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Objective: To determine the efficacy of 2 nurse-directed programmes of different intensity for the counselling and follow-up of patients hospitalised for heart failure, compared with standard care by a cardiologist., Design: Multicentre randomised clinical trial (www.trialregister.nl: NCT 98675639)., Method: A total of 1023 patients were randomized after hospitalisation for heart failure to 1 of 3 treatment strategies: standard care provided by a cardiologist, follow-up care from a cardiologist with basic counselling and support by a nurse specialising in heart failure, or follow-up care from a cardiologist with intensive counselling and support by a nurse specialising in heart failure. Primary end points were the time to rehospitalisation due to heart failure or death and the number of days lost to rehospitalisation or death during the 18-month study period. Data were analysed on an intent-to-treat basis., Results: Mean patient age was 71 years, 38% were women, 50% had mild heart failure and 50% had severe heart failure. During the study, 411 patients (40%) were rehospitalised due to heart failure or died from any cause: 42% in the control group, and 41% and 38% in the basic and intensive support groups, respectively (differences not significant). The time to rehospitalisation or death was similar in the 3 groups: hazard ratios for the basic and intensive support groups versus the control group were 0.96 (95% CI: 0.76-1.21; p = 0.73) and 0.93 (95% CI: 0.73-1.17; p = 0.53), respectively. The number of days lost to rehospitalisation or death was 39,960 in the control group; this number was 15% less in the intervention groups, but the difference was not significant. However, there was a trend toward lower mortality in the intervention groups. In all 3 groups, more visits occurred than planned, which may have had a considerable effect on care, notably in the control group., Conclusion: The results of this study indicated that the provision of additional counselling and support by a nurse specialising in heart failure as an adjuvant to intensive follow-up care provided by a cardiologist does not always lead to a reduction in rehospitalisation frequency.

The striking variability in the age of onset of and the manifestation/ absence of manifestation of cardiovascular diseases is inadequately explained by conventional risk factors, but may be explained by variation in biological age. Telomere length is possibly a reliable marker of biological age, shorter telomeres reflecting more advanced age. The initial telomere length ofa person is mainly determined by genetic factors. Moreover, the telomere length shortens with each cell division, and exposition to harmful environmental factors also results in shorter telomeres. Leukocytes of patients with atherosclerosis and heart failure display remarkably shorter telomeres compared to leukocytes of healthy subjects of similar age. Conventional cardiovascular risk factors are also associated with telomere length. If telomeres are indeed causally involved in the pathogenesis of cardiovascular disease, this might provide new avenues for future preventive and therapeutic strategies.

Anaemia is common in patients with heart failure and is associated with poorer prognosis. The aetiology of anaemia in heart failure is diverse and includes renal failure, iron and vitamin deficiency, the use of medication, and insensitivity of the bone marrow to erythropoietin. Recently, small-scale clinical trials investigating the effect of erythropoietin on anaemia showed an improvement in the surrogate cardiovascular endpoints exercise tolerance, haemodynamics and number of hospitalisations. Erythropoietin also has non-haematopoietic (pleiotropic) effects, such as inhibition of apoptosis and neovascularisation. In preclinical studies, erythropoietin had a beneficial effect on heart function following acute myocardial infarction and in heart failure. Currently, these pleiotropic effects are being studied in patients with acute myocardial infarction.

Objective: To evaluate the results of intravenous dobutamine therapy at home for ambulatory patients with severe heart failure., Design: Retrospective., Method: Data were retrieved for the 40 patients that had been treated with intravenous dobutamine at home during the period from 1 January 1994 until mid-November 2006 at the Thorax Centre of Groningen University Medical Centre, The Netherlands. The patients were guided by a nurse practitioner., Results: The study group comprised 31 men and 9 women. The 22 patients on the waiting list for a heart transplant had an average age of 49 years. For the other 18 patients, on average 63 years old, it was destination therapy. The mean administered dosage ofdobutamine was 4 microg/kg/ min (range: 2-10). Pre-transplantation and destination therapy were given for an average of 3.5 and 1.5 months, respectively. A successful transplantation was performed in 14 (64%) of the 22 waiting-list candidates; 2 patients were still on the waiting list and 6 died while on the waiting list. Intravenous access complications and ICD shocks each occurred in 6 (15%) patients. The quality of life was reasonable to fair in the waiting-list patients and moderate to reasonable in those given destination therapy. The costs for medication and hire of the infusion pump were Euro 450 per month., Conclusion: Dobutamine infusion therapy at home under the guidance of a nurse practitioner, either as a bridge to cardiac transplantation or as destination therapy in patients with severe heart failure, appeared safe, feasible and not expensive.

