ESC Heart Failure receives its first impact factor

The European Society of Cardiology Heart Failure Association Annual Congress.

Longitudinal variations in maximal oxygen intake with age and activity.

Guidelines evaluate and summarize available evidence, with the aim of assisting health professionals in proposing the best diagnostic or therapeutic approach for an individual patient with a given condition. Guidelines are intended for use by health professionals and the European Society of Cardiology (ESC) makes its Guidelines freely available. ESC Guidelines do not override the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient or the patient’s caregiver where appropriate and/or necessary. It is also the health professional’s responsibility to verify the rules and regulations applicable in each country to drugs and devices at the time of prescription, and, where appropriate, to respect the ethical rules of their profession. ESC Guidelines represent the official position of the ESC on a given topic and are regularly updated. ESC Policies and Procedures for formulating and issuing ESC Guidelines can be found on the ESC website (https://www.escardio.org/Guidelines). The Members of this Task Force were selected by the ESC to represent professionals involved with the medical care of patients with this pathology. The selection procedure aimed to include members from across the whole of the ESC region and from relevant ESC Subspecialty Communities. Consideration was given to diversity and inclusion, notably with respect to gender and country of origin. The Task Force performed a critical evaluation of diagnostic and therapeutic approaches, including assessment of the risk-benefit ratio. The strength of every recommendation and the level of evidence supporting them were weighed and scored according to pre-defined scales as outlined below. The Task Force followed ESC voting procedures, and all approved recommendations were subject to a vote and achieved at least 75% agreement among voting members. The experts of the writing and reviewing panels provided declaration of interest forms for all relationships that might be perceived as real or potential sources of conflicts of interest. Their declarations of interest were reviewed according to the ESC declaration of interest rules and can be found on the ESC website (http://www.escardio.org/Guidelines), and have been compiled in a report published in a supplementary document with the guidelines. The Task Force received its entire financial support from the ESC without any involvement from the healthcare industry. The ESC Clinical Practice Guidelines (CPG) Committee supervises and co-ordinates the preparation of new guidelines and is responsible for the approval process. ESC Guidelines undergo extensive review by the CPG Committee and external experts, including members from across the whole of the ESC region and from relevant ESC Subspecialty Communities and National Cardiac Societies. After appropriate revisions, the guidelines are signed off by all the experts involved in the Task Force. The finalized document is signed off by the CPG Committee for publication in the European Heart Journal. The guidelines were developed after careful consideration of the scientific and medical knowledge and the evidence available at the time of their writing. Tables of evidence summarizing the findings of studies informing development of the guidelines are included. The ESC warns readers that the technical language may be misinterpreted and declines any responsibility in this respect. Off-label use of medication may be presented in the current Guidelines if a sufficient level of evidence shows that it can be considered medically appropriate for a given condition. However, the final decisions concerning an individual patient must be made by the responsible health professional giving special consideration to: The specific situation of the patient. Unless otherwise provided for by national regulations, off-label use of medication should be limited to situations where it is in the patient’s interest with regard to the quality, safety, and efficacy of care, and only after the patient has been informed and has provided consent. Country-specific health regulations, indications by governmental drug regulatory agencies, and the ethical rules to which health professionals are subject, where applicable.

