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New England Journal of Medicine


Heartbeat: Primary care delays in heart failure diagnosis
Most patients with new-onset heart failure (HF) will present to a primary care provider with symptoms of fatigue, breathlessness and ankle swelling. Diagnosis can be challenging given the nonspecific nature and frequency of these symptoms in the general population as well as time constraints and competing primary care issues. In an effort to understand current adherence to recommended pathways for diagnosis of HF in primary care, Hayhoe and colleagues1 linked primary and secondary care data from the UK Clinical Practice Datalink. Of the over 42 thousand patients diagnosed with HF over a 4 year time period, about 40% presented to a primary care provider with HF symptoms. However, only 39% underwent echocardiography or a serum natriuretic peptide test, with an average delay of almost 10 months from symptom onset to diagnostic testing and a total delay from symptoms to HF treatment over 2 years. (figure 1)...
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Diagnosing heart failure: challenges in primary care
Heart failure (HF) is a common, costly and treatable clinical syndrome.1 2 Over 920 000 people in England are living with the condition and 3%–4% of the National Health Service (NHS) budget is spent on HF services.3 Large clinical trials have established the clinical and cost-effectiveness of disease-modifying drugs and device therapies in improving quality of life, reducing hospitalisations and increasing survival for patients with HF with reduced ejection fraction.4 5 The same prognostic benefit was not seen in HF with preserved ejection fraction but diagnosis remains important to explain patients’ symptoms. In both types of HF, diuretics are effective in reducing fluid overload and exercise-based cardiac rehabilitation is beneficial once patients are stable. Timely and accurate diagnosis is key to accessing appropriate, evidence-based treatment. People with HF initially experience symptoms of breathlessness, fatigue and ankle swelling which progress over...
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JACC Instructions for Authors
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Child Health Promotion in Underserved Communities: The FAMILIA Trial
AbstractBackground Preschool-based interventions offer promise to instill healthy behaviors in children, which can be a strategy to reduce the burden of cardiovascular disease later. However, their efficacy in underserved communities is not well established. Objectives The purpose of this study was to assess the impact of a preschool-based health promotion educational intervention in an underserved community. Methods This cluster-randomized controlled study involved 15 Head Start preschools in Harlem, New York. Schools and their children were randomized 3:2 to receive either a 4-month (50 h) educational intervention to instill healthy behaviors in relation to diet, physical activity, body/heart awareness, and emotion management; or their standard curriculum (control). The primary outcome was the change from baseline in the overall knowledge, attitudes, and habits (KAH) score of the children at 5 months. As secondary outcomes, we evaluated the changes in KAH subcomponents and emotion comprehension. Linear mixed-effects models were used to test for intervention effects. Results The authors enrolled 562 preschool children age 3 to 5 years, 51% female, 54% Hispanic/Latino, and 37% African-American. Compared with the control group, the mean relative change from baseline in the overall KAH score was ~2.2 fold higher in the intervention group (average absolute difference of 2.86 points; 95% confidence interval: 0.58 to 5.14; p = 0.014). The maximal effect was observed in children who received >75% of the curriculum. Physical activity and body/heart awareness components, and knowledge and attitudes domains, were the main drivers of the effect (p values <0.05). Changes in emotion comprehension trended toward favoring intervened children. Conclusions This multidimensional school-based educational intervention may be an effective strategy for establishing healthy behaviors among preschoolers from a diverse and socioeconomically disadvantaged community. Early primordial prevention strategies may contribute to reducing the global burden of cardiovascular disease. (Family-Based Approach in a Minority Community Integrating Systems-Biology for Promotion of Health [FAMILIA]; NCT02343341)
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Primordial Prevention of Cardiovascular Disease in Childhood: The Time Is Now
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Association of Skipping Breakfast With Cardiovascular and All-Cause Mortality
AbstractBackground Skipping breakfast is common among U.S. adults. Limited evidence suggests that skipping breakfast is associated with atherosclerosis and cardiovascular disease. Objectives The authors sought to examine the association of skipping breakfast with cardiovascular and all-cause mortality. Methods This is a prospective cohort study of a nationally representative sample of 6,550 adults 40 to 75 years of age who participated in the National Health and Nutrition Examination Survey III 1988 to 1994. Frequency of breakfast eating was reported during an in-house interview. Death and underlying causes of death were ascertained by linkage to death records through December 31, 2011. The associations between breakfast consumption frequency and cardiovascular and all-cause mortality were investigated by using weighted Cox proportional hazards regression models. Results Among the 6,550 participants (mean age 53.2 years; 48.0% male) in this study, 5.1% never consumed breakfast, 10.9% rarely consumed breakfast, 25.0% consumed breakfast some days, and 59.0% consumed breakfast every day. During 112,148 person-years of follow-up, 2,318 deaths occurred including 619 deaths from cardiovascular disease. After adjustment for age, sex, race/ethnicity, socioeconomic status, dietary and lifestyle factors, body mass index, and cardiovascular risk factors, participants who never consumed breakfast compared with those consuming breakfast everyday had hazard ratios of 1.87 (95% confidence interval: 1.14 to 3.04) for cardiovascular mortality and 1.19 (95% confidence interval: 0.99 to 1.42) for all-cause mortality. Conclusions In a nationally representative cohort with 17 to 23 years of follow-up, skipping breakfast was associated with a significantly increased risk of mortality from cardiovascular disease. Our study supports the benefits of eating breakfast in promoting cardiovascular health.
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Heart Rhythm