Rationale and design of the CAREFUL study

Background. Sudden cardiac death (SCD) in the young (1-45 years) is a strong risk factor for the presence of inherited cardiac diseases in surviving first-degree relatives. Postmortem investigation of the victim and cardiogenetic evaluation of the first-degree relatives is indicated to detect inherited cardiac diseases and treat relatives at an early stage to prevent SCD. In the Netherlands, postmortem investigation is often not performed and relatives of SCD and sudden unexplained death (SUD) victims are rarely evaluated for inherited cardiac diseases. Methods. A prospective population-based follow-up study carried out in two intervention regions and two control regions. In the intervention regions a comprehensive intervention (stimulate autopsy and storage of victims DNA and the referral of first-degree relatives for cardiogenetic evaluation) is applied in a ‘top down’ and ‘bottom up’ mode. In each region, young sudden death victims are registered and for all cases performance of autopsy and evaluation of relatives in a cardiogenetics outpatient clinic will be determined. Expected results. The study will provide information on the incidence of sudden death in the young and the proportion of diagnosed inherited cardiac diseases. Moreover, the additional value of the introduction of two different preventive strategies directed at early detection of inherited cardiac diseases in first-degree relatives to usual care will be evaluated. Conclusion. The CAREFUL study will help to set a new standard of care in the evaluation of young sudden death victims and their relatives to identify the presence of inherited cardiac diseases, in order to prevent sudden death. (Neth Heart J 2010;18:286-90.)     

The challenge of choosing in cardiovascular risk management

Netherlands Heart Journal - Cardiovascular disease (CVD) is a major cause of morbidity and mortality worldwide. For many years guidelines have listed optimal preventive therapy. More...     

Clinical implementation of guidelines for cardioverter defibrillator implantation: lost in translation?

Purpose: Guidelines for implantation of cardioverter defibrillators (ICD) are increasingly including indications for primary prevention of sudden cardiac death in high-risk groups, where ICDs were traditionally implanted for secondary prevention. We performed a single-centre audit to evaluate adherence to the recent Dutch guidelines. Methods: All 1886 patients visiting a large regional Dutch teaching hospital (attending 1.8 to 2.0% of the Dutch population) in November 2005 were screened using the recently updated Dutch guidelines. Patients fulfilling these criteria were categorised as having an ICD indication for primary or secondary prevention. Results: 135 patients had an indication for ICD, 19 of whom had one or received one. Of the remaining 116 patients, 14 were ‘new’ to the department of cardiology. The 102 ‘known’ patients had 466 doctor-patient contacts in the previous year, which averages 4.57 cardiology contacts per patient per year. Patients were more likely to receive an ICD for the secondary prevention of SCD (10/11, 91%) than for primary prevention (9/124, 7%). Conclusion: In a large regional teaching hospital in the Netherlands, only a small proportion of patients eligible for ICD implantation actually receive one. Cardiologists tend to implant ICDs for secondary prevention of SCD. The low ICD implantation rate for primary prevention of SCD may relate to logistics (e.g. permission to implant ICDs, the presence of an electrophysiology lab) or the perceived low cost-benefit ratio. Our results indicate that once the substantial backlog (13,500 ICDs) has been addressed, the annual implantation of new ICDs should rise from the current 125 to at least 510 per million inhabitants per year in the Netherlands. (Neth Heart J 2007;15:129-32.)     

AV blocking due to asynchronous vagal stimulation in rats

The parasympathetic nervous system innervates the heart through two cervical vagal branches. The right vagal branch mainly influences the heart rate by the modulation of the rhythmogenesis of the sinoatrial node. The left branch predominantly influences the conduction properties of the atrioventricular (AV) node. We investigated the effect of asynchronous stimulation by the vagal nerves on the occurrence of irregularities in heart rate. In rats, the vagal nerves were isolated and cut. Different vagal stimulation patterns (continuous, pulsed) were applied. The heart was beating spontaneously under continuous vagal stimulation. In case of pulsed vagal stimulation, the atria were paced at different rates. Asynchronicity was induced by delaying the right stimulus with respect to the left stimulus (early right) or the left stimulus with respect to the right stimulus (early left). The value of the fraction of deviated R-R or P-Q intervals in the distribution in the histogram was used to characterize irregularities during a stimulation protocol (duration in case of continuous stimulation: 20 s; pulsed stimulation: 120 s). Under both stimulation patterns (continuous or pulsed), we found that early left vagal stimulation introduced a much larger fraction of deviated intervals in the R-R or P-Q histogram (in R-R: 29.1 +/- 4.9%; in P-Q: 12.90 +/- 1.95%) than early right vagal stimulation (in R-R: 7.4 +/- 2.0%; in P-Q: 1. 05 +/- 0.50%) or synchronous stimulation (in R-R: 8.2 +/- 3.6%; in P-Q: 2.15 +/- 0.75%). We conclude that early stimulation by the left vagal nerve can introduce irregularities in heart rate, mainly due to different degrees of AV nodal blockade.     

Aging, physical conditioning, and exercise-induced changes in hemostatic factors and reaction products.

