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Success of a multidisciplinary heart failure disease management program in an indigent population
72
Journal of Cardiac Failure Vol. 5 No. 3 Suppl. 1 1999
268
269
Enhanced External Couuterpulsatlon Is a Safe and Effective Treatment for Angina in Patients with Severe Left Ventricular Dysfunction John E. Strobeck~1 Robin Reade, ~ Elizabeth D. Kennard, 2 Sheryl F. Kelsey, 2 Ozlem Soran, 2 Arthur M. Feldman2; ~The Heart-Lung Center, Hawthorne, NJ, 2University of Pittsburgh, Pittsburgh, PA
Success of a Multidisciplinary Heart Failure Disease Management Program in an Indigent Population Aurelia M. O'Connei1, Michael H. Crawford; Cardiology, University of New Mexico, Albuquerque, NM
The International Enhanced Counterpulsation (EECP) Registry (IEPR) is an international multicenter study of EECP for the treatment of chronic angina. The Registry lracks baseline patient characteristics, adverse events during treatment, short and long-term angina relief, medication consumption, and quality of life. While this treatment has proven value in patients with severe ischemia and preserved left ventricular function (PLVF) (EF >35%) who are not good candidates for revascularization by CABG or PTCA, little is known of the safety and efficacy in patients with angina and severe left ventricular dysfunction (LVD) (EE < = 35%). To date 466 patients have been enrolled in the IEPR for their first EECP treatment and have recorded values for ejection fraction and anginal classification pre- and post treatment. 127 (27.3%) patients had LVD and 339 (72.8%) had PLVF. Demographics, risk factors, medical history, angina classification, medication use, extent of coronary disease, and quality of life pre-EECP treatment were similar in both groups, while prior MI, prior CABG, ACE Inhibitor use, and a history of clinicai congestive heart failure (CHF) were more prevalent in the LVD group. 106/127 (83%) of patients with LVD and 278/339 (82%) with PLVF completed a full course of treatment, with a mean of 38 treatment hours. The degree of diastolic blood pressure augmentation achieved with EECP treatment was similar in both groups. Adverse events during treatment were infrequent and not statistically different between the two groups. Aggravation of CHF causing cessation of treatment occurred in 3.9% of LVD patients and 1.9% of PLVF patients(p=NS). For those completing treatment, mean anginal class improved significantly from 3.1 to 1.7 in the LVD group and from 2.8 to 1.4 in the PLVF group. Both groups demonstrated similar reductions in sublingual nitroglycerin use post EECP treatment. For all patients completing treatment, overall patient assessment of quality of life post EECP demonstrated improvements of 65-70% over pre-EECP assessements.
Multidisciplinary disease management programs (MDMP) have demonstrated reduced hospitalizations in motivated pre-transplant heart failure populations, but little is known about their effectiveness in largely indigent patients who are not transplant candidates. Thus, we studied 35 heart failure patients with left ventricular ejection fraction (EF) --<.45%, enrolled in a MDMP who were either indigent or funded by Medicaid/Medicare. This non-randomized sample consisted of 14 patients identified because they had hospital readmission rates -> 2/year (Group A), and 21 patients referred by their primary care physician because they were difficult to manage (group B). Group A patients were NYHA Class 3 o1"4, aged 25-87 years (mean 5 7+- 17 SD) and had EF 15-45% (29-+ 11%). Group B patients were NYHA Class 2 or 3, aged 35-86(57_ + 16) years and had EF 20-45% (28 + _ 10%). Data were compared for the year prior to enrollment in the MDMP and the year afterward. In Group A, hospital admissions decreased from 33 to 3, a 91% reduction and NYHA Class improved to Class 2-3 (p<.001). In group B, hospital admissions decreased from 9 to zero, and NYHA class improved to Class 1-2 (p<.001). When hospital and clinic charges were assessed for both groups, the net savings were $162,000/year or $4,600/patient. Conclusions: A mulfidisciplinary heart failure program can improve functional status, reduce hospitalizations and net costs, compared to conventional care in indigent nontransplant candidate patients.
In conclusion, EECP is a safe and effective treatment for angina in patients with severe left ventricular dysfunction who are not good candidates for revascularization by CABG or PTCA. The magnitude of improvement in angina classification and quality of life produced by EECP is independent of the degree of left ventricular dysfunction before treatment.