Background The European Society of Cardiology (ESC) guidelines for the diagnosis and management of pericardial diseases identify predictive factors of poor prognosis and advise either in favour or against hospitalisation accordingly. Our aim is to evaluate the adequacy of hospitalisation criteria in a cohort of patients presenting to the emergency department (ED) with acute pericarditis. Methods Retrospective analysis of patients admitted in ED with acute pericarditis, from 2009 to 2019. All patients were evaluated by a cardiologist during ED stay who decided if the patient was to be discharged or hospitalized. Hospitalized and discharged patients were compared regarding primary outcome, defined by a composite of: need for pericardiocentesis and/or cardiac surgery, pericarditis recurrence and all-cause death. Clinical decision was then counterpoised with ESC guidelines. Results A total of 192 patients were included in the analysis (aged 46±18.5 years-old, 83.3% male) of which 87 (45.5%) were hospitalized. A total of 25% registered the primary outcome, mainly due to acute pericarditis recurrence, occurring in 21.9%. Predictors of recurrence were: glucocorticoid therapy (OR=11.93, 95% CI 3.13–45.5, p<0.001), fever at admission (OR=2.67, 95% CI 1.29–5.49, p=0.008), immunosuppression (OR=4.03, 95% CI 1.280–12.659, p=0.017) and increased cardiothoracic index (OR 3.85, CI 95% 1.67–8.86, p=0.002). Regarding hospitalisation/discharge decision, the ESC guidelines were respected in 72.9% of the cases. However, no significant difference in primary outcome was noted whether the ESC guidelines were respected or not (27.5% vs. 24.3%, p=0.707). Conclusions Discrepancy between current guidelines and clinical decision did not translate into a different outcome. Funding Acknowledgement Type of funding source: None

