Patient-reported outcomes (PRO) are defined as reports coming directly from patients about how they feel or function in relation to a health condition and its therapy. Although there are numerous compelling reasons why PRO could be an important help in clinical care, they have not evolved into clinical tools integrated into care. The purpose of this review is to assess existing PRO instruments for heart failure with respect to their psychometric properties and potential for use in clinical care. We performed a systematic search of articles published between July 2008 and January 2015 within the MEDLINE, PROMIS, PROQOLID, and Cochrane Library databases. Included instruments had to be developed and tested for heart failure and have had their development processes and psychometric properties described. A total of 31 instruments were identified, 9 of which met all inclusion criteria. After evaluating each remaining instrument in terms of psychometric and clinical criteria and symptom coverage, only 2 instruments-Minnesota Living with Heart Failure and Kansas City Cardiomyopathy questionnaire-met all evaluation criteria. Although clinically useful PRO instruments exist, increasing education to providers on the value and interpretability of PRO instruments, as well as a more streamlined approach to their implementation in the clinical setting is necessary. A clinical trial comparing the routine use of disease-specific PRO with clinical care could further support their incorporation into practice.

Acute worsening heart failure (WHF) is seen in a sizable portion of patients hospitalized for heart failure, and is increasingly being recognized as an entity that is associated with an adverse in-hospital course. WHF is generally defined as worsening heart failure symptoms and signs requiring an intensification of therapy, and is reported to be seen in anywhere from 5% to 42% of heart failure admissions. It is difficult to ascertain the exact epidemiology of WHF due to varying definitions used in the literature. Studies indicate that WHF cannot be precisely predicted on the basis of baseline variables assessed at the time of admission. Recent data suggest that some experimental therapies may reduce the risk of development of WHF among hospitalized heart failure patients, and this is associated with a reduction in risk of subsequent post-discharge cardiovascular mortality. In this respect, WHF holds promise as a endpoint for acute heart failure clinical trials to better elucidate the benefit of targeted novel therapies. Better understanding of the pathophysiology and a consensus on the definition of WHF will further improve our epidemiological and clinical understanding of this entity.

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Objective To examine long-term prognosis of a zero coronary artery calcium (CAC) score among asymptomatic individuals and its associated warranty period. Background Emerging evidence supports CAC=0 as a favorable cardiovascular short-to-intermediate term prognostic factor. Methods 9715 individuals undergoing CAC imaging were stratified by age, Framingham risk score (FRS) and Adult Treatment Panel III (NCEP ATP III) categories and followed for a mean of 14.6 (12.9–16.8) years. Cox regression, area under the receiver operating characteristic curve (AUC) and net reclassification information (NRI) were used to assess all-cause mortality, discrimination and reclassification of CAC=0 compared with FRS and NCEP ATP III, respectively. A warranty period was pre-defined as <1% annual mortality rate. Vascular age was estimated by linear regression. Results Among 4864 individuals with baseline CAC=0 (mean age 52.1±10.8 years; 57.9% male), 229 deaths occurred. The warranty period of CAC=0 was almost 15 years for individuals at low and intermediate risk with no significant differences regarding age and gender. CAC=0 was associated with a vascular age of 1, 10, 20, and 30 years below chronologic age for individuals between 50–59, 60–69, 70–79, and ≥80 years, respectively. CAC score was the strongest predictor of death (HR 2.67, 95% CI 2.29–3.11) that enabled discrimination and consistent reclassification beyond FRS (AUC 0.71 vs. 0.64, p<0.001) and NCEP ATP III (AUC 0.72 vs. 0.64, p<0.001). Conclusions CAC=0 confers a 15-year warranty period against mortality among individuals at low-to-intermediate risk, which is unaffected by age or gender. Furthermore, in individuals considered at high-risk by clinical risk scores the presence of CAC=0 confers better survival than in individuals at low-to-intermediate risk but with any CAC.

