Comparison of incidences of congestive heart failure in older African-Americans, Hispanics, and whites

Medical therapies for prevention of cardiovascular and renal events in patients with atrial fibrillation and diabetes mellitus

Atrial fibrillation (AF), type 2 diabetes mellitus (DM), and chronic kidney disease (CKD) are three global epidemics with significant effects on morbidity and mortality. Diabetes is a risk factor for AF, and a risk factor for thromboembolism, comorbidity, and mortality when AF is present. The pathophysiology of diabetes-related AF and interrelationships with cardiovascular events and renal events is not fully understood but is in part related to structural, electrical, electromechanical, and autonomic remodelling. The current practice guidelines offer limited recommendations on the management of patients with AF (or risk of AF) and diabetes with its own heterogeneity for the prevention of cardiovascular and renal events. This document discusses possible clinical approaches for these patients. In the last decade, there have been major improvements for the prevention of stroke in AF patients with direct oral anticoagulants, which are preferable to vitamin K antagonists for stroke prevention in DM. Because of the increased risk rate for several cardiovascular adverse events in diabetic patients, a similar relative risk reduction generally translates into greater absolute risk reduction in the diabetic population. Recent trials with non-insulin diabetes drugs using glucagon-like peptide-1 agonists and sodium-glucose cotransporter-2 inhibitors showed a significant reduction for the risk of major adverse cardiovascular events in patients with type 2 DM. Sodium-glucose cotransporter-2 inhibitors also showed a large reduction in hospitalization for heart failure and renal events, which need to be more completely evaluated in patients with AF. Mechanisms, risks, and optimal management of AF patients with DM who have or are under risk of developing heart failure or CKD are also discussed in this document. The benefits of medical therapies for these patients still need to be put into perspective, and gaps in evidence on some of these issues are likely to be addressed in future years.

Prognosis and outcome determinants after heart failure diagnosis in patients who underwent aortic valvular intervention

AIMS

To study clinical phenotype, prognosis for all-cause and cardiovascular (CV) mortality and predictive factors in patients with incident heart failure (HF) after aortic valvular intervention (AVI) for aortic stenosis (AS).

METHODS AND RESULTS

In this retrospective, observational study we included patients from the Swedish Heart Failure Registry (SwedeHF) recorded 2003-2016, with AS diagnosis and AVI before HF diagnosis. The AS diagnosis was established according to International Classification of Diseases 10th revision (ICD-10) codes, thus without information concerning clinical or echocardiographical data on the aortic valve disease. The patients were divided into two subgroups: left ventricular ejection fraction (LVEF) ≥ 50% (AS-HFpEF) and <50% (AS-HFrEF). We individually matched three controls with HF from the SwedeHF without AS (control group) for each patient. Baseline characteristics, co-morbidities, survival status and outcomes were obtained by linking the SwedeHF with two other Swedish registries. We used Kaplan-Meier curves to present time to all-cause mortality, cumulative incidence function for time to CV mortality and Cox proportional hazards model to evaluate the relative difference between AS-HFrEF and AS-HFpEF and AS-HF and controls. The crude all-cause mortality was 49.0%, CV mortality 27.9% in AS-HF patients, respectively 44.7% and 26.6% in matched controls. The adjusted risk for all-cause mortality and CV mortality was similar in HF, regardless of LVEF vs. controls. No significant difference in factors predicting higher all-cause mortality was observed in AS-HFrEF vs. AS-HFpEF, except for diabetes (only in AS-HFrEF), with statistically significant interaction predicting death between the two groups.

CONCLUSIONS

In this nationwide SwedeHF study, we characterized incident HF population after AVI. We found no significant differences in all-cause and CV mortality compared with general HF population. They had virtually the same predictors for mortality, regardless of LVEF.

