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Examining the clinical role and educational preparation of heart failure nurses across Europe. A survey of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) and the Association of Cardiovascular Nursing and Allied Professions (ACNAP) of the ESC
Get PDFAims
To describe the clinical practice and educational preparation of heart failure (HF) nurses across Europe and determine the key differences between countries.
Methods and results
A survey tool was developed, in English, by the Heart Failure Association Patient Care committee of the European Society of Cardiology (ESC). It was translated into eight languages, before electronically disseminated by nurse ambassadors, presidents of HF national societies and through social media. A total of 837 nurses involved in the daily care of patients with HF from 15 countries completed the survey. Most nurses, 78% (n = 395) worked within a hospital outpatient setting, and 51% (n = 431) had access to a specialized HF multidisciplinary team. Nurses performed a range of activities including patient education to promote self‐care, virtual and in‐person symptom monitoring. A third had more than 5‐year experience in cardiac care and 22% (n = 182) prescribed HF medications. There was a significant correlation between HF nurses that prescribed HF medications and access to a specialist multidisciplinary team (p = 0.04). A small number of nurses, mainly from Belgium, supported invasive monitoring (n = 68, 8%) with 14% (n = 120) of mostly Danish nurses supporting exercise programmes. The majority of nurses surveyed were committed to further academic professional development, with 41% (n = 343) having completed a HF course.
Conclusion
The role of the HF nurse varies across Europe, however involvement in patient education, symptom monitoring and follow‐up remain core to their practice. In specific activities including the prescribing of HF medications and involvement in invasive monitoring, practice has advanced with collaboration in the multidisciplinary team. Consequently, harmonization of education, training and career pathways are required to standardize HF care aligned with expert guidelines across Europe
Global Innovations in the Care of Patients With Heart Failure
Get PDFThe prevalence of heart failure (HF) is increasing in many regions of the world, particularly within the context of aging populations in many countries. The Heart Failure Society of America (HFSA) sought to explore areas of global HF innovation with the goal of exchanging ideas and best practices internationally. The HFSA Annual Scientific Meeting included roundtable discussions focused on the challenges faced by each of the participating regions and sharing innovative solutions. Themes identified include the lack of high-quality region-specific HF registry data that is required to accurately define patient needs and to facilitate outcome metrics; the tension between providing care that is accessible to the patient vs. concentrating highly-specialized care within tertiary centers; the need to accredit and coordinate HF care across a spectrum of healthcare delivery centers within regions; opportunities to improve the prevention and timely diagnosis of HF to enhance population outcomes, especially in communities facing healthcare disparities; and the evolution of multidisciplinary team-based care, particularly in optimizing access to guideline-directed medical therapies. This article summarizes the major themes that emerged during the roundtable sessions
Users’ Perspectives on Primary Care and Public Health Services in the State of Rio de Janeiro, Brazil: A Cross-Sectional Study with Implications for Healthcare Quality Assessment
Get PDFThis study focuses on the Unified Health System (SUS) in five regions of the state of Rio de Janeiro, Brazil, one of Brazil’s most important states, as part of a comprehensive analysis of a research project, which has generated publications in earlier phases. The objective was to assess users’ perceptions of SUS in terms of access to and the quality of public health services, including primary care and pharmaceutical services. A cross-sectional study was conducted using a structured questionnaire comprising 66 questions, administered to a purposive sample of 1000 participants between August 2023 and August 2024. Data were analyzed using Pearson’s chi-square test with R software version 4.3. Among the participants, 54.5% were female, 62.5% were aged between 26 and 60 years, and 29% reported having private health insurance. Vaccination services were the most frequently used SUS service (25.1% of respondents). Participants who reported more frequent use of SUS services rated access more positively than those who used them less frequently (p = 0.002). The regions that evaluated SUS access and quality most favorably were Middle Paraíba and the metropolitan region, while the Coastal Lowlands region received the most negative assessments. Participants with lower socioeconomic status gave more favorable evaluations of access to public health services (p = 0.001). These findings highlight concerns about access to, and the quality of, SUS healthcare services and regional disparities in users’ perceptions of SUS services in Rio de Janeiro. The results underscore the importance of social participation as a key element in the evaluation and continuous improvement of responsive public healthcare