During the past decade, developments in the field of DNA diagnostics have resulted in the confirmation of the genetic nature of several cardiac diseases. In a cardiogenetics outpatient clinic, a cardiologist and a clinical geneticist together evaluate persons with a (possible) hereditary cardiac disease. It is of utmost importance that patients with hereditary cardiac diseases be recognised and subsequently referred for genetic counselling as several preventive and therapeutic options are available.

There is an ever-growing need for medical staff to provide health care, and several tasks that have traditionally been carried out by physicians are increasingly being undertaken by specialized nurses. Both nurse practitioners and physician's assistants now commonly work in-hospital. In The Netherlands, there have been relatively few studies which have examined the potential role of specialized nurses. A study from Alkmaar shows that the care of patients who have recently had a myocardial infarction, which is normally done by a resident/physician-in-training, can also be carried out by a nurse practitioner, when working within the limits of well-defined protocol, and under the supervision of a staff cardiologist. Although no difference in clinical endpoints was found during the follow-up period, the study shows that patients who were under the care of the nurse practitioner were overall more satisfied with the information that was provided to them, than those under the care of the resident. These findings are important and need confirmation in larger studies and in other patient populations.

The non-pharmacological therapy of heart failure, in particular an implantable cardioverter defibrillator (ICD) and cardiac resynchronisation therapy or biventricular stimulation, improves symptoms and survival in patients with heart failure. An ICD is indicated in many patients with heart failure following cardiac arrest unless reversible causes are demonstrable. Selected patients with a left ventricular ejection fraction < or = 35% due to either ischaemic (>40 days after a myocardial infarction) or nonischaemic cardiomyopathy are candidates for ICD implantation as the primary prevention of sudden cardiac death. Patients who continue to have severe symptoms despite maximal pharmacotherapy, with a left ventricular ejection fraction < or = 35% and a wide QRS complex, are candidates for cardiac resynchronisation therapy to improve both symptoms and survival.

A 37-year-old man with symptomatic acute atrial fibrillation and a low-voltage electrocardiogram was treated with flecainide intravenously. Instead of conversion to sinus rhythm, he developed a wide-complex tachycardia suggestive of ventricular tachycardia. The patient recovered following electric cardioversion. First-choice therapy for symptomatic atrial fibrillation of recent onset (duration < 48 hours) is chemical conversion with a class IC antiarrhythmic drug (e.g. flecainide, propafenone). However, in patients with structural heart disorders, these drugs may induce ventricular tachycardia. A low-voltage electrocardiogram is suggestive of left ventricular damage. For these patients, electric cardioversion is a better alternative.

Two men aged 47 and 56 and one woman aged 21 presented at our cardiology department with presyncope, heart failure and exercise induced palpitations, respectively. Using the criteria of McKenna et al., a diagnosis of arrhythmogenic right-ventricular cardiomyopathy (ARVC) was made. Following implantation of a defibrillator, one of the men experienced seven appropriate interventions within six months and also developed psychological problems. The other man was problem-free and the woman recovered reasonably well, having only one appropriate intervention from the defibrillator one year after implantation. Indications of ARVC were also found in her mother but not in any other family members. Because ARVC manifests itself in various different ways it is difficult to diagnose. It is important to consider ARVC in patients with exercise-induced palpitations, presyncope, and unexplained cardiomyopathies or arrhythmias, especially if there is a family history of unexpected deaths. ARVC is a potentially life-threatening disease, that may require implantation of a cardioverter defibrillator. Furthermore, since genetics play an important role and ARVC can be asymptomatic, evaluation of close relatives for preclinical symptoms is important.

