is a syndrome with symptoms and signs caused by cardiac dysfunction, resulting in reduced longevity. To establish a diagnosis of heart failure, the European Society of Cardiology guidelines warrant the presence of symptoms and signs (tables 1 and 2), objective evidence of cardiac dysfunction (preferably by echocardiography), and, in case of remaining doubt, a favourable response to treatment directed towards heart failure.w5 To support the failing heart numerous compensatory mechanisms occur, including activation of the neurohormonal system.2 An increase in natriuretic peptide concentrations (particularly B type natriuretic peptide) is considered a hallmark of heart failure. View this table: Table 1  European Society of Cardiology definition of heart failure View this table: Table 2  Heart failure: symptoms and signs The diagnosis of heart failure, especially when relying solely on symptoms and signs (which is often the …

Packer M., Poole-Wilson P.A., Armstrong P.W., Cleland J.G., Horowitz J.D., Massie B.M., Rydén L., Thygesen K., Uretsky B.F.

Background —Angiotensin-converting enzyme (ACE) inhibitors are generally prescribed by physicians in doses lower than the large doses that have been shown to reduce morbidity and mortality in patients with heart failure. It is unclear, however, if low doses and high doses of ACE inhibitors have similar benefits. Methods and Results —We randomly assigned 3164 patients with New York Heart Association class II to IV heart failure and an ejection fraction ≤30% to double-blind treatment with either low doses (2.5 to 5.0 mg daily, n=1596) or high doses (32.5 to 35 mg daily, n=1568) of the ACE inhibitor, lisinopril, for 39 to 58 months, while background therapy for heart failure was continued. When compared with the low-dose group, patients in the high-dose group had a nonsignificant 8% lower risk of death ( P =0.128) but a significant 12% lower risk of death or hospitalization for any reason ( P =0.002) and 24% fewer hospitalizations for heart failure ( P =0.002). Dizziness and renal insufficiency was observed more frequently in the high-dose group, but the 2 groups were similar in the number of patients requiring discontinuation of the study medication. Conclusions —These findings indicate that patients with heart failure should not generally be maintained on very low doses of an ACE inhibitor (unless these are the only doses that can be tolerated) and suggest that the difference in efficacy between intermediate and high doses of an ACE inhibitor (if any) is likely to be very small.

Pitt B., Zannad F., Remme W.J., Cody R., Castaigne A., Perez A., Palensky J., Wittes J.

Aldosterone is important in the pathophysiology of heart failure. In a doubleblind study, we enrolled 1663 patients who had severe heart failure and a left ventricular ejection fraction of no more than 35 percent and who were being treated with an angiotensin-converting-enzyme inhibitor, a loop diuretic, and in most cases digoxin. A total of 822 patients were randomly assigned to receive 25 mg of spironolactone daily, and 841 to receive placebo. The primary end point was death from all causes.The trial was discontinued early, after a mean follow-up period of 24 months, because an interim analysis determined that spironolactone was efficacious. There were 386 deaths in the placebo group (46 percent) and 284 in the spironolactone group (35 percent; relative risk of death, 0.70; 95 percent confidence interval, 0.60 to 0.82; P

Vinson J.M., Rich M.W., Sperry J.C., Shah A.S., McNamara T.

Repetitive hospitalizations are a major health problem in elderly patients with chronic disease, accounting for up to one fourth of all inpatient Medicare expenditures. Congestive heart failure, one of the most common indications for hospitalization in the elderly, is also associated with a high incidence of early rehospitalization, but variables identifying patients at increased risk and an analysis of potentially remediable factors contributing to readmission have not previously been reported. We prospectively evaluated 161 patients 70 years or older that had been hospitalized with documented congestive heart failure. Hospital mortality was 13% (n = 21). Among patients discharged alive, 66 (47%) were readmitted within 90 days. Recurrent heart failure was the most common cause for readmission, occurring in 38 patients (57%). Other cardiac disorders accounted for five readmissions (8%), and noncardiac illness led to readmission in 21 cases (32%). Factors predictive of an increased probability of readmission included a prior history of heart failure, four or more admissions within the preceding 8 years, and heart failure precipitated by an acute myocardial infarction or uncontrolled hypertension (all P less than .05). Using subjective criteria, 25 first readmissions (38%) were judged possibly preventable, and 10 (15%) were judged probably preventable. Factors contributing to preventable readmissions included noncompliance with medications (15%) or diet (18%), inadequate discharge planning (15%) or follow-up (20%), failed social support system (21%), and failure to seek medical attention promptly when symptoms recurred (20%). Thus, early rehospitalization in elderly patients with congestive heart failure may be preventable in up to 50% of cases, identification of high risk patients is possible shortly after admission, and further study of nonpharmacologic interventions designed to reduce readmission frequency is justified.