Breast Cancer in the Modern Era: A Comprehensive Review on Advances in Understanding and Managing Breast Cancer
Get PDFEven with advances in screening and prevention methods, breast cancer is more often diagnosed in women than any other malignancy. An increased knowledge of genetics made it possible for researchers to sort breast cancer into four types: luminal A, luminal B, HER2‑enriched, and triple‑negative, all marked by specific biomarkers and estimations for the outcome. High‑throughput genomic classifiers such as the Breast Cancer Classifier (BCC) have allowed doctors to more accurately choose the best medicine for HER2‑low tumors. Now, liquid biopsies and multiplex immunofluorescence tests are being used, in addition to imaging and samples taken from tissue, to help recognize minimal amounts of disease at an early stage. Among hormone receptor‑positive and BRCA‑mutant patients, CDK4/6 inhibitors, antibody–drug conjugates, and PARP inhibitors have improved progression‑free survival. Tools powered by artificial intelligence are regularly being included in the work of many health professionals, helping them detect diseases more accurately and measure a patient’s probability of illness. However, because some cancer treatments can cause serious side effects in young people and early menopause, efforts are being made to trial new therapies that focus clearly on how these patients feel after surviving cancer. There is a need to explore how neoadjuvant therapy can be improved, use different kinds of data for assessing treatment needs, and ensure that all patients receive the best treatment available. The current review aimed to investigate advances in understanding and managing breast cancer
SGLT2 inhibitors for the prevention and treatment of heart failure: A scientific statement of the HFA and the HFAI
Get PDFIn the 2021 European Society of Cardiology (ESC) heart failure (HF) guidelines, sodium–glucose cotransporter 2 (SGLT2) inhibitors were recommended for the prevention of HF in patients with type 2 diabetes mellitus (T2DM) and for the treatment of HF with reduced ejection fraction (HFrEF). Further trials showed efficacy of empagliflozin and dapagliflozin in patients with HF with preserved ejection fraction (HFpEF). These results prompted a broadened recommendation for the SGLT2 inhibitors dapagliflozin or empagliflozin across the whole left ventricular ejection fraction (LVEF) spectrum in the 2023 Focused Update of the ESC HF guidelines and in other international guidelines. In SOLOIST‐WHF and EMPULSE, sotagliflozin (enrolling only patients with T2DM) and empagliflozin, respectively, were beneficial when initiated at the end or soon after an episode of decompensated HF. Based on these results and on the early appearance of their beneficial effects, the administration of SGLT2 inhibitors should start early in patients hospitalized for acute HF. Analyses after study drug withdrawal in randomized clinical trials have shown that their benefits may decline rapidly after discontinuation, and thus, persistence of treatment is advised. In EMPACT‐MI, empagliflozin did not reduce the primary outcome of cardiovascular (CV) death/HF hospitalization but reduced first/recurrent HF hospitalizations. Potential benefits of SGLT2 inhibitors in further specific conditions (i.e., cardiac amyloidosis, grown‐up congenital heart disease and paediatric patients with HF) have been reported in observational studies but need confirmation from prospective trials. This scientific statement summarizes current evidence regarding the effects of SGLT2 inhibitors for the prevention and treatment of HF
Automated patch clamp data improve variant classification and penetrance stratification for SCN5A–Brugada syndrome
Get PDFBackground and Aims
Brugada Syndrome (BrS) is an inherited arrhythmia disorder that causes an elevated risk of sudden cardiac death. Approximately 20% of patients with BrS have rare variants in SCN5A, which encodes the cardiac sodium channel NaV1.5. Genetic workup of BrS is often complicated by SCN5A variants of uncertain significance (VUS) and/or incomplete penetrance. This study deployed an SCN5A-BrS functional assay at cohort scale to facilitate the implementation of genetic and precision medicine.
Methods
All 252 missense and in-frame insertion/deletion SCN5A variants from a previously published large cohort of BrS cases (n = 3335 patients) were analysed using a calibrated high-throughput automated patch-clamp (APC) assay. Variant functional Z-scores were assigned evidence levels ranging from BS3_moderate (normal function) to PS3_strong (loss-of-function), as defined by American College of Medical Genetics and Genomics criteria. Functional evidence was combined with population frequency, hotspot, case counts, protein-length changes, and in silico predictions. Odds ratios of BrS case–control enrichment and penetrance for BrS were calculated from variant frequencies in the BrS cohort and in gnomAD.