As an electrophysiologist, I am referred large numbers of patients with, or at risk of, arrhythmias as part of the heart failure complex. In this review I will concentrate on the role of pacemakers and defibrillators in heart failure, because these are my areas of greatest experience. Left ventricular assist devices and implantable hemodynamic monitors will not be reviewed. The first controversy for discussion is how to assess patients for suitability to receive these devices. Patients with heart failure are frequently fitted into a New York Heart Association (NYHA) class. The NYHA class is, however, a blunt instrument for decision-making that is based on a physician's or nurse's impression of how patients express their symptoms. Two patients with similar levels of symptomatology but with different responses to their symptoms may therefore receive different NYHA classifications and be candidates for different management approaches. Guidelines such as those from the European Society of Cardiology (ESC) offer valuable guidance on the use of cardiac resynchronization therapy (CRT).12 There are, however, issues in the use of CRT which the guidelines do not consider. Controversies that relate particularly to CRT include the identification of which patients benefit most from this technique and the characterization of its role in atrial fibrillation, in patients with bradycardia, and in non-responders. CRT has been available for approximately 10 years. An early meta-analysis of randomized controlled trials of CRT, including CONTAK-CD, InSync ICD, MIRACLE, and MUSTIC, showed that CRT reduced death from progressive heart failure by 51%, reduced heart failure hospitalization by 29%, and showed a trend to reduced all-cause mortality2 (Figures 12–3). Some of these trials included a defibrillator component, which made characterization of the effects of CRT alone problematic. Subsequent to these trials, the CARE-HF study was performed. CARE-HF observed that CRT produced a 37% reduction in all-cause mortality or unplanned hospitalization compared to medical therapy over 4 years (P < 0.0001)5 (Figure 4). All-cause mortality alone was reduced 36% by CRT when compared to optimal medical therapy (P = 0.0019). CARE-HT was the first major trial to demonstrate a definite improvement in all-cause mortality from CRT pacing. The COMPANION study included patients at higher risk than those in CARE-HF and investigated three treatment limbs – optimal pharmacological therapy, biventricular pacing, and biventricular defibrillation.3 COMPANION was not powered to detect a difference in outcome between the two types of biventricular device, but did appear to show that biventricular defibrillation was superior to medical therapy based on the secondary endpoint of all-cause mortality at 12 months (Figure 5). On the basis of these trials, the ESC guidelines recommend that “CRT using biventricular pacemakers can be considered [my italics] in patients with reduced ejection fraction and ventricular asynchrony (QRS width ≥120 ms) who remain symptomatic despite optimal medical therapy (NYHA III/IV) to improve symptoms, hospitalizations, and mortality”.12 From my viewpoint, this statement may require to be updated in the revised ESC guidelines and CRT should be performed much more commonly than presently. National guidelines from the Scottish Intercollegiate Guidelines Network (SIGN), which have been more produced recently (2007) than those from the ESC (2005), make a similar statement – namely, that CRT “should be considered” in patients with characteristics similar to those described in the ESC guidelines. The English National Institute for Clinical Excellence (NICE) Health Technology Appraisal of the place of CRT in heart failure (2007) states that: “CRT with a pacing device (CRT-P) is recommended as a treatment option for patients with heart failure who fulfill the following criteria. They are currently experiencing or have recently experienced NYHA class III-IV symptoms. They are in sinus rhythm either with a QRS duration 150 ms or longer … or with a QRS duration of 120–149 ms and mechanical dyssynchrony. They have a LVEF of 35% or less. They are receiving optimal pharmacological therapy.” The NICE guidelines therefore strongly recommend CRT for a precisely defined group of patients. The NICE guidelines also offer guidance on the use of CRT with a defibrillator (CRT-D). “CRT-D may be considered for people who fulfill the criteria for implantation of a CRT-P device and who separately fulfill the criteria for use of an ICD as recommended in NICE Technology Appraisal Guidance 95.” The latter criteria include wide QRS and poor LV function post-myocardial infarction. There is controversy over whether mechanical dyssynchrony is also required for the selection of patients for CRT. Considerable heterogeneity exists in the echocardiographic criteria adopted to define dyssynchrony, but a few small observational studies suggest that echocardiographic measurement of mechanical dyssynchrony may best identify patients who are likely to benefit from CRT.7 Further work is required in this area. What are the cost implications of using CRT-P and CRT-D? Based on data from the CARE-group using data from COMPANION, the incremental cost-effectiveness of CRT-P versus medical therapy was €7538 per quality-adjusted life-year (QALY), and the incremental cost-effectiveness of CRT-D versus CRT-P was €47 909.13 CRT-P was concluded to be relatively inexpensive, while CRT-D was of borderline cost-effectiveness. The patient's age comes into consideration in deciding who, among eligible patients, should receive CRT-D. In younger patients, CRT-D may be considered affordable in order to keep patients alive for as long as possible. In patients aged above 70 years, by contrast, other factors are more likely to cause death and the cost of CRT-D compared to CRT-P becomes prohibitive. The use of CRT in patients with atrial fibrillation (AF) is a contentious issue. The ESC guidelines do not specify a rhythm, but most other guidelines do specify the presence of sinus rhythm (SR) in their recommendations. Most trials have included only patients in SR, although the MUSTIC study included approximately equal numbers of patients in SR and AF. In MUSTIC, patients in SR improved significantly, whereas those in AF did not.4,8 For patients in SR, activation of the pacemaker was associated with an improvement in 6-min walking distance, which worsened when the device was inactivated. However, it is notable that only 37 of 64 patients in AF completed both limbs of the study. A long-term follow-up of patients in MUSTIC at 9 and 12 months found that all SR patients and 88% of AF patients were programmed to biventricular pacing.9 The two groups experienced similar magnitudes of improvement in walking distance, peak VO2, quality of life, NYHA class, and ejection fraction (Figure 6). Therefore, for every factor measured, AF patients appeared to do as well as SR patients in the long term. MUSTIC and some smaller studies represent the only trial evidence on which to base treatment in patients with AF. This raises the question of whether the potential benefits of CRT should be denied to AF patients in the absence of large-scale randomized studies. Opinions obtained from members of the Heart Rhythm UK suggest that most large centers are implanting CRT devices in a proportion of AF patients. There are two schools of thought on the type of AF patient who may benefit from CRT. In one school, CRT should be offered to the relatively small numbers of patients in whom rigorous rate control can be achieved by medical therapy and, if necessary, ablation of atrioventricular conduction to ensure biventricular pacing all of the time. According to the results of MUSTIC, this group may improve. This is called the “rate control” group. In the second school of thought, patients should be selected in whom stringent efforts will be made to restore and maintain SR. CRT may help by increasing the ejection fraction, lowering mitral regurgitation, and lowering left ventricular pressure. Cardioversion will be easier, and amiodarone and atrial catheter ablation may be added. This is called the “rhythm control” group. It is clear that the rate control group and the rhythm control groups encompass almost all patients with AF who fit CRT criteria. In other words, there is little agreement on which patients not to implant. Another controversial area is that, in every trial, there are patients classified as “non-responders”, who represent approximately 40% of the study population. In a proportion of these cases, however, the CRT device is stabilizing the patient who would otherwise deteriorate. Although the patient may complain of not feeling better, the device may actually be preventing deterioration or death. This situation illustrates the difficulty in measuring response. Other indices may need to be assessed, such brain natriuretic peptide levels, echocardiography/magnetic resonance imaging, and evidence of dyssynchrony, in order to identify patients who will benefit from CRT. CRT-D is an option in younger patients, especially those considered for future transplantation, while CRT-P may be provided in older patients to improve symptoms and reduce hospitalization. CRT-D may be considered in the presence of risk factors for sudden death, such as non-sustained ventricular tachycardia (VT) or T-wave alternans. The role of CRT-D in Class IV heart failure and AF requires clarification. Controversies that relate particularly to the use of implantable cardioverters-defibrillators (ICDs) include the identification of which patients will benefit from an ICD or from a CRT plus an ICD, whether the trial evidence for coronary artery disease can be extrapolated to dilated cardiomyopathy (DCM), and issues of deactivation at end of life. The ESC guidelines state that: “Implantation of an ICD in combination with biventricular pacing can be considered (my italics) in patients who remain symptomatic with severe heart failure (NYHA class III/IV) with LVEF [left ventricular ejection fraction] ≤35% and QRS duration >120 ms to improve morbidity or mortality”. “ICD therapy is recommended (my italics) to improve survival in patients who have survived cardiac arrest or who have sustained VT, which is either poorly tolerated or associated with reduced systolic LV function.” “ICD implantation is reasonable (my italics) in selected symptomatic patients with LVEF <30–35%, not within 40 days of a myocardial infarction, on optimal background therapy … to reduce sudden death.” The largest trial that has provided evidence to substantiate these statements is SCD-HeFT.1 SCD-HeFT randomized 2500 patients with symptomatic heart failure (NYHA II/III) and LVEF <35% to no antiarrhythmic therapy, amiodarone, or ICD with a 5-year follow-up. One half of the patients had an ischaemic etiology and one half had idiopathic DCM. Patients were relatively young (mean 60 years) and a proportion were overweight (mean 85 kg). Background medication use with an ACE inhibitor or angiotensin receptor blocker and beta-blocker was good, with rates approaching 90% and 80%, respectively, and use of spironolactone (31% at last follow-up) was reasonable. Loop diuretics were prescribed in the majority. Annual mortality over 5 years was 7.2% in the placebo group. Amiodarone had no influence on morality (hazard ratio [HR] 1.06. P = 0.529 vs placebo), but ICD significantly reduced the mortality rate (HR 0.77, P = 0.007 vs placebo) (Figure 7). Analysis of subgroups showed that the HR of mortality for ICD versus placebo was 0.54 in patients with NYHA II and 1.16 in those with NYHA class III, indicating that patients with Class II heart failure benefited while those with Class III tended to fare worse. Patients with an ischaemic or non-ischaemic etiology had HRs of 0.79 and 0.73, respectively, suggesting equal benefit from ICD. Further subgroup analyses indicated that patients with a low EF (≤30%) had the most to gain (HR 0.73, vs 1.08 for those with an EF >30%), as did those on beta-blocker therapy (HR 0.68, vs 0.92 for those not on beta-blocker therapy), which emphasizes that ICD therapy is not a substitute for good medical therapy. There have been problems in interpreting the outcomes of studies such as SCD-HeFT and MADIT-II.10 The reliance on subgroup analyses in these trials has reduced the power of these studies. Inaccuracies in measurement utilizing LVEF cutoff values and NYHA class has further hampered interpretation, and the relationship between the severity of the condition and the magnitude of improvement requires clarification. No “evidence base” exists on which to guide practice at end of life. Discussing these issues with the patient and relatives is difficult, but needs to be done openly and with sensitivity if any crisis or deterioration develops. Booklets and websites are a valuable source of information that patients can choose to look at, and base decisions on, at their own pace. In the UK, information for patients on websites is available from the British Heart Foundation (www.bhf.org) and the Arrhythmia Alliance (www.arrhythmiaalliance.org.uk). Primary prevention ICDs may be considered in stable heart failure patients who are already receiving optimal medical therapy. ICD should not be considered as a substitute for medical therapy. Ischaemic and non-ischaemic patients benefit equally from ICD, and the worse the LV function, the greater is the benefit. ICD may be considered as a bridge to transplant or, alternatively, as a means to keep the patient away from transplant.