270
271
High Prevalence of Negative Self Image among Heart Failure Patients Susan Zichmund, 1 Caroline Carney Doebbeling, 2 Carla J. Pies? William G. Cotts, IRon M. Oren~; IDepts of Medicine, 2Psychiatry, 3Nursing, University of Iowa, Iowa City, IA
Direct Measurements of Lipid Peroxidation are Present in Patients with Heart Failure: Do They Correlate with Disease Severity? Lawrence Baruch, Tariq Jamil, Prnseffino Patacsil, Sujjud Afimed, Jill Kaiman, Jack Singer, Stuart Bursten; Bronx VA Medical Center, Bronx, NY, Cardiovascular Institute, Mr. Sinai Hospital, NY, NY, Cell Therapeutics, Inc., Seattle, WA
Patients with heart failure (HF) face limitations in their daily life. Little is known about psychological mechanisms facilitating an adjustment to the disease. These mechanisms are important to developing adequate self care tasks and compliance.
PROTOCOL: Patients in our Heart Failure Clinic were randomly identified and asked to participate in a structured interview. The responses were transcribed, coded and analyzed for dominant psychological themes using the ATLAS.ti software package. To assess differences in coping strategies, two subgroups were identified based on general outlook on life and conception of self. Patients who gave ambiguous responses were excluded from the close textual analysis. RESULTS: 21 patients with advanced HF were enrolled. (Age 61-+2years, LVEF 26+- 1%, mean -+ SE). Patients were separated into either those who indicated a negative outlook towards life and a negative conception of self (Grp A, n = 14) or those with positive attitudes towards life and a positive image of self (Grp B, n-7). Age & LVEF did not differ between Grps A & B. Striking differences in the reaction to the HF experience were seen between the groups. Grp A (negative self image) experienced significantly higher emotional stressors and reported more physical pain than did Grp B (positive self image). This included expressions of anxiety (Grp A = 7/14 vs. Grp B = 1/7) or other emotional upheavals (Grp A - 8/14 vs. Grp B 0/7). In Grp A, 9/14 complained of pain vs 0/7 in Grp B. Negative patient outlook also related to increased interpersonal difficulties. Problems in familial relationships were noted in 7/14 in Grp A (negative self image), compared to 0/7 in Grp B (positive self image). In addition, only patients in Grp A (4/14) mentioned difficulties or conflicts with their healthcare providers. Finally, patients in Grp A expressed a greater sense of helplessness and loss of capacity (13/14) than did those in Grp B (4/7). These feelings resulted in greater dependency (GrpA= 7/14, GrpB = 1/7).
CONCLUSION: For many patients with HF, a progressive loss of physical abilities and independence is associated with a negative conception of self, a high prevalence of pain, and pessimistic attitudes towards family and healthcare workers. This additional strain further complicates feelings of loss and dependency. These attitudes can interfere in self-care tasks & health care follow-up. Addressing negative self image may assist in adjustment to chronic HF.
Background: Free radicals may he important contributors to the deterioration of the failing myocardium. A number of factors associated with the failing heart, including catecholamines and cytokine stimulation, are known for peroxidative damage. The formation of lipid peroxides within cell membranes is an important mechanism of free radical cell mediated injury. Lipid peroxidation in patients with CHF has been associated with increasing disease severity. Prior studies of lipid peroxidation (LPO) have measured changes in free fatty acid levels or serum thiols which are general measures of acyl chain utilization or reducing capacity. Assays of linoleate or arachidonate serum concentrations are at best indirect measurements of lipid peroxide formation. Thiobarhituric acid assays measure many oxidized species from proteins and nucleic acids as well as lipids. Direct measures of LPO utilizing a modified HPLC-based assay are available. Methods: We measured levels of the oxidized lipids (Lip) 5, 8, 9, 11, 12 and 15 hydroxyeicosatetraenoate (HETE), 9 and 13 hydroxyoctadecadienoate (HODE), and 9 and 13 hydroperoxyoctadecadienoate (HPODE), using an HPLC assay in 33 pts with NYHA Class I (n=3), II (n = 13) and III (n= 17) CHF, and 5 controls. Results: 85% of pts with CHF had evidence of LPO; no controls had evidence ofLPO (p <.0001). Detectable levels of 9 and 13 HPODE, 9 and I3 HODE and 5 and 12 HETE were demonstrated.
Lip (ng/ml) p (vs control)
(p
Control
Class I
Class II
Class III
0
8.63 .09
9.77 .001
19.7 .004
Class III pts had higher levels than Class II ( p = . 0 9 6 ) and Class I .057).%
Conclusion: Direct measures of lipid peroxidation are present in pts with CHF mad correlate with severity of CHF. Further investigation is required to determine if inhibition of lipid peroxidafion favorably effects CHF progression.