A 23-year-old female with familial long-QT syndrome and a 48-year-old male with familial dilated cardiomyopathy were given an implantable cardioverter-defibrillator (ICD) as prophylaxis. About half a year after the implantation, there was an appropriate and successful ICD-discharge in both patients in connection with ventricular tachycardia. Treatment with an ICD can be life-saving in patients with cardiac rhythm disorders. The most common indication is ventricular tachycardia or fibrillation due to ischaemic heart disease, but an ICD may also be indicated in patients with cardiomyopathy, congenital heart disease, hereditary arrhythmia or a planned heart transplantation.

Cardiac rehabilitation is no longer just used to treat patients after the manifestation of a coronary artery disease such as a myocardial infarct, after a PTCA or after a coronary bypass operation. Patients with a congenital heart disease, patients who have received an implantable cardioverter defibrillator (ICD) and patients with stable chronic heart failure are also suitable candidates for a multidisciplinary cardiac rehabilitation programme. The new Dutch guidelines for cardiac rehabilitation, published in 2004, can be helpful in identifying potential candidates for a programme. Physical training is often a component of the treatment, but psycho-social counselling and education targeted at reducing anxiety and uncertainty, accepting the heart disease and learning to cope with it, can be just as important as those aspects targeted at improving the physical condition. Cardiac rehabilitation that includes physical training is safe for patients with congenital heart disease, for patients who have undergone an ICD implantation and for patients with stable chronic heart failure, as long as the pretraining exercise test is given a guiding role in selecting the appropriate physical work load. Patients with stable chronic heart failure should continue their physical training in order to maintain its beneficial physical and psychological effects.

Until recently, beta-blocking drugs were considered to be contraindicated in patients with chronic heart failure. However, several well-conducted randomised clinical trials have now proven otherwise. Yet, it was still not clear whether nonselective alpha-, beta 1- and beta 2-receptor blockade with carvedilol would be superior to selective beta 1-receptor blockade with metoprolol. One of the studies ('Carvedilol or metoprolol European trial' (COMET)) demonstrated a statistically significant 17% reduction of all-cause mortality with carvedilol. Although striking, the results may have been influenced by differences in blood pressure and heart rate, as well as the short-acting formula of metoprolol that was used. Furthermore, the 'Carvedilol hibernation reversible ischaemia trial; marker of success' (CHRISTMAS) study demonstrated myocardial hibernation in the majority of ischaemic heart-failure patients, and showed beneficial effects on left-ventricle function with carvedilol in both hibernated and non-hibernated patients. Despite this and the rest of the overwhelming evidence, at present only a minority of eligible chronic heart-failure patients are treated with beta-blockers.

Current clinical guidelines state that only beta-blockers, diuretics, calcium channel antagonists and ACE inhibitors should be used for initial pharmacotherapy for uncomplicated hypertension. On basis of experience, efficacy and costs beta-blockers and diuretics are first choice. However, the importance of the renin-angiotensin-aldosterone-system in the pathophysiology of hypertensive end-organ damage is increasingly recognised nowadays, and modulation of this system may therefore exert favourable effects on cardiovascular and cerebrovascular complications. In the LIFE study, a recently published double-blinded, randomised trial, the angiotensin-II receptor (A-II) antagonist losartan was compared with the beta-blocker atenolol in patients with essential hypertension and left ventricular hypertrophy (LVH). Patients randomised to the A-II antagonist suffered statistically significantly fewer clinical end-points, specifically fewer cerebrovascular accidents, whereas both treatments resulted in a similar decrease in blood pressure. In the subset of diabetic patients, the use of the A-II antagonist yielded an even more favourable outcome. In our opinion, it should now also be permitted to prescribe A-II antagonists as initial pharmacotherapy for patients with uncomplicated essential hypertension. It might be considered to prescribe A-II antagonists as preferred treatment for patients with essential hypertension and known LVH, especially in diabetic patients.