AimsOur aim is to describe the clinical characteristics and management of patients hospitalized with acute heart failure (HHF) and ambulatory patients with chronic heart failure (CHF) in Egypt and compare them with heart failure (HF) patients from other countries in the European Society of Cardiology‐Heart Failure (ESC‐HF) registry.Methods and resultsThe ESC‐HF Long‐term Registry is a prospective, multi‐centre, observational study of patients presenting to cardiology centres in member countries of the ESC. From April 2011 to February 2014, a total of 2145 patients with HF were recruited from 20 centres all over Egypt. Of these patients, 1475 (68.8%) were hospitalized with HHF, while 670 (31.2%) had CHF. Less than one‐third (32.1%) of all patients were females. HHF patients {median age of 61 years [interquartile range (IQR), 53–69]} were older than CHF patients [median age of 57 years (IQR,46‐64)]; P < 0.0001. They had more diabetes mellitus (45.4% vs. 31.8%; P < 0.0001). Left ventricular ejection fraction > 45% was present in 22% of HHF vs. 25.6% of CHF (P = 0.17). Atrial fibrillation existed in about a quarter of all patients (24.5%). Ischaemic heart disease was the main cause of HF in Egyptian patients. All‐cause in‐hospital mortality was 5%. Egyptian patients presented at a much earlier age than in other regions in the registry. They had more diabetes mellitus. Atrial fibrillation prevalence was remarkably lower. Other co‐morbidities (renal dysfunction, stroke, and peripheral arterial disease) occurred less frequently.ConclusionPatients in the Egyptian cohort exhibited distinct features from HF patients in other countries in the ESC‐HF Long‐term Registry.