Diabetes mellitus and risk of new-onset and recurrent heart failure: a systematic review and meta-analysis

Despite mounting evidence of the positive relationship between diabetes mellitus (DM) and heart failure (HF), the entire context of the magnitude of risk for HF in relation to DM remains insufficiently understood. The principal reason is because new‐onset HF (HF occurring in participants without a history of HF) and recurrent HF (HF re‐occurring in patients with a history of HF) are not discriminated. This meta‐analysis aims to comprehensively and separately assess the risk of new‐onset and recurrent HF depending on the presence or absence of DM. We systematically searched cohort studies that examined the relationship between DM and new‐onset or recurrent HF using EMBASE and MEDLINE (from 1 Jan 1950 to 28 Jul 2019). The risk ratio (RR) for HF in individuals with DM compared with those without DM was pooled with a random‐effects model. Seventy‐four and 38 eligible studies presented data on RRs for new‐onset and recurrent HF, respectively. For new‐onset HF, the pooled RR [95% confidence interval (CI)] of 69 studies that examined HF as a whole [i.e. combining HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF)] was 2.14 (1.96–2.34). The large between‐study heterogeneity (I² = 99.7%, P < 0.001) was significantly explained by mean age [pooled RR (95% CI) 2.60 (2.38–2.84) for mean age < 60 years vs. pooled RR (95% CI) 1.95 (1.79–2.13) for mean age ≥ 60 years] (P < 0.001). Pooled RRs (95% CI) of seven and eight studies, respectively, that separately examined HFpEF and HFrEF risk were 2.22 (2.02–2.43) for HFpEF and 2.73 (2.71–2.75) for HFrEF. The risk magnitudes between HFpEF and HFrEF were not significantly different in studies that examined both HFpEF and HFrEF risks (P = 0.86). For recurrent HF, pooled RR (95% CI) of the 38 studies was 1.39 (1.33–1.45). The large between‐study heterogeneity (I² = 80.1%, P < 0.001) was significantly explained by the proportion of men [pooled RR (95% CI) 1.53 (1.40–1.68) for < 65% men vs. 1.32 (1.25–1.39) for ≥65% men (P = 0.01)] or the large pooled RR for studies of only participants with HFpEF [pooled RR (95% CI), 1.73 (1.32–2.26) (P = 0.002)]. Results indicate that DM is a significant risk factor for both new‐onset and recurrent HF. It is suggested that the risk magnitude is large for new‐onset HF especially in young populations and for recurrent HF especially in women or individuals with HFpEF. DM is associated with future HFpEF and HFrEF to the same extent.

Diabetes Mellitus Is an Independent Predictor for the Development of Heart Failure: A Population Study

OBJECTIVES

To delineate the impact of diabetes mellitus (DM) on the development of cardiovascular diseases in a community population.

PATIENTS & METHODS

Cross-sectional survey of residents randomly selected through the Rochester Epidemiology Project, 45 years or older, of Olmsted County as of June 1, 1997, through September 30, 2000. Responders (2042) underwent assessment of systolic and diastolic function using echocardiography. The current analyses included all participants with DM and were compared with a group of participants without DM matched 1:2 for age, sex, hypertension, and coronary artery disease. Baseline characteristics and laboratory and echocardiography findings between groups were compared along with rates of mortality due to various cardiovascular conditions.

RESULTS

We identified 116 participants with DM and 232 matched participants without DM. Those with DM had a higher body mass index and plasma insulin and serum glucose levels. Although left ventricular ejection fractions were similar, E/e' ratio (9.7 vs 8.5; P=.001) was higher in DM vs non-DM. During a follow-up of 10.8 (interquartile range, 7.8-11.7) years, participants with DM had a higher incidence of heart failure (HF); hazard ratio, 2.1; 95% confidence limits, 1.2-3.6; P=.01) and 10-year Kaplan-Meier rate of 21% (22 of 116) vs 12% (24 of 232) compared with those without DM. We also examined the subgroup of participants without diastolic dysfunction. In this subgroup, those with DM had an increased risk for HF; hazard ratio, 2.5; 95% confidence limits, 1.0-6.3; P=.04).

CONCLUSION

In this cohort, participants with DM have an increased incidence of HF over a 10-year follow-up period even in the absence of underlying diastolic dysfunction. These findings suggest that DM is an independent risk factor for the development of HF and supports the concept of DM cardiomyopathy.

Influence of Race in the Association of Diabetes and Heart Failure

Heart failure is a global public health problem with high mortality and readmission rates. Race and ethnicity are useful concepts when attempting to understand differential health risks and health disparities. With cardiovascular diseases accounting for most deaths globally, eliminating racial disparities in cardiac care has become a new challenge in cardiology. Significant racial differences exist in patients with heart failure. African American patients in the US have a significantly higher incidence of heart failure, lower ejection fraction and are younger at presentation compared to White, Hispanic and Chinese American patients. These findings are explained by a higher burden of risk factors such as diabetes mellitus, hypertension, obesity and lower household incomes among African Americans. The authors believe that these findings are applicable to other racial groups across the globe. The prevalence of predisposing risk factors probably has a stronger influence on the incidence of heart failure than the racial factor alone. The interaction between race and diabetes mellitus has important public health implications for the management and prevention of heart failure.

