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One in four adults in the UK have two or more medical conditions. One in three adults admitted to hospital in the UK have five or more conditions. People with multimorbidity have poorer functional status, quality of life and health outcomes, and are higher users of ambulatory and inpatient care than those without multimorbidity. The entire healthcare system needs to change so that it can provide a better service for patients with multimorbidity. The system of healthcare professional education needs to change also. Clinical decision support has a clear role in the management of patients with multimorbidity. But, until now, clinical decision support tools have offered no support when dealing with patients with comorbidities; they have covered single conditions only. In light of this, BMJ Best Practice recently launched the Comorbidities Manager. This enables healthcare professionals to add a patient's comorbidities to an existing management plan and get a tailored plan instantly. This article outlines the importance of taking into account comorbidities when managing patients and the role that the BMJ Comorbidities Manager can play in this regard.

BackgroundAdaptive servo-ventilation (ASV) effectively suppresses central sleep apnoea (CSA) but has been associated with increased all-cause and cardiovascular mortality in chronic heart failure patients with reduced ventricular ejection fraction (HFrEF). All-cause and, especially, cardiovascular mortality in chronic heart failure is highly correlated with sympathetic tone. This analysis of SERVE-HF data investigated the effect of ASV on sympathetic tone in patients with HFrEF and CSA.MethodsHFrEF patients in the SERVE-HF trial (left ventricular ejection fraction (LVEF) ≤45%, apnoea–hypopnoea index (AHI) ≥15 events·h−1with predominant CSA) were randomly assigned to receive guideline-based heart failure treatment alone (controls) or plus ASV. For this analysis, the primary outcome was change in muscle sympathetic nerve activity (MSNA) at 3-month follow-up. The effects of baseline MSNA and change in MSNA over time on mortality in the main study were also assessed.Results40 patients with HFrEF were included in this analysis (age 71.3±11.7 years, LVEF 34.2±7.7%, 57.5% in New York Heart Association (NYHA) Functional Class II, 42.5% in NYHA Functional Class III, AHI 35.2±11 events·h−1). Sympathetic tone evolution during follow-up did not differ between groups (controls: 47.6±8.3 bursts·min−1at baseline to 44.6±11.2 bursts·min−1; ASV group: 43.0±9.0 bursts·min−1at baseline to 42.74±9.45 bursts·min−1). The reduction in sympathetic tone was associated with significantly increased cardiovascular mortality in the ASV group, whereas in the control group reduced sympathetic tone appeared to be protective.ConclusionsSuppression of CSA with ASV did not seem to have a significant effect on chronic heart failure-related sympathetic activation. Simultaneous suppression of CSA and reduction in MSNA was associated with increased cardiovascular mortality.

Atrial fibrillation (AF) is a common irregular heart rhythm associated with a five-fold increase in stroke risk. It is often not recognised as it can occur intermittently and without symptoms. A promising approach to detect AF is to use a handheld electrocardiogram (ECG) sensor for screening. However, the ECG recordings must be manually reviewed, which is time-consuming and costly. Our aims were to: (i) evaluate the manual review workload; and (ii) evaluate strategies to reduce the workload. In total, 2141 older adults were asked to record their ECG four times per day for 1-4 weeks in the SAFER (Screening for Atrial Fibrillation with ECG to Reduce stroke) Feasibility Study, producing 162,515 recordings. Patients with AF were identified by: (i) an algorithm classifying recordings based on signal quality (high or low) and heart rhythm; (ii) a nurse reviewing recordings to correct algorithm misclassifications; and (iii) two cardiologists independently reviewing recordings from patients with any evidence of rhythm abnormality. It was estimated that 30,165 reviews were required (20,155 by the nurse, and 5005 by each cardiologist). The total number of reviews could be reduced to 24,561 if low-quality recordings were excluded from review; 18,573 by only reviewing ECGs falling under certain pathological classifications; and 18,144 by only reviewing ECGs displaying an irregularly irregular rhythm for the entire recording. The number of AF patients identified would not fall considerably: from 54 to 54, 54 and 53, respectively. In conclusion, simple approaches may help feasibly reduce the manual workload by 38.4% whilst still identifying the same number of patients with undiagnosed, clinically relevant AF.

