Circulation
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Randomized Controlled Trial Clinical Trial
Home-based intervention in congestive heart failure: long-term implications on readmission and survival.
It is not known to what extent initially observed benefits of postdischarge programs of care for patients with chronic congestive heart failure (CHF) in respect to event-free survival, readmissions, and healthcare costs persist in the long term. Methods and Results- We prospectively studied the long-term effects of a multidisciplinary home-based intervention (HBI) in a cohort of CHF patients randomly allocated to either to HBI (n=149) or usual care (n=148). During a median of 4.2 years of follow-up, there were significantly fewer primary end points (unplanned readmission or death) in the HBI versus usual care group: a mean of 0.21 versus 0.37 primary events per patient per month (P<0.01). Median event-free survival was more prolonged in the HBI than usual care group (7 versus 3 months; P<0.01). Fewer HBI patients died (56% versus 65%; P=0.06) and had more prolonged survival (a median of 40 versus 22 months; P<0.05) compared with usual care. Assignment to HBI was both an independent predictor of event-free survival (RR 0.70; P<0.01) and survival alone (RR 0.72; P<0.05). Overall, HBI patients had 78 fewer unplanned readmissions compared with usual care (0.17 versus 0.29 readmissions per patient per month; P<0.05). The median cost of these readmissions was $A325 versus $A660/month per HBI and usual care patient (P<0.01). ⋯ The beneficial effects of HBI in reducing frequency of unplanned readmissions in CHF patients persist in the long term and are associated with prolongation of survival.
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Comparative Study Clinical Trial
Ventricular afterload and ventricular work in fontan circulation: comparison with normal two-ventricle circulation and single-ventricle circulation with blalock-taussig shunts.
Recent studies have indicated that there are inherent limitations associated with Fontan physiology. However, there have been no quantitative analyses of the effects of right heart bypass on ventricular afterload, hydraulic power, and resultant overall hemodynamics. Methods and Results- During routine cardiac catheterization, aortic impedance and ventricular hydraulic power were determined, both at rest and under increased ventricular work induced by dobutamine, in 17 patients with Fontan circulation, 15 patients with a single ventricle whose pulmonary circulation was maintained only by Blalock-Taussig shunts, and 13 patients who had normal 2-ventricle circulation. Both vascular resistance (nonpulsatile load on the ventricle) and pulsatile components of ventricular afterload (represented by low-frequency impedance) were significantly higher in the Fontan group than in the other groups (P<0.01), and this was associated with decreased cardiac output in the Fontan patients. In addition, hydraulic power cost per unit forward flow was 40% lower in the 2-ventricle circulation than in the single-ventricle circulation, suggesting lower ventricular efficiency in single-ventricle circulation attributable to the lack of a pulmonary ventricle. Furthermore, in the Fontan group, beta-adrenergic reserve was markedly decreased because of a limited preload reserve. ⋯ Fontan physiology is associated with disadvantageous ventricular power and afterload profiles and has limited ventricular reserve capacity. Thus, to improve the long-term prognosis of patients after Fontan surgery, future research should be conducted into medical interventions that can overcome these limitations inherent in Fontan circulation.
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Randomized Controlled Trial Multicenter Study Clinical Trial
Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study.
Patent foramen ovale (PFO) is associated with stroke, but there are no randomized studies to evaluate the efficacy of antithrombotic therapies. ⋯ On medical therapy, the presence of PFO in stroke patients did not increase the chance of adverse events regardless of PFO size or the presence of atrial septal aneurysm.