Prediction and Subtyping of Hypertension from Pan-Tissue Transcriptomic and Genetic Analyses

Hypertension (HT) is a complex systemic disease involving transcriptional changes in multiple organs. Here we systematically investigate the pan-tissue transcriptional and genetic landscape of HT spanning dozens of tissues in hundreds of individuals. We find that in several tissues, previously identified HT-linked genes are dysregulated and the gene expression profile is predictive of HT. Importantly, many expression quantitative trait loci (eQTL) SNPs associated with the population variance of the dysregulated genes are linked with blood pressure in an independent genome-wide association study, suggesting that the functional effect of HT-associated SNPs may be mediated through tissue-specific transcriptional dysregulation. Analyses of pan-tissue transcriptional dysregulation profile, as well as eQTL SNPs underlying the dysregulated genes, reveals substantial heterogeneity among the HT patients, revealing two broad groupings - a Diffused group where several tissues exhibit HT-associated molecular alterations and a Localized group where such alterations are localized to very few tissues. These two patient subgroups differ in several clinical phenotypes including respiratory, cerebrovascular, diabetes, and heart disease. These findings suggest that the Diffused and Localized subgroups may be driven by different molecular mechanisms and have different genetic underpinning.

Heart Failure Complicating Acute Mtyocardial Infarction

Factors predisposing the older person with acute myocardial infarction (MI) to develop heart failure (HF) include an increased prevalence of MI, multivessel coronary artery disease, decreased left ventricular (LV) contractile reserve, impairment of LV diastolic relaxation, increased hypertension, LV hypertrophy, diabetes mellitus, valvular heart disease, and renal insufficiency. HF associated with acute MI should be treated with a loop diuretic. The use of nitrates, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, aldosterone antagonists, beta-blockers, digoxin, and positive inotropic drugs; treatment of arrhythmias and mechanical complications; and indications for use of implantable cardioverter-defibrillators and cardiac resynchronization is discussed.

Prevalence and risk factors of heart failure in the USA: NHANES 2013 - 2014 epidemiological follow-up study

Background: Heart Failure (HF) is a progressive epidemic associated with considerable morbidity and mortality. Self-reported data from the National Health and Nutrition Examination Survey (NHANES) provides a unique representation of individuals suffering from HF. The purpose of this study is to analyze updated NHANES 2013-2014 data to identify any changes in the prevalence and current risk factors of HF, especially given the novel lifestyles and increased medical awareness of current generations. Methods: NHANES uses a multistage probability sampling design under the Centers for Disease Control and Prevention (CDC). The Student's t-test and Chi-square test/ Fisher's exact test was used for analysis of variables. A multiple logistic regression model was used to identify statistically significant risk factors for HF. Analyses were performed with the use of SAS software, version 9.4. Results: Based on our analysis, the primary risk factor was coronary artery disease followed by hypertension, diabetes mellitus, age ≥ 65 years, and obesity. Conclusion: The findings revealed that despite improved population awareness and advancements in diagnostics and therapeutics, the same risk factors continue to persist. This provided an insight into the path towards which our resources need to be directed, so as to effectively tackle the aforementioned risk factors.

Clinical prediction of incident heart failure risk: a systematic review and meta-analysis

BACKGROUND

Early treatment may alter progression to overt heart failure (HF) in asymptomatic individuals with stage B HF (SBHF). However, the identification of patients with SBHF is difficult. This systematic review sought to examine the strength of association of clinical factors with incident HF, with the intention of facilitating selection for HF screening.

METHODS

Electronic databases were systematically searched for studies reporting risk factors for incident HF. Effect sizes, typically HRs, of each risk variable were extracted. Pooled crude and adjusted HRs with 95% CIs were computed for each risk variable using a random-effects model weighted by inverse variance.