Results
Most variants (146/252) were functionally abnormal (Z ≤ −2), with 100 having severe loss-of-function (Z ≤ −4). Functional evidence enabled the reclassification of 110 of 225 VUS; 104 to likely pathogenic and 6 to likely benign. SCN5A variants with loss-of-function were mainly localized to the transmembrane domains, especially the regions comprising the central pore. SCN5A variant penetrance was proportional to the severity of loss-of-function; variants with Z ≤ −6 had penetrance of 24.5% (15.9%–37.7% CI) and an odds ratio of 501 for BrS.
Conclusions
This cohort-scale APC dataset stratifies SCN5A variants found in BrS patients into normal function ‘bystander’ variants that have a low risk of BrS and loss-of-function variants that have a high risk for BrS. Functional data can be integrated with other criteria to reclassify a substantial fraction of VUS. The dataset helps clarify the SCN5A–BrS relationship and will improve the diagnosis and clinical management of BrS probands and their families
Patient-Reported Importance of Functional Benefit in Geographic Atrophy
Get PDFImportance
Intravitreal complement inhibitors injections (IVCIs) slowed progression of geographic atrophy (GA) lesions in several registration phase 3 trials although without benefit for prespecified secondary functional vision outcomes. Patient acceptability of these therapies needs further exploration.
Objective
To quantify the acceptability of IVCI therapy to United Kingdom patients with GA, assuming vision outcome benefits are expected.
Design, Setting, and Participants
This cross-sectional study took place at 9 geographically dispersed UK National Health Service centers from April 2023 to April 2024 among 153 participants with treatment-naive GA in at least 1 eye.
Exposures
GA in at least 1 eye.
Main Outcomes and Measures
Main outcomes were (1) acceptability of IVCI therapy based on completion of validated acceptability questionnaire. Participants were provided with a treatment information leaflet coproduced by a patients with lived experience of GA to inform them about the risks and benefits of IVCI for GA, assuming there were vision outcome benefits to this treatment and (2) response to the EuroQol 5-dimension with a vision bolt-on questionnaire to assess general health and vision-related quality of life. Spearman rank correlations and χ2 tests were used to explore associations between acceptability levels and specific ocular and sociodemographic characteristics.
Results
A total of 153 participants were recruited (93 [60%] women; mean [SD] age, 82 [7]), 57 (38%) of whom had bilateral foveal involvement. Median (IQR) visual acuity with habitual correction in the better-seeing eye and in eyes where neither eye was better or worse was logMAR, 0.30 (0.14-0.54; approximate Snellen equivalent, 20/40) and 0.47 (0.14-0.84; approximate Snellen equivalent, 20/63), respectively. Among the 153 participants, 81 (53%; 95% CI, 45-61) reported IVCIs were very much or extremely acceptable under the theoretical scenarios provided. The proportion finding IVCIs acceptable rose to 82% (95% CI, 76-88) when including those who rated prospective treatment as moderately acceptable. Belief in the perceived effectiveness of the treatment (ρ, 0.52; 95% CI, 0.40-0.63; P<.001) and confidence in their ability to attend the eye clinic regularly (ρ, 0.51; 95% CI, 0.38-0.62; P<.001) correlated with overall acceptability.
Conclusions and Relevance
IVCI therapy for GA may be acceptable to most UK patients with GA under the assumption that there are vision outcome benefits to this treatment. While current treatments do not result in vision outcome benefits, perceived effectiveness by patients was associated with acceptability, emphasizing the desire to quantify vision functional benefit concomitant with anatomical slowing of progression
Gait Rehabilitation for Early rheumatoid Arthritis Trial (GREAT): lessons learnt from a mixed-methods feasibility study and internal pilot trial
Get PDFBackground: People with rheumatoid arthritis experience foot and lower limb pain due to active synovitis, resulting in impaired lower limb function. Earlier intervention may help with prevention of functional decline. The aims of this research were to develop and evaluate a new gait rehabilitation intervention for people with early rheumatoid arthritis, evaluate its feasibility, and to test whether or not gait rehabilitation plus usual care is more clinically and cost-effective than usual care alone.
Design and methods: We undertook a single-arm, repeated measures, pre- and post-intervention, mixed methods feasibility study with embedded qualitative components. We planned to undertake a pragmatic, two-arm, multi-centre, superiority randomised controlled trial, with health economic evaluation, process evaluation, and internal pilot.
Setting and participants: Participants with early rheumatoid arthritis (<2 years post-diagnosis) were identified from early arthritis and rheumatology outpatient clinics and referred for intervention in either podiatry or physiotherapy clinics.
