Heart failure : Aspects on treatment and prognosis

Abstract: The aim of this thesis was to describe aspects on treatment and prognosis in heart failure. In paper I, we studied two hundred and seventy-nine hospitalised heart failure patients, and related clinical and demograhic data to the use of diagnostic tests, treatment and follow up. The main part of the thesis, papers II-V, describe results from the OPTIMAL study which included two hundred and eight patients aged ¡Ý 60 years, hospitalised with systolic heart failure, and followed for (mean) 3.3 years. In Paper I the patients had a poor prognosis, with a 1-year mortality of 30 %. In spite of this, only approximately half of them were followed-up within three months after discharge. The majority of the patients, 57%, were planned for follow up in primary care and 21 % in the hospital outpatient clinic. Young age, male gender and treatment with beta-blocking agents were related to follow up at the out patient clinic. There was an underuse of echocardiography and treatment with angiotensin converting enzyme-inhibitors, more pronounced in women than in men. In Paper II a nurse-based management program on heart failure was shown to be more effective than primary care in optimising medication. However, the program did not have a favourable influence on quality of life, readmission rates or mortality. In Paper III traditional markers on prognosis such as age, gender, brain natriuretic peptide levels, left ventricular function and creatinine were shown to influence mortality rates. A poor quality of life predicted increased readmission rates. In Paper IV we report on a subgroup of sixty-seven patients who underwent cardio-pulmonary exercise testing. Peak ventilatory equivalents for carbon dioxide and oxygen, and peak oxygen consumption, were predictors of mortality. In Paper V we describe echocardiographic findings in one hundred and fifty-eight patients and conclude left ventricular mass index to be an important prognostic marker in women. Conclusions: There is an underuse of investigation and treatment in heart failure and this is more pronounced in women. A nurse based management program is effective in optimising medication but did not influence quality of life, readmission rate or mortality. To the traditional markers on heart failure prognosis in the elderly, cardiopulmonary exercise test results can be added. We suggest further studies on left ventricular mass index and measurements on quality of life as predictors of prognosis.