RESULTS

Twenty-seven clinical factors were identified to be associated with risk of incident HF in 15 observational studies in unselected community populations which followed 456 850 participants over 4-29 years. The strongest independent associations for incident HF were coronary artery disease (HR=2.94; 95% CI 1.36 to 6.33), diabetes mellitus (HR=2.00; 95% CI 1.68 to 2.38), age (HR (per 10 years)=1.80; 95% CI 1.13 to 2.87) followed by hypertension (HR=1.61; 95% CI 1.33 to 1.96), smoking (HR=1.60; 95% CI 1.45 to 1.77), male gender (HR=1.52; 95% CI 1.24 to 1.87) and body mass index (HR (per 5 kg/m(2))=1.15; 95% CI 1.06 to 1.25). Atrial fibrillation (HR=1.88; 95% CI 1.60 to 2.21), left ventricular hypertrophy (HR=2.46; 95% CI 1.71 to 3.53) and valvular heart disease (HR=1.74; 95% CI 1.07 to 2.84) were also strongly associated with incident HF but were not examined in sufficient papers to provide pooled hazard estimates.

CONCLUSIONS

Prediction of incident HF can be calculated from seven common clinical variables. The risk associated with these may guide strategies for the identification of high-risk people who may benefit from further evaluation and intervention.

Status of cardiovascular disease and stroke in Hispanics/Latinos in the United States: a science advisory from the American Heart Association

BACKGROUND AND PURPOSE

This American Heart Association (AHA) scientific statement provides a comprehensive overview of current evidence on the burden cardiovascular disease (CVD) among Hispanics in the United States. Hispanics are the largest minority ethnic group in the United States, and their health is vital to the public health of the nation and to achieving the AHA's 2020 goals. This statement describes the CVD epidemiology and related personal beliefs and the social and health issues of US Hispanics, and it identifies potential prevention and treatment opportunities. The intended audience for this statement includes healthcare professionals, researchers, and policy makers.

METHODS

Writing group members were nominated by the AHA's Manuscript Oversight Committee and represent a broad range of expertise in relation to Hispanic individuals and CVD. The writers used a general framework outlined by the committee chair to produce a comprehensive literature review that summarizes existing evidence, indicate gaps in current knowledge, and formulate recommendations. Only English-language studies were reviewed, with PubMed/MEDLINE as our primary resource, as well as the Cochrane Library Reviews, Centers for Disease Control and Prevention, and the US Census data as secondary resources. Inductive methods and descriptive studies that focused on CVD outcomes incidence, prevalence, treatment response, and risks were included. Because of the wide scope of these topics, members of the writing committee were responsible for drafting individual sections selected by the chair of the writing committee, and the group chair assembled the complete statement. The conclusions of this statement are the views of the authors and do not necessarily represent the official view of the AHA. All members of the writing group had the opportunity to comment on the initial drafts and approved the final version of this document. The manuscript underwent extensive AHA internal peer review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

This statement documents the status of knowledge regarding CVD among Hispanics and the sociocultural issues that impact all subgroups of Hispanics with regard to cardiovascular health. In this review, whenever possible, we identify the specific Hispanic subgroups examined to avoid generalizations. We identify specific areas for which current evidence was less robust, as well as inconsistencies and evidence gaps that inform the need for further rigorous and interdisciplinary approaches to increase our understanding of the US Hispanic population and its potential impact on the public health and cardiovascular health of the total US population. We provide recommendations specific to the 9 domains outlined by the chair to support the development of these culturally tailored and targeted approaches.

CONCLUSIONS

Healthcare professionals and researchers need to consider the impact of culture and ethnicity on health behavior and ultimately health outcomes. There is a need to tailor and develop culturally relevant strategies to engage Hispanics in cardiovascular health promotion and cultivate a larger workforce of healthcare providers, researchers, and allies with the focused goal of improving cardiovascular health and reducing CVD among the US Hispanic population.