Background Physicians’ adherence to guideline-recommended therapy is associated with short-term clinical outcomes in heart failure (HF) with reduced ejection fraction (HFrEF). However, its impact on longer-term outcomes is poorly documented. In this analysis we assessed the longer-term association of physicians’ adherence with clinical outcomes, including mortality and unplanned hospitalisations, at 18-month follow-up of the QUALIFY registry (Clinical trial registration ISRCTN87465420) Method and results Data at 18 months were available for 6118 ambulatory HFrEF patients from this international prospective observational survey. Adherence was measured as a continuous variable, ranging from 0 to 1, and was assessed with regard to five classes of recommended HF medications and dosages. Most deaths were cardiovascular (CV) (228/394) and HF-related (191/394) and the same was true for unplanned hospitalisations (1175 CV and 861 HF-related hospitalisations, out of a total of 1541). According to univariable analysis, CV and HF deaths were significantly associated with physician adherence to guidelines. In multivariable analysis, HF death was associated with adherence level [subdistribution hazard ratio (SHR) 0.93, 95% confidence interval (CI) 0.87–0.99 per 0.1 unit adherence level increase; P = 0.034] as was composite of HF hospitalisation or CV death (SHR 0.97, 95% CI 0.94–0.99 per 0.1 unit adherence level increase; P = 0.043), whereas unplanned all-cause, CV or HF hospitalisations were not (all-cause: SHR 0.99, 95% CI 0.9–1.02; CV: SHR 0.98, 95% CI 0.96–1.01; and HF: SHR 0.99, 95% CI 0.96–1.02 per 0.1 unit change in adherence score; P = 0.52, P = 0.2, and P = 0.4, respectively). Conclusion These results suggest that physicians’ adherence to guideline-recommended HF therapies is associated with improved outcomes in HFrEF. Practical strategies should be established to improve physicians’ adherence to guidelines.

Despite therapy advances in the management of heart failure, symptomatic congestion and low cardiac output in acute heart failure is a leading cause of mortality and morbidity. The purpose of this study was to investigate transvenous cardiac autonomic nerve stimulation (CANS) effects on in-hospital hemodynamics and signs and symptoms of congestion. The study was a single-center, observational, clinical investigation of CANS. Twelve subjects with left ventricular ejection fraction (LVEF)

Heart rate (HR) is associated with cardiovascular outcomes in all the stages of the cardiovascular continuum as well as in patients with pulmonary, cerebrovascular, and renal disease, sepsis, cancer, and erectile dysfunction. In patients with cardiovascular disease, but also in the general population, increased HR represents an important indicator of mortality with each acceleration of HR over 70 b.p.m. increasing the risk. In patients in sinus rhythm with chronic heart failure with reduced ejection fraction (HFrEF), a HR70 b.p.m. increased the risk of hospitalization, and75 b.p.m. the risk of cardiovascular death as shown in the Systolic Heart Failure Treatment with the I

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Guidelines and Expert Consensus documents aim to present all the relevant evidence on a particular issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or therapeutic procedure. They should be helpful in everyday clinical decision-making. A great number of Guidelines and Expert Consensus Documents have been issued in recent years by different organizations, the European Society of Cardiology (ESC) and by other related societies. By means of links to web sites of National Societies several hundred guidelines are available. This profusion can put at stake the authority and validity of guidelines, which can only be guaranteed if they have been developed by an unquestionable decision-making process. This is one of the reasons why the ESC and others have issued recommendations for formulating and issuing Guidelines and Expert Consensus Documents. In spite of the fact that standards for issuing good quality Guidelines and Expert Consensus Documents are well defined, recent surveys of Guidelines and Expert Consensus Documents published in peer-reviewed journals between 1985 and 1998 have shown that methodological standards were not complied within the vast majority of cases. It is therefore of great importance that guidelines and recommendations are presented in formats that are easily interpreted. Subsequently, their implementation programmes must also be well conducted. Attempts have been made to determine whether guidelines improve the quality of clinical practice and the utilisation of health resources. The ESC …

ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary : a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias).

There is overwhelming evidence that cholesterol-lowering with a statin is a key component of a global approach to risk reduction in cardiovascular disease. However, spiralling costs have made some question the cost-effectiveness of these compounds. This article reviews the evidence and suggests how to maximise health gain.

AIMS: Low pulse pressure is a marker of adverse outcome in patients with heart failure (HF) and reduced ejection fraction (HF-REF) but the prognostic value of pulse pressure in patients with HF and preserved ejection fraction (HF-PEF) is unknown. We examined the prognostic value of pulse pressure in patients with HF-PEF [ejection fraction (EF) ≥ 50%] and HF-REF.METHODS AND RESULTS: Data from 22 HF studies were examined. Preserved left ventricular ejection fraction (LVEF) was defined as LVEF ≥ 50%. All-cause mortality at 3 years was evaluated in 27 046 patients: 22 038 with HF-REF (4980 deaths) and 5008 with HF-PEF (828 deaths). Pulse pressure was analysed in quintiles in a multivariable model adjusted for the previously reported Meta-Analysis Global Group in Chronic Heart Failure prognostic variables. Heart failure and reduced ejection fraction patients in the lowest pulse pressure quintile had the highest crude and adjusted mortality risk (adjusted hazard ratio 1.68, 95% confidence interval 1.53-1.84) compared with all other pulse pressure groups. For patients with HF-PEF, higher pulse pressure was associated with the highest crude mortality, a gradient that was eliminated after adjustment for other prognostic variables.CONCLUSION: Lower pulse pressure (especially