The influence of age on training-induced changes in resting and stimulated hemostatic potential was studied in three age categories (Cat I-III; 20-30 yr, 35-45 yr, and 50-60 yr, respectively) of sedentary men before and after 12 wk of training. Coagulation, fibrinolytic activity, and activation markers (reflecting fibrin formation and degradation) were determined. Physical conditioning resulted in a more pronounced increase in von Willebrand factor (vWF) and factor VIII clotting activity (FVIII:c) in Cat I and II and a more pronounced shortening of the activated partial thromboplastin time in all categories at maximal exertion and during recovery. Enhanced increases in tissue-type plasminogen activator (t-PA) antigen and activity and single-chain (sc) urokinase-type plasminogen activator (u-PA) at maximal exercise and 5 min of recovery were observed in all age groups after training. The effects on FVIII:c, vWF, and scu-PA were most pronounced in the youngest age group (Cat I). Increases in the marker of thrombin generation were highest in Cat III; no effect was seen on thrombin-antithrombin complex, plasmin-antiplasmin complex, and D-dimer in any of the age groups. We concluded that training enhances both coagulation and fibrinolytic potential during strenuous exercise. The effect on FVIII/vWF and t-PA/u-PA is most pronounced in younger individuals, whereas thrombin formation is most pronounced in older individuals.     

One-year mortality after a first visit to a cardiology outpatient clinic: a useful performance indicator?

Purpose In 2003 the Dutch Health Care Inspectorate introduced performance indicators to monitor and compare quality of care in Dutch hospitals. In 2007, the new performance indicator ‘one-year mortality after a first visit to a cardiology outpatient clinic’ was introduced. We set out to evaluate this new indicator in three Dutch teaching hospitals. Methods Using electronic medical records, information was collected retrospectively of patients aged ≥70 years who visited the cardiology outpatient clinic of Medical Centre Alkmaar, Meander Medical Centre Amersfoort and Deventer Hospital between 1 January 2006 and 31 January 2006. Diagnoses were based on the diagnosis treatment combination (DBC) coding system. Results 547 patients (mean age 78.0 years, 53% men) were included, 35 (6.4%) of whom had died after one year. Cardiovascular disease was the most frequent cause of death (22/35, 62.9%). The oneyear mortality among the three hospitals varied from 5.0 to 7.3% (NS). Conclusion One-year mortality after the first visit to a cardiology outpatient clinic amounted to 6.4% in patients aged ≥70 years and did not differ significantly between the three Dutch teaching hospitals. The administrative load to obtain the necessary information was considerable. One-year mortality should be regarded as an ‘outcome’ parameter rather than a ‘performance’ indicator. (Neth Heart J 2009;17:52-5.)     

Nationwide claims data validated for quality assessments in acute myocardial infarction in the Netherlands

Introduction

Since health insurance is compulsory in the Netherlands, the centrally registered medical claims data might pose a unique opportunity to evaluate quality of (cardiac) care on a national level without additional collection of data. However, validation of these claims data has not yet been assessed.

Design

Retrospective cohort study.

Methods

National claims data (‘national registry’) were compared with data collected by patient records reviews in four representative hospitals (‘validation registry’). In both registries, we extracted the national diagnosis codes for ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction of 2012 and 2013. Additionally, data on medication use at one year after acute myocardial infarction (AMI) was extracted from the Dutch pharmacy information systems and also validated by local patient records reviews. The data were compared at three stages: 1) validation of diagnosis and treatment coding; 2) validation of the hospital where follow-up has taken place; 3) validation of follow-up medical treatment after 365 days.

Results

In total, 3,980 patients (‘national registry’) and 4,014 patients (‘validation registry’) were compared at baseline. After one-year follow-up, 2,776 and 2,701 patients, respectively, were evaluated. Baseline characteristics, diagnosis and individual medication were comparable between the two registries. Of all 52,672 AMI patients in the Netherlands in 2012 and 2013, 81% used aspirin, 76% used P2Y12 inhibitors, 85% used statins, 82% used beta-blockers and 74% angiotensin converting enzyme inhibitors/angiotensin II antagonists. Optimal medical treatment was achieved in 49% of the patients with AMI.

Conclusion

Nationwide routinely collected claims data in patients with an acute myocardial infarction are highly accurate. This offers an opportunity for use in quality assessments of cardiac care.

     

The SPORTCOR registry: a national databank for sports cardiology

Being physically active is generally regarded as the best buy to prevent (cardiovascular) disease. Although the positive effects of regular exercise prevail, negative aspects of sports activity, particularly sportsrelated injuries, should not be ignored. Sudden cardiac death can be regarded as the most tragic sports-related injury.     

Targeting residual inflammatory risk in coronary disease: to catch a monkey by its tail

Netherlands Heart Journal - Patients with coronary disease remain at high risk for future cardiovascular events, even with optimal risk factor modification, lipid-lowering drugs and antithrombotic...     

Physical training in patients with chronic heart failure: An elaboration of the statements from the Committee on Cardiac Rehabilitation of the Netherlands Society of Cardiology and the Netherlands Heart Foundation and review of studies on physical training in chronic heart failure

Chronic heart failure (CHF) can be defined as a complex of symptoms and signs caused by cardiac dysfunction. Dyspnoea on exertion, fatigue, reduced exercise tolerance and fluid retention are hallmarks of the syndrome.Reduced peripheral blood flow, endothelial dysfunction, alterations in skeletal muscle structure and function, an increased activity of the muscle ergoreflex, as well as autonomic and neurohormonal activation reduce exercise performance, ultimately leading to physical deconditioning in CHF patients.The beneficial effects of physical training for CHF patients are increasingly acknowledged. Based on European and American guidelines on physical training in CHF, results from controlled randomised trials (summarised in this paper) and expert opinions, the Dutch Committee on Cardiac Rehabilitation has formulated statements on physical training in CHF.In addition, recommendations implementing physical training programmes in CHF patients are given. The selection criteria, contraindications and methods, and duration of a physical training programme in heart failure are discussed. Concomitant with the training programme, a multidisciplinary intervention programme is needed to stimulate patients to adopt and maintain an active and healthy lifestyle.