CLINICAL
NEWS JOURNAL WRAP
Kim Eagle, MD, and the editors of ACC.org, present relevant
articles taken from various journals.
Note to HFpEF Patients:
Eat Well and Keep Moving
Patients with heart failure with
preserved ejection fraction (HFpEF)
may benefit from aerobic exercise or
dieting, according to a study published
Jan. 5 in the Journal of the American
Medical Association.
HFpEF is the fastest-growing form
of heart failure and the most common
among older patients. More than 80%
of HFpEF patients are overweight or
obese, which can lead to inflammation,
hypertension, impaired cardiac function and other health problems.
Dalane W. Kitzman, MD, and
colleagues studied the effects of diet,
alone and combined with exercise, on
exercise capacity and quality of life
in obese older patients with HFpEF.
Subjects were 60 years or older, had
a body mass index of 30 of higher,
symptoms and signs of heart failure
and left ventricular ejection fraction of
50% or more.
A total of 92 patients completed
the trial. They were randomized to
either exercise only (n = 24); diet only
(n = 24), exercise and diet (n = 22) and
control (n = 22). Dietary adherence
(99%) and exercise attendance (84%)
were both high. Both diet and exercise
significantly increased exercise capacity, and the largest increase was seen
with diet and exercise combined. The
change in peak oxygen consumption
positively correlated with the change in
percent lean body mass and the change
in thigh muscle. Body weight was
reduced by 7% in the diet group, 3% in
the exercise group, 10% in the exercise
and diet group, and 1% in the control
group. Quality of life was not significantly different with exercise or diet.
The authors add that the increased
exercise capacity seen in these patients
may be due to reduced inflammation
and enhance mitochondrial function,
attenuated reactive oxygen species generation, increased vascular oxidative
stress resistance, increased nitric oxide
bioavailability, and improved vascular
function. “Together, these may increase
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CardioSource WorldNews
diffusive oxygen transport or oxygen
utilization by the active muscles,” they
write.
Kitzman and colleagues add that
“because of the ‘heart failure obesity
paradox’ (lower mortality observed
in overweight or obese individuals),
before diet can be recommended for
obese patients with HFpEF, further
studies are likely needed to determine
whether these favorable changes are associated with reduced clinical events.”
In an accompanying editorial comment, Nanette K. Wenger, MD, examines the possibility of testing these
findings on a community population
with longer follow-up. However, she
acknowledges that doing so would be
challenging. “Whether unprofessionally administered diet and nonmedically
supervised exercise could safely attain
similar benefit is uncertain but worthy
of exploration,” she writes.
Dr. Wenger suggests multiple potential approaches for implementation
including smartphone applications,
dietary provisions, wearable exercise
monitors and enlisting senior centers.
“Or, more simply,” she concludes, “it
seems that clinicians could communicate the transformative message to the
older obese population of primarily
women with HFpEF that improvement
in exercise capacity might be attained
by inexpensive and readily available
lifestyle measures (such as caloric
restriction and aerobic exercise) and
by encouragement and guidance to do
either or both.”
Kitzman DW, Brubaker P, Morgan T, et al.
JAMA. 2016;315:36-46.
Patient-Centered
Outcome Measures
After Stroke
Stroke experts recently came together
to publish a standard set of patient-centered outcome measures after stroke.
The paper, published in Stroke, was
developed to increase the value of care
in these patients.
An expert panel representing
stroke patients, stroke specialists from
all phases of stroke care, and major
international professional societies,
stroke registers, and centers convened
to define the Stroke Standard Set, “a
minimum set of outcomes and risk
adjustment variables that are highest
priority to collect for all patients hospitalized with stroke and designed to
be able to be measured in any country
within an existing register or as a freestanding set.”
The Standard Set was developed
for adults presenting to a hospital
with ischemic stroke or intracerebral
hemorrhage. This group covers over
90% of the global burden of stroke.
The treatments in the Standard Set are
restricted to thrombolysis, endovascular
thrombectomy, and hemicraniectomy,
as these are the only procedures for
which evidence convincingly shows a
large impact on mortality and disability.
The panel selected overall survival and recurrence of disease as core
measures of treatment effectiveness
and disease prevention. Effectiveness
of smoking cessation was also selected.
Survival is measured by all-cause mortality, collected at 7 days from index
hospital admission from stroke or at
discharge, whichever is first, and then
again at 90 to 120 days and 1 year
after admission. Recurrence of disease
is self- or proxy-reported at 90 days.
Patient-reported outcomes were proposed for assessment at 90 days were
pain, mood, feeding, self-care, mobility,
commun ication, cognitive functioning,
social participation, ability to return
to usual activities, and health-related
quality of life.
“An established set of standard data
collection items creates an opportunity
to increase patient value by improving
the reliability and consistency of data
about the quality of stroke care,” the
authors write. “Our aim acknowledges
the challenges and certain uncertainty
“The use of the
Standard Set will
help inform health
care providers in
the delivery of
effective, equitable,
patient-centered,
value-based stroke
care worldwide.”
—Salinas, et al.
that confront patients during the acute
and subacute stroke periods.” They add
that, in order to obtain high rates of
complete data, “the Standard Set favors
simplicity and pragmatism of data
collection over complexity and highly
detailed data specification.”
The next phase of implementation
will include pilot collection, development of a standardized collection platform, and comparison of data quality
and outcomes from the Standard Set in
various settings.
“The stroke outcomes working
group has defined a minimum recommended set of consensus patientcentered outcomes for collection in
all adults with new stroke that can
be implemented in a variety of health
care settings,” the authors conclude.
“The use of the Standard Set will help
inform health care providers in the
February 2016