Journal of Cardiac Failure Vol. 5 No. 3 Suppl. 1 1999
268
269
Enhanced External Couuterpulsatlon Is a Safe and Effective Treatment for Angina in Patients with Severe Left Ventricular Dysfunction John E. Strobeck~1 Robin Reade, ~ Elizabeth D. Kennard, 2 Sheryl F. Kelsey, 2 Ozlem Soran, 2 Arthur M. Feldman2; ~The Heart-Lung Center, Hawthorne, NJ, 2University of Pittsburgh, Pittsburgh, PA
Success of a Multidisciplinary Heart Failure Disease Management Program in an Indigent Population Aurelia M. O'Connei1, Michael H. Crawford; Cardiology, University of New Mexico, Albuquerque, NM
The International Enhanced Counterpulsation (EECP) Registry (IEPR) is an international multicenter study of EECP for the treatment of chronic angina. The Registry lracks baseline patient characteristics, adverse events during treatment, short and long-term angina relief, medication consumption, and quality of life. While this treatment has proven value in patients with severe ischemia and preserved left ventricular function (PLVF) (EF >35%) who are not good candidates for revascularization by CABG or PTCA, little is known of the safety and efficacy in patients with angina and severe left ventricular dysfunction (LVD) (EE < = 35%). To date 466 patients have been enrolled in the IEPR for their first EECP treatment and have recorded values for ejection fraction and anginal classification pre- and post treatment. 127 (27.3%) patients had LVD and 339 (72.8%) had PLVF. Demographics, risk factors, medical history, angina classification, medication use, extent of coronary disease, and quality of life pre-EECP treatment were similar in both groups, while prior MI, prior CABG, ACE Inhibitor use, and a history of clinicai congestive heart failure (CHF) were more prevalent in the LVD group. 106/127 (83%) of patients with LVD and 278/339 (82%) with PLVF completed a full course of treatment, with a mean of 38 treatment hours. The degree of diastolic blood pressure augmentation achieved with EECP treatment was similar in both groups. Adverse events during treatment were infrequent and not statistically different between the two groups. Aggravation of CHF causing cessation of treatment occurred in 3.9% of LVD patients and 1.9% of PLVF patients(p=NS). For those completing treatment, mean anginal class improved significantly from 3.1 to 1.7 in the LVD group and from 2.8 to 1.4 in the PLVF group. Both groups demonstrated similar reductions in sublingual nitroglycerin use post EECP treatment. For all patients completing treatment, overall patient assessment of quality of life post EECP demonstrated improvements of 65-70% over pre-EECP assessements.
Multidisciplinary disease management programs (MDMP) have demonstrated reduced hospitalizations in motivated pre-transplant heart failure populations, but little is known about their effectiveness in largely indigent patients who are not transplant candidates. Thus, we studied 35 heart failure patients with left ventricular ejection fraction (EF) --<.45%, enrolled in a MDMP who were either indigent or funded by Medicaid/Medicare. This non-randomized sample consisted of 14 patients identified because they had hospital readmission rates -> 2/year (Group A), and 21 patients referred by their primary care physician because they were difficult to manage (group B). Group A patients were NYHA Class 3 o1"4, aged 25-87 years (mean 5 7+- 17 SD) and had EF 15-45% (29-+ 11%). Group B patients were NYHA Class 2 or 3, aged 35-86(57_ + 16) years and had EF 20-45% (28 + _ 10%). Data were compared for the year prior to enrollment in the MDMP and the year afterward. In Group A, hospital admissions decreased from 33 to 3, a 91% reduction and NYHA Class improved to Class 2-3 (p<.001). In group B, hospital admissions decreased from 9 to zero, and NYHA class improved to Class 1-2 (p<.001). When hospital and clinic charges were assessed for both groups, the net savings were $162,000/year or $4,600/patient. Conclusions: A mulfidisciplinary heart failure program can improve functional status, reduce hospitalizations and net costs, compared to conventional care in indigent nontransplant candidate patients.
In conclusion, EECP is a safe and effective treatment for angina in patients with severe left ventricular dysfunction who are not good candidates for revascularization by CABG or PTCA. The magnitude of improvement in angina classification and quality of life produced by EECP is independent of the degree of left ventricular dysfunction before treatment.