Influence of Article Type on the Impact Factor of Dermatology Journals

Update from the <i>Radiology</i> Editorial Office: 2020

Background Hypercholesterolemia is a major risk factor of cardiovascular disease (CVD) leading to premature death. The European Society of Cardiology (ESC) guideline on dyslipidemia recommends LDL cholesterol (LDL-C) targets based on individual risk of fatal CVD. This study aims to determine the proportion of individuals in a German population-based cohort with LDL-C levels above the ESC target level, with and without lipid-lowering medication. Methods The ‘Study of Health in Pomerania’ was conducted between 2008-2012 in Western Pomerania, Germany. We performed a descriptive analysis of CVD risk and lipid levels in 4,215 individuals aged 40-69 years. Individuals were classified into ESC risk categories (low, moderate, high, very high) based on comorbidities and cardiovascular history, with LDL-C targets of &amp;lt; 3.0, &amp;lt;2.6, and &amp;lt;1.8 mmol/L, respectively. Results Males (n = 1,997) had a mean LDL-C level of 3.45 mmol/L (CI 3.41-3.49 mmol/L), while females (n = 2,211) had a slightly higher mean level of 3.52 mmol/L (CI 3.48-3.56 mmol/L). Individuals not on lipid-lowering therapy (n = 3,634) had a mean LDL-C level of 3.59 mmol/L (CI 3.56-3.62), compared to 2.86 mmol/L (CI 2.79-2.92) for those on treatment (n = 574). Overall, 73% of the individuals missed their ESC LDL-C targets, and 58% of those already on treatment also missed their targets. Notably, over 90% of high and very high-risk individuals exceeded their targets. Conclusions The majority of individuals have LDL-C levels above the targets recommended by the ESC guidelines. An attempt to reach target values would necessitate a massive expansion and intensification in drug therapy. Given its uncertain benefits in primary prevention, it is crucial to reevaluate these thresholds. Key messages • There is a discrepancy between the ESC targets and actual population levels. • These targets need to be critically assessed in terms of their benefits, harms, feasibility and the implications of medicalizing the population.

