AimsDiagnosis of heart failure in older people in long-term care is challenging because of co-morbidities, cognitive deficit, polypharmacy, immobility, and poor access to services. This study aimed to ascertain heart failure prevalence and clinical management in this population.Methods and resultsA total of 405 residents, aged 65–100 years, in 33 UK care facilities were prospectively enrolled between April 2009 and June 2010. The presence of heart failure was determined using European Society of Cardiology guidelines, modified where necessary for immobility. Evaluation of symptoms and signs, functional capacity, and quality of life, portable on-site echocardiography, and medical record review were completed in 399 cases. The point prevalence of heart failure was 22.8% [n = 91, 95% confidence interval (CI) 18.8–27.2%]; of these, 62.7% (n = 57, 95% CI 59.6–66.5%) had heart failure with preserved ejection fraction and 37.3% had left ventricular systolic dysfunction (n = 34, 95% CI 34.8–40.5%). A total of 76% (n = 61) of previous diagnoses of heart failure were not confirmed, and up to 90% (n = 82) of study cases were new. No symptoms or signs were reliable predictors of heart failure.ConclusionHeart failure was diagnosed in almost a quarter of residents: the prevalence was substantially higher than in other populations. The majority of heart failure cases were undiagnosed, while three-quarters of previously recorded cases were misdiagnosed. Common symptoms and signs appear to have little clinical utility in this population. Early, accurate differential diagnosis is key to the effective management of heart failure; this may be failing in long-term care facilities.Trial registrationISRCTN19781227

BackgroundThe performance of biomarkers for heart failure (HF) in older residents in long-term care is poorly understood and has not differentiated between left ventricular systolic dysfunction (LVSD) and HF with preserved ejection fraction (HFpEF).MethodsThis is the first diagnostic accuracy study in this population to assess the differential diagnostic performance and acceptability of a range of biomarkers against a clinical diagnosis using portable echocardiography. A total of 405 residents, aged 65–100 years (mean 84.2), in 33 UK long-term care facilities were enrolled between April 2009 and June 2010.ResultsFor undifferentiated HF, BNP or NT-proBNP were adequate rule-out tests but would miss one in three cases (BNP: sensitivity 67%, NPV 86%, cut-off 115 pg/ml; NT-proBNP: sensitivity 62%, NPV 87%, cut-off 760 pg/ml). Using higher test cut-offs, both biomarkers were more adequate tests of LVSD, but would still miss one in four cases (BNP: sensitivity 76%, NPV 97%, cut-off 145 pg/ml; NT-proBNP: sensitivity 73%, NPV 97%, cut-off 1000 pg/ml). At these thresholds one third of subjects would test positive and require an echocardiogram. Applying a stricter ‘rule out’ threshold (sensitivity 90%), only one in 10 cases would be missed, but two thirds of subjects would require further investigation. Biomarkers were less useful for HFpEF (BNP: sensitivity 63%, specificity 61%, cut-off 110 pg/ml; NT-proBNP: sensitivity 68%, specificity 56%, cut-off 477 pg/ml). Novel biomarkers (Copeptin, MR-proADM, and MR-proANP) and common signs and symptoms had little diagnostic utility.ConclusionsNo test, individually or in combination, adequately balanced case finding and rule-out for heart failure in this population; currently, in-situ echocardiography provides the only adequate diagnostic assessment.Trial RegistrationControlled-Trials.com ISRCTN19781227

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Abstract:The most common cause of pulmonary hypertension (PH) due to left heart disease (LHD) was previously rheumatic mitral valve disease. However, with the disappearance of rheumatic fever and an aging population, nonvalvular LHD is now the most common cause of group 2 PH in the developed world. In this review, we examine the challenge of investigating patients who have PH and heart failure with preserved ejection fraction (HF-pEF), where differentiating between pulmonary arterial hypertension (PAH) and PH-LHD can be difficult, and also discuss the entity of combined precapillary and postcapillary PH. Given the proven efficacy of targeted therapy for the treatment of PAH, there is increasing interest in whether these treatments may benefit selected patients with PH associated with HF-pEF, and we review current trial data.Keywords: pulmonary arterial hypertension, combined pre-and postcapillary pulmonary hypertension, heart failure with preserved ejection fraction, diastolic dysfunction. (Table 1) by a mean pulmonary arterial pressure (PAP) of ≥25 mmHg at right heart catheterization (RHC), with the most recent classification identifying 5 groups (Fig. 1): 2 group 1, pulmonary arterial hypertension (PAH), which can be idiopathic (IPAH) or associated with other conditions (most frequently systemic sclerosis and congenital heart disease); group 2, PH owing to left heart disease (PH-LHD); group 3, PH owing to lung disease (PH-Lung); group 4, chronic thromboembolic PH (CTEPH); and group 5, PH owing to unclear or multifactorial mechanisms. Accurate classification of disease is important in identifying the most appropriate form of therapy 3 and defining prognosis. 4 This requires a systematic approach to the evaluation of the breathless patient and an awareness of conditions associated with particular forms of PH. Pulmonary hypertension (PH) is definedThe most commonly encountered form of PH is related to left heart disease (LHD). 5,6 PH may be seen in heart failure with preserved ejection fraction (HF-pEF) and heart failure with reduced ejection fraction (HF-rEF), and its presence in HF-rEF is known to convey a poor prognosis. 7 HF-pEF accounts for approximately half of all new heart failure (HF) diagnoses. 8,9 While HF-pEF was initially believed to confer a better outcome than HF-rEF, the two conditions have equivalent morbidity and mortality. [10][11][12] The prevalence of PH-HF-pEF is unclear and varies with diagnostic criteria. Studies quote rates of between 53% and 83% (based on an echocardiographic systolic PAP [sPAP] > 35 mmHg or mean PAP > 25 mmHg at RHC). 13-15 A recent study 16 found that only 7% of heart failure (HF) patients had PH (but used an sPAP cutoff of ≥45 mmHg at echocardiography). PATHOPHYSIOLOGY OF PH-LHDPAH, PH-Lung, and CTEPH are precapillary in nature, caused by obstruction or destruction of the pulmonary arterial bed, whereas PH-LHD is thought to be primarily due to postcapillary abnormalities. 5 In patients with LHD, an increase in left ventricular (LV) and left atrial (LA) filling pressu...