270
271
High Prevalence of Negative Self Image among Heart Failure Patients Susan Zichmund, 1 Caroline Carney Doebbeling, 2 Carla J. Pies? William G. Cotts, IRon M. Oren~; IDepts of Medicine, 2Psychiatry, 3Nursing, University of Iowa, Iowa City, IA
Direct Measurements of Lipid Peroxidation are Present in Patients with Heart Failure: Do They Correlate with Disease Severity? Lawrence Baruch, Tariq Jamil, Prnseffino Patacsil, Sujjud Afimed, Jill Kaiman, Jack Singer, Stuart Bursten; Bronx VA Medical Center, Bronx, NY, Cardiovascular Institute, Mr. Sinai Hospital, NY, NY, Cell Therapeutics, Inc., Seattle, WA
Patients with heart failure (HF) face limitations in their daily life. Little is known about psychological mechanisms facilitating an adjustment to the disease. These mechanisms are important to developing adequate self care tasks and compliance.
PROTOCOL: Patients in our Heart Failure Clinic were randomly identified and asked to participate in a structured interview. The responses were transcribed, coded and analyzed for dominant psychological themes using the ATLAS.ti software package. To assess differences in coping strategies, two subgroups were identified based on general outlook on life and conception of self. Patients who gave ambiguous responses were excluded from the close textual analysis. RESULTS: 21 patients with advanced HF were enrolled. (Age 61-+2years, LVEF 26+- 1%, mean -+ SE). Patients were separated into either those who indicated a negative outlook towards life and a negative conception of self (Grp A, n = 14) or those with positive attitudes towards life and a positive image of self (Grp B, n-7). Age & LVEF did not differ between Grps A & B. Striking differences in the reaction to the HF experience were seen between the groups. Grp A (negative self image) experienced significantly higher emotional stressors and reported more physical pain than did Grp B (positive self image). This included expressions of anxiety (Grp A = 7/14 vs. Grp B = 1/7) or other emotional upheavals (Grp A - 8/14 vs. Grp B 0/7). In Grp A, 9/14 complained of pain vs 0/7 in Grp B. Negative patient outlook also related to increased interpersonal difficulties. Problems in familial relationships were noted in 7/14 in Grp A (negative self image), compared to 0/7 in Grp B (positive self image). In addition, only patients in Grp A (4/14) mentioned difficulties or conflicts with their healthcare providers. Finally, patients in Grp A expressed a greater sense of helplessness and loss of capacity (13/14) than did those in Grp B (4/7). These feelings resulted in greater dependency (GrpA= 7/14, GrpB = 1/7).
CONCLUSION: For many patients with HF, a progressive loss of physical abilities and independence is associated with a negative conception of self, a high prevalence of pain, and pessimistic attitudes towards family and healthcare workers. This additional strain further complicates feelings of loss and dependency. These attitudes can interfere in self-care tasks & health care follow-up. Addressing negative self image may assist in adjustment to chronic HF.
Background: Free radicals may he important contributors to the deterioration of the failing myocardium. A number of factors associated with the failing heart, including catecholamines and cytokine stimulation, are known for peroxidative damage. The formation of lipid peroxides within cell membranes is an important mechanism of free radical cell mediated injury. Lipid peroxidation in patients with CHF has been associated with increasing disease severity. Prior studies of lipid peroxidation (LPO) have measured changes in free fatty acid levels or serum thiols which are general measures of acyl chain utilization or reducing capacity. Assays of linoleate or arachidonate serum concentrations are at best indirect measurements of lipid peroxide formation. Thiobarhituric acid assays measure many oxidized species from proteins and nucleic acids as well as lipids. Direct measures of LPO utilizing a modified HPLC-based assay are available. Methods: We measured levels of the oxidized lipids (Lip) 5, 8, 9, 11, 12 and 15 hydroxyeicosatetraenoate (HETE), 9 and 13 hydroxyoctadecadienoate (HODE), and 9 and 13 hydroperoxyoctadecadienoate (HPODE), using an HPLC assay in 33 pts with NYHA Class I (n=3), II (n = 13) and III (n= 17) CHF, and 5 controls. Results: 85% of pts with CHF had evidence of LPO; no controls had evidence ofLPO (p <.0001). Detectable levels of 9 and 13 HPODE, 9 and I3 HODE and 5 and 12 HETE were demonstrated.
Lip (ng/ml) p (vs control)
(p
Control
Class I
Class II
Class III
0
8.63 .09
9.77 .001
19.7 .004
Class III pts had higher levels than Class II ( p = . 0 9 6 ) and Class I .057).%
Conclusion: Direct measures of lipid peroxidation are present in pts with CHF mad correlate with severity of CHF. Further investigation is required to determine if inhibition of lipid peroxidafion favorably effects CHF progression.