BACKGROUND: In heart failure (HF), obesity, defined as body mass index (BMI) X30 kgm 2, is paradoxically associated with higher survival rates compared with normal-weight patients (the ‘obesity paradox’). We sought to determine if the obesity paradox differed by HF subtype (reduced ejection fraction (HF-REF) versus preserved ejection fraction (HF-PEF)). PATIENTS AND METHODS: A sub-analysis of the MAGGIC meta-analysis of patient-level data from 14 HF studies was performed. Subjects were divided into five BMI groups: o22.5, 22.5–24.9 (referent), 25–29.9, 30–34.9 and X35 kgm 2. Cox proportional hazards models adjusted for age, sex, aetiology (ischaemic or non-ischaemic), hypertension, diabetes and baseline blood pressure, stratified by study, were used to examine the independent association between BMI and 3-year total mortality. Analyses were conducted for the overall group and within HF-REF and HF-PEF groups. RESULTS: BMI data were available for 23 967 subjects (mean age, 66.8 years; 32% women; 46% NYHA Class II; 50% Class III) and 5609 (23%) died by 3 years. Obese patients were younger, more likely to receive cardiovascular (CV) drug treatment, and had higher comorbidity burdens. Compared with BMI levels between 22.5 and 24.9 kgm 2, the adjusted relative hazards for 3-year mortality in subjects with HF-REF were: hazard ratios (HR)¼1.31 (95% confidence interval¼1.15–1.50) for BMI o22.5, 0.85 (0.76–0.96) for BMI 25.0–29.9, 0.64 (0.55–0.74) for BMI 30.0–34.9 and 0.95 (0.78–1.15) for BMI X35. Corresponding adjusted HRs for those with HF-PEF were: 1.12 (95% confidence interval¼0.80–1.57) for BMI o22.5, 0.74 (0.56–0.97) for BMI 25.0–29.9, 0.64 (0.46–0.88) for BMI 30.0–34.9 and 0.71 (0.49–1.05) for BMI X35. CONCLUSIONS: In patients with chronic HF, the obesity paradox was present in both those with reduced and preserved ventricular systolic function. Mortality in both HF subtypes was U-shaped, with a nadir at 30.0–34.9 kgm 2.

A detailed study is presented of solid-state structure, oxidation state, and electron transport in Ni(dpg)/sub 2/I and Pg(dpg)/sub 2/I, dpg = diphenylglyoximato. The crystal structure of Ni(dpg)/sub 2/I has been studied by x-ray diffraction at 23 and -160/sup 0/C. The compound crystallizes in the tetragonal space group D/sub 4h//sup 8/-P4/ncc, with four formula units of Ni(dpg)/sub 2/I in a unit cell having dimensions at -160/sup 0/C of a = 19.774 (8), c = 6.446 (3) A. Full-matrix least-squares refinement of 31 variables gave a final value of the conventional R index (on F) of 0.093 for 353 reflections having F/sub 0//sup 2/ > 3 sigma(F/sub 0//sup 2/). The crystal structure consists of stacked Ni(dpg)/sub 2/ units (staggered by 90/sup 0/) and disordered chains of iodine atoms extending in the c direction. At -160/sup 0/C the Ni--Ni separation is 3.223 (2) A; other important distances are Ni--N = 1.868 (15), N--C = 1.33 (3), N--O = 1.34 (3) A. The Ni(dpg)/sub 2/ moiety is decidedly nonplanar (D/sub 2/ symmetry) with coordinated N atoms displaced 0.12 (2) A above or below the mean molecular plane. Analysis of diffuse x-ray scattering associated with the disordered iodine chains is consistent with I/sub 5//sup -/more » being the predominant species. This result is in agreement with resonance Raman spectroscopic studies on Ni(dpg)/sub 2/I and Pd(dpg)/sub 2/I as well as on model compounds. Fundamental polyiodide transitions in the M(dpg)/sub 2/I materials are observed(..nu../sub 0/ = 4880--6471 A)at 161 vs and 107 w cm/sup -1/; weak M(dpg)/sub 2/-centered scattering is also noted. Iodination brings about an increase in conductivity of > 10/sup 8/ (Ni) and > 10/sup 7/ (Pd), which is especially noteworthy since the only major change in crystal structure upon iodination is a ca. 0.27 A decrease in the M(dpg)/sub 2/ stacking distance. Variable-temperature studies show the Ni(dpg)/sub 2/I and Pd(dpg)/sub 2/I conductivities to be thermally activated.« less

These practice guidelines are intended to assist physicians in clinical decision making by describing a range of generally acceptable approaches for the diagnosis and management of supraventricular arrhythmias. These guidelines attempt to define practices that meet the needs of most patients in most

Plasma natriuretic peptide (NP) testing is not widely used in heart failure clinical practice in the UK or Ireland, despite a large evidence base. This article reports the views of a consensus group that was set up to develop guidance on the place of NP testing for clinicians in primary and secondary care. There is firm evidence for NP testing as part of the heart failure diagnostic pathway. Measuring NPs is also a useful prognostic tool and can help with discharge planning, and there is emerging evidence for use in treatment monitoring particularly in younger patients. For the future, NP measurement might also prove to be useful for screening high-risk patients for asymptomatic left ventricular systolic dysfunction. Copyright Medinews (Cardiology) Limited Reproduction Prohibited.