| 1. |
- Agvall, Björn, 1963-
(författare)
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Heart failure in primary care with special emphasis on costs and benefits of a disease management programme
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background and aim. Heart failure (HF) is a common condition associated with poor quality of life (QoL), high morbidity and mortality and is frequently occurring in primary health care (PHC). It involves a substantial economic burden on the health care expenditure. There are modern pharmacological treatments with evident impact on QoL, morbidity, mortality, and proved to be cost-effective. Despite this knowledge, the treatment of HF is considered somewhat insufficient. There are several HF management programmes (HFMP) showing beneficial effects but these studies is predominantly based in hospital care (HC).The first aim of this thesis was to describe patients with HF in the PHC regarding gender differences, diagnosis, treatment and health related costs (I, II).The second aim was to evaluate whether HFMP have beneficial effects in the PHC regarding cardiac function, quality of life, health care utilization and health care-related costs (III,IV).Methods. The initial study involved retrospective collection of data from 256 patients with symptomatic HF in PHC (I). The data collected were gender, age, diagnostics and ongoing treatment. The second study was an economic calculation performed on 115 patients (II). The economic data was retrospectively retrieved as the number of hospital days, visits to nurses and physicians in HC and PHC, prescribed cardiovascular drugs and performed investigation during retrospectively for one year. The third and fourth study was based on a randomized, prospective, open-label study which was subsequently performed (III,IV). The study enrolled 160 patients with systolic HF who were randomized to either an intervention or a control group. The patients in the intervention group retrieved follow-up of HF qualified nurses and physicians in the PHC, involving education about HF and furthermore, optimizing the treatment according to guidelines if possible. The patients in the control group had a followup performed by their regular general practitioner (GP) receiving customary management according to local routines but there was no contact with HF nurses. The primary endpoint of the study was a composite endpoint consisting of changes in survival, hospitalization, heart function and quality of life (QoL) and to compare differences in resource utilization and costs (III,IV).Results. In the first study, the prevalence was 2% and the average age was 78 years (I). The most frequent cause of HF was IHD followed o hypertension. The diagnosis in the study population was based on clinical criteria and only 31% had been subjected to echocardiography. The most common treatment was diuretics (84%) and angiotensin converting enzyme inhibitors (ACEI) were used in 56% of patients. In the following prospective study, the intervention group had significant improvements in composite endpoints. There were in the intervention group more patients with reduced levels of NTproBNP (p=0.012) and improved cardiac function (p=0.03). No significant changes were found in New York Heart Association (NYHA) functional class or QoL. The intervention involved less health care contacts (p=0.04), less emergency ward visits (p=0.002) and hospitalizations (p=0.03). The total cost for HC and PHC was EUR 4471 in the intervention group and EUR 6638 in the control group which implies a cost reduction of EUR 2167 (33%).Conclusions. HF is common in PHC with a prevalence of 2% the study population had an average age of 78 years. Only 31 % of the HF patients have performed an echocardiographic investigation. Treatment with ACEI occurred in 56 %. Differences were found between genders since women had performed significantly fewer echocardiographic investigations and, had less treatment with ACEI. When implementing HFMP in PHC, beneficial effects were found regarding cardiac function and health care-related costs in patients with systolic HF. These findings indicate that HFMP might be used even in PHC.
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| 2. |
- Johansson, Peter, 1962-
(författare)
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Health‐related quality of life, depression, sleep and breathing disorders in the elderly : With focus on those with impaired systolic function/heart failure
- 2008
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim of this thesis was to describe the prevalence of depressive symptoms, sleep disordered breathing (SDB) and sleep complaints, as well as to investigate the prognostic value of health-related quality of life (Hr-QoL) and depressive symptoms on mortality in an elderly community living population with a focus on those with impaired systolic function/heart failure (HF). Descriptive, prognostic and explorative study designs were used to examine if a single question about global perceived health (GPH) is associated with the domains of Hr-QoL as assessed by the SF-36 (I), as well as to evaluate whether GPH provided prognostic information concerning cardiovascular mortality (II). The aim was also to evaluate if depressive symptoms are associated with mortality (III), and to describe the prevalence of SDB and its relationship to impaired systolic function, different insomnia symptoms, as well as excessive daytime sleepiness (IV).In primary care elderly patients with HF, GPH correlated to the physical and mental aspects of Hr-QoL. Patients who rated poor GPH also scored worse physical and mental Hr-QoL compared to patients with good GPH, but the mental aspect of Hr-QoL was however not significant (p<0.07) (I). Moreover, GPH also had an independent association with cardiovascular mortality during a ten-year follow-up. Compared to patients with good GPH, those who scored poor GPH had a four times increased risk for cardiovascular mortality (II). A total of 24% of the patients with HF suffered from depressive symptoms, not significantly different compared to 19% among those without HF. Depressive symptoms were a poor prognostic sign during the six-year follow-up and HF patients with depressive symptoms had the highest risk for cardiovascular mortality compared to HF patients without depressive symptoms (III). SDB is common among elderly people living in the community, almost one quarter (23%) had moderate or severe SDB. However, people with moderate impaired systolic function had a median apnea hypopnea index that was more than twice as high compared to those with normal systolic function (10.9 vs. 5.0, p<0.001). No obvious associations between SDB and excessive daytime sleepiness or the insomnia symptoms; difficulties maintaining sleep; non-restorative sleep; or early morning awakenings were detected. Difficulties initiating sleep were however more common in those with moderate or severe SDB (IV).GPH can be used as a simple tool in clinical routine practice as an aid in identifying patients in need of additional management. SDB is a common phenomenon among elderly people and associated with impaired systolic function, but with a limited impact on subjective sleep complaints. Depressive symptoms were shown to be a poor prognostic sign and may amplify the patient’s experience of suffering. Screening for depressive symptoms could therefore be an important action in the management of patients with HF.
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| 3. |
- Ljungberg, Liza, 1980-
(författare)
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Angiotensin-converting enzyme in cardiovascular function and dysfunction
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Angiotensin-converting enzyme (ACE) is a key enzyme in the renin-angiotensin system, converting angiotensin I to the vasoactive peptide angiotensin II, and degrading bradykinin. Angiotensin II is a multifunctional peptide, acting on a number of different tissues. A common genetic variation in the gene encoding ACE; ACE I/D polymorphism influences the level of ACE in the circulation, and has been linked to increased risk for cardiovascular disease. This thesis aimed to explore the connection between ACE and cardiovascular function and dysfunction.The impact of nicotine and nicotine metabolites on ACE in cultured human endothelial cells was studied. Nicotine as well as nicotine metabolites induced increased ACE activity in cultured human endothelial cells. In elderly men a higher ACE level was seen in smokers compared to non-smokers. Furthermore, diabetes was associated with higher circulating ACE. Increased ACE level may represent a cellular mechanism which contributes to vascular damage.Elderly men carrying the ACE D allele had higher abdominal aortic stiffness compared to men carrying the I/I genotype. Our data suggest that the mechanism by which the ACE D allele modulates aortic wall mechanics is independent of circulating ACE levels. Previous studies have indicated a link between the D allele and abdominal aortic aneurysm. Increased aortic stiffness suggests impaired vessel wall integrity, which combined with local hemodynamic and/or inflammatory factors may have a role in aneurysm formation.Subjects with left ventricular dysfunction had higher levels of circulating ACE compared to those with normal left ventricular function, while there was no association between ACE and central hemodynamics. ACE might play a role in the pathogenesis of left ventricular dysfunction and our findings suggest a direct effect on the heart rather than affecting central blood pressure.
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