Effect of ambient temperature on Australian northern territory public hospital admissions for cardiovascular disease among indigenous and non-indigenous populations

Hospitalisations are associated with ambient temperature, but little is known about responses in population sub-groups. In this study, heat responses for Indigenous and non-Indigenous people in two age groups were examined for two categories of cardiac diseases using daily hospital admissions from five Northern Territory hospitals (1992-2011). Admission rates during the hottest five per cent of days and the coolest five per cent of days were compared with rates at other times. Among 25-64 year olds, the Indigenous female population was more adversely affected by very hot days than the non-Indigenous female population, with admission rates for ischaemic heart disease (IHD) increasing by 32%. People older than 65 were more sensitive to cold, with non-Indigenous male admissions for heart failure increasing by 64%, and for IHD by 29%. For older Indigenous males, IHD admissions increased by 52% during cold conditions. For older non-Indigenous females, increases in admissions for heart failure were around 50% on these cold days, and 64% for older Indigenous females. We conclude that under projected climate change conditions, admissions for IHD amongst younger Indigenous people would increase in hot conditions, while admissions among elderly people during cold weather may be reduced. The responses to temperature, while showing significant relationships across the Northern Territory, may vary by region. These variations were not explored in this assessment.

Effect of race on left ventricular ejection fraction decline after initial improvement with beta blockers in patients with non-ischemic cardiomyopathy: a retrospective analysis

Background

Although beta blockers (BBs) are established therapy in heart failure, some patients whose left ventricular ejection fraction (LVEF) initially increases on BB therapy experience a subsequent LVEF decline. This study aimed to evaluate the proportion of patients with non-ischemic cardiomyopathy (NICM) whose LVEF declines while on BB therapy and determine important predictors of LVEF decline.

Methods

A retrospective analysis of 238 patients receiving a BB (carvedilol, metoprolol succinate, or tartrate), with an ejection fraction of ≤40 % and NICM, whose LVEF initially rose ≥5 % after 1 year of BB therapy, was conducted. Post-response LVEF decline ≥5 % to a final LVEF of ≤35 % was evaluated within 4 years of BB initiation.

Results

In our study, we had 52 Caucasians (22 %), 78 Hispanics (33 %), and 108 African Americans (45 %). Overall, 32 patients (13.44 %) had post-response LVEF decline. The nadir LVEF of patients with post-response LVEF decline was 25 % (interquartile range 20–27). Compared with others, Hispanics had lower nadir LVEF (22 %, p < 0.001). Important predictors of LVEF decline were Hispanic race (odds ratio (OR) 6.094, p < 0.001), New York Heart Association (NYHA) class (OR 2.287, p < 0.05), baseline LVEF (OR 1.075, p < 0.05), and age (OR 0.933, p < 0.001).

Conclusion

A significant proportion (13.44 %) of NICM patients with LVEF increase over 1 year of BB therapy experienced subsequent LVEF decline. Race, NYHA class, baseline LVEF, and age are important predictors of this decline.

Pharmacology of antiarrhythmic drugs in elderly patients

Bradyarrhythmias and tachyarrhythmias are common in elderly patients as a result of aging and acquired cardiac disease. Antiarrhythmic drugs are effective in elderly patients for the management of supraventricular and ventricular arrhythmias; however, dosing of drugs must be performed with care because of age-related changes in drug pharmacokinetics, the presence of concomitant disease, and frequent drug-drug interactions. Despite the large number of antiarrhythmic drugs having different electrophysiologic actions, as described in this article, only the β-blockers have been shown to be effective in reducing mortality and to lack proarrhythmic actions.

Update on diastolic heart failure or heart failure with preserved ejection fraction in the older adults

Nearly half of all heart failure (HF) patients have diastolic HF (DHF) or clinical HF with normal or near-normal left ventricular ejection fraction (LVEF). Although the terminology has not been clearly defined, it is increasingly being referred to as HF with preserved ejection fraction (HFPEF). The prevalence of HFPEF increases with age, especially among older women. Identifying HFPEF is important because the etiology, pathogenesis, prognosis, and optimal management may differ from that for systolic HF (SHF) or HF with reduced ejection fraction. The clinical presentation of HF is similar for both SHF and HFPEF. As in SHF, HFPEF is a clinical diagnosis. Once a clinical diagnosis of HF has been made, the presence of HFPEF can be established by confirming a normal or near-normal LVEF, often by an echocardiogram. HFPEF is often associated with a history of hypertension, concentric left ventricular hypertrophy, vascular stiffness, and left ventricular diastolic dysfunction. As in SHF, HFPEF is also associated with poor outcomes. While therapies with angiotensin-converting enzyme inhibitors and beta-blockers improve outcomes in SHF, there is currently no such evidence of their benefits in older HFPEF patients. In this review recent advances in the diagnosis and management of HFPEF in older adults are discussed.