Aldosterone escape during chronic angiotensin-converting enzyme (ACE) inhibition may contribute to the high mortality among patients with heart failure. Aldosterone exerts several detrimental effects in the pathophysiology of heart failure. Spironolactone, an aldosterone antagonist, has proved beneficial when added to ACE inhibitors in patients with severe heart failure. However, spironolactone has substantial side effects mostly due to anti-androgen and anti-progestagen actions. This may limit its use in less severe heart failure. Recently, more selective aldosterone antagonists have been developed, which appear to have the same potential as spironolactone with fewer side effects. Trials to assess efficacy of these drugs in hypertension and mild heart failure are now being started.

Chronic heart failure is an increasing cause of hospital admission in the Netherlands and Belgium. Despite numerous medical treatment modalities, the mortality remains high. Recent placebo-controlled randomized studies suggest that the addition of beta-blockers in stabilized, optimally pretreated patients with chronic heart failure using angiotensin converting enzyme (ACE) inhibitors, diuretics and digitalis, is accompanied by an additional absolute decrease in mortality by about 5% and a relative decrease in mortality by about 35%. Also the number hospitalization frequency decreases. Initially, the beneficial effects of beta-blockers on symptoms are only minor or absent. During the initiation period some clinical deterioration may occur which has to be treated accordingly; these patients are, however, difficult to identify. Initiation has to be done using low doses and should be restricted to stabilized, optimally treated patients. Doses should only be increased every 2 to 4 weeks until target doses are reached. These findings must not be extrapolated automatically to all cases of heart failure, since patients in the trials may differ considerably from those encountered in general practice.

A woman aged 64 was severely handicapped by dyspnoea due to 'terminal heart failure' resulting from idiopathic dilated cardiomyopathy. The mitral valve was seriously insufficient; the coronary vessels were normal. The patient was not eligible for heart transplantation. Partial left ventriculectomy by Batista's method was performed and the mitral valve replaced by an artificial one. The left ventricular ejection fraction increased from 0.12 before the operation to 0.35 postoperatively and to 0.43 two years later. Patient was then capable of normal exercise (New York Heart Association (NYHA): class I-II). In the Netherlands partial left ventriculectomy is the last surgical option for patients rejected for heart transplantation.

Heart failure is a major and still growing medical and epidemiological problem, but in the last 10-20 years great progress has been made in its treatment. Alleviating symptoms is not (any longer) the only aim of the treatment; improving the life expectation or reducing the mortality has become a different, at least as important aim. Left ventricular dysfunction, even if asymptomatic, should be regarded, just as hypertension and hypercholesterolaemia, as a risk factor for which efficacious treatment is available and which consequently should be treated. A problem in this respect is that the effect of treatment of asymptomatic left ventricular dysfunction and of mild forms of heart failure is difficult to measure. Beta-blocking agents have proved to be the greatest gain in the treatment of heart failure in recent years, in addition to ACE inhibitors, diuretics and digoxin. These preparations should be prescribed with caution and due consideration. However, their favourable influence is such that use on a much larger scale than currently appears to be justified.

It has for years been a matter of debate whether digoxin may/should be used in chronic heart failure with sinus rhythm. Interest in digoxin was renewed when it was found that the substance had a vagotonic as well as a sympatholytic effect in heart failure patients. A recent clinical trial led to the conclusion that although digoxin had no effect on the mortality among heart failure patients, it did lead to a reduction of the number of hospital admissions, particularly because of heart failure (indicating reduced morbidity and deceleration of the progression of the disease). Many heart failure patients continue to have symptoms in spite of treatment with diuretics and ACE inhibitors. As only few alternatives are available, many physicians in the near future will go on using digoxin in these patients- and as the recent study shows, rightly so.

Cardiac transplantation was carried out in three men, aged 50, 34 and 36 years with severe chronic heart failure. They did not completely meet the Dutch criteria, notably with respect to absence of contraindications and the requirement of thorough screening. The treatment was successful.

A male aged 70 became unwell during work on the motor of his boat. He had an acute myocardial infarction, complicated by arrhythmias, which had probably been triggered by carbon monoxide intoxication. After treatment with, among other things, oxygen he recovered. Although the patient had experienced mild angina pectoris in the past, he had been symptom-free for years without medication. It is therefore suggested that the carbon monoxide intoxication played an important part in this case.