Summary: Heart failure affects 5 million persons in the United States, with 400,000 new cases occurring every year. Paradoxically, although advances in coronary angioplasty and effective drugs have increased survival post infarction, the myocardial damage and subsequent neurohormonal activation-induced remodeling causes significant morbidity years later in the form of heart failure. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) together with beta blockers modify the neurohormonal activation associated with heart failure and are key treatments for improving cardiac function and survival. Anemia is a significant risk factor predicting morbidity and mortality in heart failure. This article describes the various etiologies of anemia in heart failure. Of particular importance is the fact that recent stem cell studies have shown that the drugs acting on the renin-angiotensin system inhibit erythropoiesis in vivo and may cause anemia in patients with both normal renal function and end-stage renal disease (ESRD). The role of angiotensin-II as an erythropoietic growth factor and ACE in facilitating erythropoiesis is described in this article. Anemia has been shown to be a modifiable risk factor and its treatment correlates with improvement in clinical outcomes. Thus, anemia, its etiology (especially the contribution of ACEIs and ARBs), physiologic and prognostic impact, and treatment in the setting of heart failure are critical areas for investigation.
enrolled in HF rehabilitation programmes reflecting poor national provision. Two-thirds of patients lived outside of London, making it impractical for them to frequently visit our hospital. Hence a hospital-based rehabilitation programme would not improve this care priority. Added questions demonstrated less than optimal numbers receive exercise education within clinic. Conclusion This audit demonstrated that a tertiary HF service has high rates of documentation, follow-up and compliance with established medical therapies. Notably many patients did not receive cardiac rehabilitation. This may be influenced by geographical limitations and the configuration of local services. To improve patient management further, alternative strategies including telehealth and enhanced multi-disciplinary team education are currently being explored. In the Health Care Commission Audit in 2005, our hospital had an in-patient (IP) mortality of 30%. A Heart Failure Team (HFT) was introduced to provide specialist in-patient care wherever the patients presented. The HFT was composed of two specialist nurses, a part time pharmacist and a clinical fellow and was led by a Consultant Cardiologist with a special interest in HF. The service commenced in April 2008. In the first year of the service 211 IPs were seen by the HFT. The mean age was 72.0 years (SD 613.0), 40% were female, 53% had ischaemic heart disease and 28% were diabetic. Examination findings on admission revealed a mean heart rate of 89 (626) bpm and a mean systolic BP of 126 (625) mm Hg; mean QRS duration was 116 (644) ms. 79% had an IP echo: of these 70% were classified as having moderate/severe left ventricular systolic dysfunction with 15% having preserved LV systolic function. Admission bloods revealed a mean Na of 135 (66) mmol/l, urea 12 (612) mmol/l, eGFR 51 (622) and Hb 124 (623) g/l. Mean length of stay (LOS) was 19 (618) days. In the preceding 6 months 215 patients were coded with a primary diagnosis for HF. Subsequent case note review confirmed that 196 patients had been correctly coded. The baseline characteristics and outcome of these 196 patients are described. The mean age was 73.5 years (614.7), 36% were female, 51% had ischaemic heart disease and 26% were diabetic. Examination findings on admission revealed a mean heart rate of 87 (621) bpm and a mean systolic BP of 126 (628) mm Hg; mean QRS duration was 117 (637) ms. 82% had an IP echo: of these 63% were classified as moderate/severe left ventricular systolic dysfunction with 17% having preserved LV systolic function. Admission bloods revealed a mean Na of 135 (66) mmol/l, urea 11 (612) mmol/l, eGFR 48 (623) and Hb 122 (622) g/l. Mean LOS was 17(619) days. All ns vs HFT baseline demographics. Despite very similar baseline characteristics and LOS, outcomes were very different. The IP mortality in the pre-HFT cohort was 23% whereas the patients managed by the HFT had an IP mortality of 6% (p<0.001). Analysis of discharge medications shows patients managed by the HFT received higher doses of loop diuretics (me...
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