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Heart failure is a common, costly, and debilitating syndrome that is associated with a highly complex drug regimen, a large number of comorbidities, and a large and often disparate number of healthcare providers. All of these factors conspire to increase the risk of heart failure exacerbation by direct myocardial toxicity, drug-drug interactions, or both. This scientific statement is designed to serve as a comprehensive and accessible source of drugs that may cause or exacerbate heart failure to assist healthcare providers in improving the quality of care for these patients.

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Sleep deprivation occurs for many reasons but, when chronic in nature, has many consequences for optimal health and performance. Despite its high prevalence, sleep-disordered breathing is underrecognized and undertreated. This is especially true in the setting of heart failure, where sleep-disordered breathing affects more than 50% of patients. Although the optimal strategy to best identify patients is currently unknown, concerted and consistent efforts to support early recognition, diagnosis, and subsequent treatment should be encouraged. Optimization of guideline-directed medical therapy and concurrent treatment of sleep-disordered breathing are necessary to improve outcomes in this complex high-risk population.

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With initiation of VBP, acute care hospitals are rewarded based on how closely clinical guidelines and practices are followed and how well hospitals enhance patients' experiences. Thus, the VBP program requires reengineering of acute care processes. Patient-centered care must remain the focus of a rigorous curriculum of goals and metrics for acute care hospitals.

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Although of proven health benefit to persons with obstructive sleep apnea (OSA), adherence to continuous positive airway pressure (CPAP) therapy is suboptimal, with patterns of use that are established early and that are not easily altered after the initial experience. In a randomized controlled trial, 70 participants with OSA and cardiovascular disease were assigned to receive either positively or negatively framed education about CPAP. Objective adherence was measured following 30 days of home CPAP therapy. Daytime sleepiness, dispositional optimism, self-efficacy, and depression were also evaluated at baseline and after 30 days. CPAP use was greater in the group receiving negative message framing (p = .015).

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Left ventricular dysfunction and renal dysfunction are common chronic conditions that frequently coexist in the same individual, and both are associated with significant morbidity and mortality. Disorders in 1 organ generally lead to dysfunction in the other, and this bidirectional interaction serves as the pathophysiological basis for cardiorenal syndrome (CRS). Until recently, CRS has been neither well defined nor well understood, making its diagnosis and treatment challenging for clinicians. This article presents the pathophysiology of CRS and the new classification for types of CRS, therapeutic interventions targeting CRS, and novel therapies on the basis of the 2010 Acute Dialysis Quality Initiative consensus conference recommendations.

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BACKGROUND: Previous randomized controlled trials (RCTs) evaluating nesiritide for the treatment of acute decompensated heart failure (ADHF) have reported wide variances in mortality hazard ratios for nesiritide vs controls, but these individual trials were neither designed nor powered to evaluate mortality. This study used relevant data from all RCTs of nesiritide in ADHF completed as of June 2006 to independently estimate the effect of nesiritide on 30- and 180-day mortality. HYPOTHESIS: Administration of nesiritide to treat patients with ADHF does not significantly increase mortality at 30 or 180 days. METHODS: Six trials met prespecified criteria for inclusion in this analysis. Primary data from these trials were obtained from Scios Inc. (Fremont, CA). Statistical models were fitted to estimate 4 effects: dose response, differing control groups, vulnerable subgroup interactions, and time of death relative to nesiritide administration. All models included 4 baseline covariates that were significantly and independently associated with mortality. RESULTS: Complete covariate data were available in 1472 of 1538 subjects (96%). The risk-adjusted hazard ratio for mortality was 1.05 (95% confidence interval [CI]: 0.85-1.30) at 30 and 1.00 (95% CI: 0.88-1.14) at 180 days with no clear relationship to nesiritide dose. In addition to consistent results across 2 time points, no significant evidence of sensitivity to control group or baseline risk factors was found. CONCLUSIONS: Currently available data suggest nesiritide does not significantly increase mortality at 30 or 180 days.

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Managing patients who have heart failure is challenging and requires the integration of inpatient and outpatient care. Until evidence from clinical trials of implantable hemodynamic monitors (IHMs) is available and approval from the Food and Drug Administration is received, the best available model seems to be telemonitoring in conjunction with a comprehensive heart failure disease management program. A number of issues, including established processes for data review and interpretation, must be addressed before IHMs are widely adopted and accepted. Nurses, as the most frequent and common contact for patients, have the ability and opportunity to lead this change.

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Despite its prevalence, most cases of sleep disordered breathing (SDB) go unrecognized by the medical community, creating a mismatch between disease pervasiveness and medical appreciation of its impact. Of particular importance is that 30% of those with cardiovascular disease (CVD) have some type of sleep disorder. One explanation for this lack of recognition and under-appreciation is that common symptoms seen with SDB are non-specific and are present in many acute and chronic conditions. This article will present a brief review of current processes used to diagnose and treat SDB, followed by a discussion of the overlap that exists between CVD and SDB, and present an argument that these chronic conditions should not be considered and managed as separate entities.

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Despite a lack of trials examining the impact of educational interventions in the emergency department and observation unit, there is ample evidence in other health care settings supporting its use in the management of patients with heart failure. The challenge for the emergency department and observation unit nurse is to adapt these interventions to fit realistically within the fast-paced environment. This article addresses nursing considerations for the management of heart failure in the emergency department setting.

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A recent survey commissioned by The American Association of Heart Failure Nurses, The Preventive Cardiovascular Nurses Association, and The Society for Chest Pain Centers found that respondents had a striking lack of awareness and knowledge about heart failure. This article reviews the confusion and misperceptions surrounding heart failure, discusses implications of the survey findings, and offers suggestions for patients at risk for heart failure as well as professionals who work with these patients-including clinicians, researchers, and those in larger groups such as institutions and government bodies.

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The response to sleep-disordered breathing (SDB)-directed therapy was evaluated using the Clear Path home-based monitoring system. There were 26 patients with heart failure enrolled in the Sleep Events, Arrhythmias, and Respiratory Analysis in Chronic Heart Failure (SEARCH) study with SDB requiring treatment (apnea-hypopnea index [AHI] >or=15 events/h). Patients were monitored using both standard polysomnography and the Clear Path system to determine the change in SDB parameters before and after initiation of therapy. Accuracy of the Clear Path system compared with polysomnography was >or=87% to detect SDB events. A marked reduction in the mean number of sleep time respiratory disturbances was observed by both techniques after the initiation of SDB-directed therapy, and 21 patients (87.5%) experienced a 16.7-events/h mean reduction in AHI. Thus, the Clear Path system appears to be a useful device to monitor response to SDB-directed treatment for apnea in patients with heart failure.

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Heart failure (HF) is well recognized as a condition resulting from chronic neurohormonal activation. Sleep-disordered breathing (SDB) as a neurohormonal disorder is less recognized. In SDB, whether obstructive or central in nature, nightly repetitive cycles of hypoxia-reoxygenation produce intense sympathetic activation and deprive the body of much needed sleep. Both HF and SDB are associated with fatigue, cognitive impairment, and challenges for adherence to prescribed therapies. Together, the combination of HF and SDB can have particularly ominous consequences for cognitive functioning, decision making, adherence and, ultimately, outcomes. The suboptimal adherence seen in patients with both HF and SDB may result from a neurohormonal synergism that exists between the 2 conditions.

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