We witnessed major advances in the management of heart failure (HF) in 2022. Results of recent clinical and preclinical investigations aid preventive strategies, diagnostic efforts, and therapeutic interventions, and collectively, they hold promises for a more effective HF care for the near future. Accordingly, currently available information extends the 2021 European Society of Cardiology guidelines and provides a solid background for the introduction of improved clinical approaches in the number of HF-related cases. Elaboration on the relationships between epidemiological data and risk factors lead to better understanding of the pathophysiology of HF with reduced ejection fraction and HF with preserved ejection fraction. The clinical consequences of valvular dysfunctions are increasingly interpreted not only in their haemodynamic consequences but also in association with their pathogenetic factors and modern corrective treatment possibilities. The influence of coronavirus disease 2019 pandemic on the clinical care of HF appeared to be less intense in 2022 than before; hence, this period allowed to refine coronavirus disease 2019 management options for HF patients. Moreover, cardio-oncology emerges as a new subdiscipline providing significant improvements in clinical outcomes for oncology patients. Furthermore, the introduction of state-of-the-art molecular biologic methods, multi-omic approaches forecast improved phenotyping and precision medicine for HF. All above aspects are addressed in this article that highlights a selection of papers published in ESC Heart Failure in 2022.

The British Society for Heart Failure (BSH) organized last March the 25in25 Summit, an event attended by global leaders who endorsed the 25in25 declaration. The wonderful aim of the 25in25 declaration is to decrease mortality rates associated with heart failure by 25% in the next 25 years.1 The 25in25 initiative will establish a comprehensive roadmap for national and international implementation and has received full endorsement from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). The HFA has already in place numerous initiatives that aim to improve the quality of life and longevity of individuals affected by heart failure. The HFA strives to accomplish this objective by promoting research, education, and guidelines for the prevention, diagnosis, and treatment of heart failure.2-5 It also seeks to raise awareness of heart failure and provide support to healthcare professionals, patients, and their families.6, 7 No question that prevention and early identification of individuals at risk of developing heart failure is crucial within the framework outlined above. Prevention is by far the most effective way to curtail the increasing burden of heart failure on public health services. Timely detection and intervention would decrease hospital admissions and release valuable resources. The 25in25 and Peptide for Life initiatives share a common goal of improving the early detection and management of heart failure. The Peptide for Life initiative of the HFA aims to increase awareness of heart failure and promote early access to and adoption of natriuretic peptide testing, which is critical for early diagnosis in primary care settings.8 This initiative is aligned with the goal of the 25in25 initiative to reduce mortality rates attributable to heart failure through improved detection and early management of heart failure. There are considerable differences in healthcare organization and available resources for managing heart failure across Europe.9 These disparities result in the uneven delivery of modern diagnostic modalities and guideline-directed therapies. Moreover, in many countries, there is a scarcity of dedicated institutions for heart failure management, which are inadequate to meet the increasing demand for specialized heart failure care. The HFA has recognized the importance of providing standardized multidisciplinary management of heart failure,10 which is also a goal of the 25in25 initiative. The HFA has also launched the iCARE project, as one of its strategic priorities. The primary aim of iCARE is to improve standards of care and adherence to guideline-directed therapies in accordance with ESC/HFA accreditation requirements. Yes, the establishment of the 25in25 initiative is a breath-taking step towards transforming the care and management of heart failure. By bringing together global leaders and experts in the field, this initiative aims to stimulate discussion and action towards more effective and successful heart failure management. With its ambitious goals and comprehensive roadmap for implementation, the 25in25 initiative has the potential to significantly reduce mortality rates attributable to heart failure and improve the quality of life for those affected by this disease. The work was funded by Italian Ministry of Health; Ricerca Corrente 20/1819.