Intervention(s): Participants were randomised to a gait rehabilitation programme (GREAT Strides) involving a 6-task gait circuit. Sessions were underpinned by motivational interviewing to facilitate behaviour change, supported by trained physiotherapists or podiatrists for a minimum of two sessions. Both groups received their normal usual care from the rheumatology multidisciplinary team.
Main outcome measures: Outcome measures for the feasibility study were intervention acceptability, adherence using the Exercise Adherence Rating Scale (EARS) and fidelity using the Motivational Interviewing Treatment Integrity Scale (MITI). The main outcome measure for the internal pilot/RCT was the Foot Function Index disability subscale. Outcomes were measured at baseline, 3-months, 6-months and 12-months. Other outcomes: intervention acceptability questionnaire (IAQ), EARS, exercise treatment beliefs via the Theory of Planned Behaviour Questionnaire, intervention fidelity (MITI), health-related quality of life (EQ5D-5L).
Results: Thirty-five participants were recruited for feasibility and 23 (65.7%) completed 12-week follow-up. Intervention acceptability was excellent; 21/23 were confident that it could help and would recommend it; 22/23 indicated it made sense to them. Adherence was good, with a median [IQR] EARS score of 17/24 [12.5–22.5]. Twelve participants’ and 9 therapists’ interviews confirmed intervention acceptability, identified perceptions of benefit, but highlighted some barriers to completion. MITI scores demonstrated good fidelity. The trial did not progress from internal pilot to full main trial as a result of low recruitment and high attrition, after fifty-three participants were recruited from nine sites over 12-months. Process evaluation confirmed good intervention acceptability and adherence, and fair fidelity. Evaluation of clinical and cost-effectiveness was not possible.
Limitations: Significant delays were experienced with the impact of COVID-19, regulatory approvals, contracts, and site readiness, resulting in few sites opening in time and low recruitment capacity. Foot and/or ankle pain prevalence was lower than anticipated, resulting in a low potential participant pool and a low conversion rate from screening to enrolment.
Conclusions: The GREAT Strides intervention was acceptable to people with early RA and intervention clinicians, safe, with good levels of adherence by participants, and fair intervention fidelity. The RCT stopped early following failure to meet recruitment targets. GREAT Strides is a promising intervention that could be adapted for future evaluations. A definitive trial of the GREAT Strides gait rehabilitation intervention still needs to be done.
Study registration: ISRCTN (International Standard Randomised Controlled Trial Number) registry as ISRCTN14277030.
Funding details: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme (15/165/04)
An international physician survey of current ablation practices in atrial fibrillation: An AIM-AF substudy
Get PDFBACKGROUND: Practice guidelines recommend Ablation (ABL) in atrial fibrillation (AF) for rhythm control; guidance for antiarrhythmic drugs (AADs) post-ablation is limited. OBJECTIVE: To understand AAD and ABL practices in USA and Europe. METHODS: An online survey of experienced cardiologists (CDs, n=360) and interventional electrophysiologists (EPs, n=269) was conducted. AAD and ABL related survey questions and responses were analyzed. RESULTS: ABL was preferred more often as first-line AF therapy (Rx) by US CDs/EPs (p<.001). ABL was selected to avoid AAD Rx by 46% (50% CDs, 40% EPs), prevent AF progression by 41% (36% CDs, 47% EPs) and for superior efficacy by 28% (27% CDs, 30% EPs), ABL was employed by 9% in asymptomatic AF (9% CDs, 10% EPs), by 14% in subclinical AF (13% CDs, 14% EPs), by 17% for first AF event (15% CDs, 18% EPs). Primary ABL was preferred in heart failure by 38%. Co-morbidities, age and left atrial size were limitations for ABL by 48%, 40% and 38%, respectively. AADs were used after ABL for AF/ atrial tachycardia (AT) prophylaxis by 34% for 3-6 months and 29% for 1-2 months. AADs were given for a single AF recurrence by 34%, bridging to re-ablation by 32%, and long-term Rx by 34%. AF/AT post-ABL was most often managed with amiodarone (42-48%). CONCLUSION: ABL was frequently preferred over AADs in symptomatic AF but was notably also used for asymptomatic and subclinical AF. Post-ABL AAD Rx for AF prophylaxis or recurrence was frequent with empiric amiodarone being the most often selected AAD
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