Cardiovascular disease (CVD) remains the leading cause of death in the United States. There is evidence that shows a direct relationship between an elevated uric acid level and an increased risk of cardiovascular (CV) events, which has set the foundation for the investigation of uric acid-lowering drugs for the treatment of CVD. Although traditionally the cornerstone therapy for gout, allopurinol's ability to be a competitive inhibitor of the key enzyme, xanthine oxidase, needed for uric acid formation, has prompted recent clinical research evaluating allopurinol as a CV drug. Epidemiologic and biochemical studies on uric acid formation have shown that it is not only uric acid itself that leads to worsening prognosis and increased CV events, but also the free radicals and superoxides formed during xanthine oxidase activity. The combination of uric acid formation and formed free radicals could ultimately lead to coronary endothelial dysfunction and worsening of myocardial oxidative stress. Along with preventing uric acid formation, allopurinol also has the ability to behave as a free radical scavenger of the superoxide anions and free radicals released during uric acid formation.Clinical studies have shown that allopurinol improves endothelial dysfunction and subsequently improves the exercise capacity in patients diagnosed with angina pectoris. Allopurinol has also been shown to decrease oxidative stress and ameliorate the morbidity and mortality of congestive heart failure patients by possibly improving mechanoenergetic uncoupling, with the enhancement of myocardial contractility and the left ventricular ejection fraction. This review presents the pharmacologic action of allopurinol on the CV system and describes the effectiveness of allopurinol as a potential drug to treat 2 CVD morbidities: ischemic heart disease and congestive heart failure.

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Background-Cardiovascular screening of women using traditional risk factors has been challenging, with results often classifying a majority of women as lower risk than men. The aim of this report was to determine the long-term prognosis of asymptomatic women and men classified at low-intermediate risk undergoing screening with coronary artery calcium (CAC) scoring. Methods and Results-A total of 2363 asymptomatic women and men with traditional risk factors aggregating into a lowintermediate Framingham risk score (6%-9.9%; 10-year predicted risk) underwent CAC scanning. Individuals were followed up for a median of 14.6 years. We estimated all-cause mortality using Cox proportional hazards models; hazard ratios with 95% confidence intervals were calculated. The area under the curve from a receiver operating characteristics curve analysis was calculated. There were 1072 women who were older (55.6 years) when compared with the 1291 men (46.7 years; P<0.0001), resulting in a greater prevalence and extent of CAC; 18.8% of women and 15.1% of men had a CAC score ≥100 (P=0.029). This older group of women had a 1.44-fold higher 15-year adjusted mortality hazard when compared with men (P=0.022). For women, the 15-year mortality ranged from 5.0% for those with a CAC score of 0 to 23.5% for those with a CAC score ≥400 (P<0.001). For men, the 15-year mortality ranged from 3.5% for those with a CAC score of 0 to 18.0% for those with a CAC score ≥400 (P<0.001). Women with CAC scores >10 had a higher mortality risk when compared with men. Conclusions-Our findings extend previous work that CAC effectively identifies high-risk women with a low-intermediate risk factor burden. These data require validation in external cohorts but lend credence to the use of CAC in women to improve risk detection algorithms that are currently based on traditional risk factors. (Circ Cardiovasc Imaging. 2016;9:e003742.

Background Data regarding coronary artery calcification (CAC) prognosis in diabetic individuals are limited to 5-years follow-up. We investigated the long-term risk stratification of CAC among diabetics, compared to non-diabetic individuals. Methods and Results 9715 asymptomatic individuals undergoing CAC scoring were followed for a median (IQR) of 14.7 (13.9–15.6) years The incidence density rate and hazard ratios (HR) with 95% confidence intervals (95%CI) were used to calculate all-cause mortality. Incremental prognostic utility of CAC was evaluated using the area under the receiver operator characteristic curve (AUC) and net reclassification improvement (NRI). Diabetics (54.7±10.8 years; 59.4% male) comprised 8.3% of the cohort (n=810), of which 188 (23.2%) died. For CAC=0, the rate of mortality was similar between diabetic and non-diabetic individuals for the first 5 years (p>0.05), with a non-linear increased risk of mortality for diabetics after 5 years (p<0.05). The adjusted risk of death for those in the highest (CAC>400) versus the lowest (CAC=0) category of CAC increased by a hazards of 4.64 (95%CI=3.74–5.76) and 3.41 (95%CI=2.22–5.22) for non-diabetic and diabetic individuals, respectively. The presence of CAC improved discrimination (AUC range: 0.73–0.74, P<0.01) and reclassification (category-free NRI range: 0.53–0.50, P<0.001) beyond conventional risk factors in non-diabetic and diabetic respectively. Conclusions CAC=0 is associated with a favorable 5-year prognosis for asymptomatic diabetic and non-diabetic individuals. After 5 years, the risk of mortality increases significantly for diabetic individuals even in the presence of a baseline CAC=0.