IntroductionNational Institute for Health and Clinical Excellence (NICE) have removed the use of pre-test probability risk score (RS) in patients with new onset stable chest pain. They recommend computed tomography...

Background: Iron deficiency (ID) is common amongst patients with heart failure (HF). The European Society of Cardiology (ESC) guidelines recommends intravenous (IV) Iron supplementation in symptomatic HF patients with reduced left ventricular ejection fraction (LVEF) and ID to alleviate HF symptoms and improve quality of life. The current study aims to assess adherence to the latest ESC guidelines in treatment of ID in HF patients admitted to non-cardiac (outlier) wards at St. George's University Hospital (SGH), London. The results were compared to standard practice at a dedicated heart failure unit (HFU) at SGH. Methods: Retrospective data was collected on consecutive HF patients, admitted to SGH between September 2022 and September 2023. 386 patients met the inclusion criteria, defined as HF with LVEF &lt; 50% and ID according to ESC guidelines. Of total population, 190/386 patients were admitted to the outlier wards and 196/386 to the HFU. Patients considered ineligible for administration of IV Iron therapy, were those not meeting the guideline thresholds for treatment of ID, patients with active cancer or bleeding and patients on oral Iron supplementation. Results: The mean age of patients admitted to HFU was 71 +/- 13 SD, 66% male. 72% (141/196) of the patients were tested for ID, of which 51% (72/141) had ID as per inclusion criteria. 57% (41/72) of those with ID were prescribed IV Iron, whilst 43% (31/72) were not treated. The reason for not treating patients identified as Iron deficient was presence of active infection (19/31) or bleeding (3/31). In 9/31 of untreated patients with ID, the reason for not being prescribed with IV Iron was not identifiable through review of medical notes. It is important to note that 28% (55/196) were not tested for ID during their hospitalisation and missed the opportunity for treatment. (Figure 1) In outlier wards, mean age was 77 +/- 14 SD, 66% male. 46% (87/190) patients were tested for ID, of which 16% (14/87) were identified as Iron deficient and were prescribed IV Iron. 4% (12/87) were not treated for no obvious reason and 18% (16/87) met the criteria for ID, but due to presence of contraindication did not receive IV Iron. Missed opportunity was 54% in outlier population. (Figure 2) Conclusion: This study demonstrated that patients admitted to HFU, were more likely to be tested for ID and receive IV Iron, compared to patients admitted to outlier wards but there is still room for considerable improvement in both settings.

BackgroundN-terminal pro-brain natriuretic peptide (NT-proBNP) is a valuable biomarker for diagnosis and prognosis of heart failure in adults, included into the European Society Guidelines for heart failure (2016).1 It is...

Background: Whether the journal impact factor (JIF) indicator reflects the number of citations to an average article of a journal in different subject categories is controversial. We sought to further investigate this issue in general and internal medicine journals.Methods: We selected to evaluate three journals of the above subject category, in each of three different JIF levels (high: 15.5–28.6, moderate: 4.4–4.9 and low: 1.6). Using the Scopus database, we retrieved the original research articles (after detailed screening) and review articles (as classified by Scopus) that were published in the selected journals in 2005 along with the number of citations they received in 2006 and 2007. We pooled the citations for articles of the same type in journals with the same JIF level into distinct variables.Results: There was no marked association between the distribution of citations per article published in general medical journals and their JIF. All distributions studied were skewed to the right (higher number of citations). Specifically, 16–22% of the original research articles accounted for 50% of the total citations to this type of article for all three categories of studied journals; 34–37% of original research articles accounted for 75% of citations. The respective values for review articles were 12–18% and 29–39%.Conclusion: The distribution of citations received by articles published in high, moderate and low impact factor journals in clinical medicine seems similar. The JIF is not an accurate indicator of the citations the average article receives; articles published in low impact factor journals can still be highly cited and vice versa.