High prevalence of undetected heart failure in long-term care residents: findings from the Heart Failure in Care Homes (HFinCH) study

AIMS

Diagnosis 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 RESULTS

A 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.

CONCLUSION

Heart 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.

Current approaches to the treatment of hypertension in older persons

Hypertension is a major risk factor for cardiovascular disease and is present in 69% of patients with a first myocardial infarction, in 77% of patients with a first stroke, in 74% of patients with chronic heart failure, and in 60% of patients with peripheral arterial disease. Double-blind, randomized, placebo-controlled trials have demonstrated that antihypertensive drug therapy reduces cardiovascular events in patients aged 65 to 79 years. In the Hypertension in the Very Elderly Trial, patients aged ≥ 80 years who were treated with antihypertensive drug therapy had, at 1.8-year follow-up, a 30% reduction in fatal or nonfatal stroke (P = 0.06), a 39% reduction in fatal stroke (P = 0.05), a 21% reduction in all-cause mortality (P = 0.02), a 23% reduction in cardiovascular death (P = 0.06), and a 64% reduction in heart failure (P < 0.001). Although the optimal blood pressure (BP) treatment goal in the elderly has not been determined, existing epidemiologic and clinical trial data suggest that a reasonable therapeutic BP goal should be < 140/90 mm Hg in persons aged < 80 years and a systolic BP of 140 to 145 mm Hg if tolerated in persons aged ≥ 80 years. Nonpharmacologic lifestyle measures should be encouraged both to prevent development of hypertension and as adjunctive therapy in persons with hypertension. Diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, and calcium channel blockers have all shown benefit in reducing cardiovascular events in randomized trials. The choice of specific drugs depends on efficacy, tolerability, presence of specific comorbidities, and cost. Adverse effects from treatment, such as electrolyte disturbances, renal dysfunction, and excessive orthostatic BP reduction, should be avoided.

Future of personalized pharmacotherapy in chronic heart failure patients

There is a significant amount of diversity among heart failure (HF) patients. Contemporary HF regimens often do not take into consideration many of the factors that might influence an individual’s response to treatment. Clinical recommendations based on trial data derived from mainly younger Caucasian male study populations have, in most cases, been applied equally to women and African–Americans. Subgroup analyses of randomized HF trials and results of retrospective cohort studies have been used for customizing HF regimens in women and African–Americans. Pharmacogenetics is an emerging strategy for personalizing HF therapy. Genetic biomarkers may play an important role in predicting a patient’s response to treatment and in predicting those at risk of toxicity. HF pharmacotherapy has improved over the last two decades; however, substantial work remains in order to personalize HF management and maximize the benefit of pharmacologic interventions, while limiting adverse events.

Racial differences in incident heart failure during antihypertensive therapy

BACKGROUND

Blacks have a higher prevalence of heart failure (HF) than nonblacks, possibly reflecting a greater burden of HF risk factors, including hypertension. Although HF incidence is significantly higher in blacks during long-term follow-up of young adults, the relationship of incident HF to race in hypertensive patients undergoing treatment is unclear.

METHODS AND RESULTS

Incident HF was evaluated in 497 black and 8199 nonblack hypertensive patients with no history of HF randomly assigned to losartan- or atenolol-based treatment. During 4.7±1.1 years mean follow-up, HF hospitalization occurred in 265 patients (3.0%); 5-year HF incidence was significantly greater in black than nonblack patients (7.0 versus 3.1%, P<0.001). In Cox multivariate analyses adjusting for randomized treatment, age, sex, the presence of the strain pattern on the baseline ECG, and other HF risk factors treated as standard covariates, and for incident myocardial infarction, in-treatment QRS duration, diastolic and systolic pressure, Cornell product, and Sokolow-Lyon voltage criteria for left ventricular hypertrophy (LVH) treated as time-varying covariates, black race remained associated with a 130% increased risk of developing new HF (hazard ratio 2.30, 95% confidence interval 1.24 to 4.28).

CONCLUSIONS

Incident HF is substantially more common among black than nonblack hypertensive patients. The increased risk of developing new HF in blacks persists after adjusting for the higher prevalence of HF risk factors in blacks, for treatment effects and in-treatment blood pressure, and for the known predictive value of the ECG strain pattern and in-treatment ECG LVH and QRS duration for incident HF in this population. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00338260.

Diagnosis, treatment, and referral of hypertension or prehypertension in an emergency department after an educational program: preliminary results

The authors prospectively audited 602 randomly selected charts of patients seen in an academic emergency department (ED) for prevalence of hypertension and its management after an educational program (EP) because of results found in auditing 500 charts before the EP. Blood pressure was not measured in 11 of 500 patients (2.2%) before the EP and in 1 of 602 patients (0.2%) after the EP (P < .005). Hypertension was treated in the ED in 14 of 187 patients (8%) before the EP and in 29 of 282 patients (10%) after the EP (P = not significant). Of 187 patients with hypertension before the EP, 99 (53%) were referred to a physician or clinic for follow-up of hypertension, and 281 of 282 patients (99.6%) with hypertension were referred to a physician or clinic for follow-up of hypertension after the EP (P < .001). These data show that an EP administered to the staff of an academic ED significantly increased measurement of blood pressure in the ED, significantly increased obtaining a history of hypertension and of its treatment in ED patients, and significantly increased referral of patients with hypertension to a physician or clinic for follow-up of hypertension.

Managing anemia in patients with chronic heart failure: what do we know?

Anemia is common in patients with chronic heart failure (HF) with an incidence ranging from 4% to 55% depending on the studied population. Several studies have highlighted that the prevalence of anemia increases with worsening heart failure as reflected by New York Heart Association classification. Additionally, several epidemiological studies have highlighted its role as a prognostic marker, linking it to worse outcomes including; malnutrition, increased hospitalizations, refractory heart failure and death. The pathophysiology of anemia is multifactorial and related to various factors including; hemodilution, iron losses from anti-platelet drugs, activation of the inflammatory cascade, urinary losses of erythropoietin and associated renal insufficiency. There are a host of epidemiological studies examining HF outcomes and anemia, but only a few randomized trials addressing this issue. The purpose of this article is to review the literature that examines the interrelationship of anemia and congestive HF, analyzing its etiology, impact on outcomes and also the role of associated kidney disease as well as cardiorenal syndrome both as a marker of morbidity and mortality.

Hypertension in the elderly

Many elderly patients have hypertension, although it is more likely to go untreated in this population. Treatment goals are the same in elderly patients as in younger patients, but elderly patients are more likely to have multiple comorbidities, which must be factored into treatment plans. This article highlights the unique challenges in treating this population.

Treating hypertension in older adults: safety considerations

This article discusses the efficacy, use and adverse effects of antihypertensive drug therapy in older adults. Numerous double-blind, randomized, placebo-controlled studies have demonstrated that antihypertensive drug therapy reduces cardiovascular events in older adults. All antihypertensive drugs may predispose older patients to the development of symptomatic orthostatic hypotension and postprandial hypotension, and syncope or falls. Adverse effects of diuretics, beta-adrenergic receptor antagonists, ACE inhibitors, angiotensin receptor antagonists, calcium channel antagonists, alpha-adrenergic receptor antagonists, centrally acting drugs and direct vasodilators are discussed. The adverse effects depend on the antihypertensive drugs used, the doses used, the co-morbidities present in older patients taking these drugs and drug-drug interactions.

Diagnosis, treatment, and referral of hypertension in an emergency department

The authors prospectively audited 500 randomly selected charts of patients seen during a 6-month period ending in October 2008, in the emergency department of a university medical center for the prevalence of hypertension and how it was managed. Of the 187 patients with hypertension, 14 (8%) were treated for hypertension in the emergency department and 99 (53%) were hospitalized or referred to a physician or clinic for follow-up of their hypertension. Much improvement is needed, especially since many of the patients seen in the emergency department do not have a primary care physician.

Hypertension in the nursing home

Hypertension in a nursing home patient is a systolic blood pressure of 140 mm Hg or higher and 130 mm Hg or higher in a patient with diabetes mellitus or chronic renal insufficiency, or a diastolic blood pressure of 90 mm Hg or higher and 80 mm Hg or higher in a patient with diabetes mellitus or chronic renal insufficiency. Numerous prospective, double-blind, randomized, placebo-controlled studies have demonstrated that antihypertensive drug therapy reduces the development of new coronary events, stroke, and congestive heart failure in older persons. The goal of treatment of hypertension in elderly persons is to lower the blood pressure to less than 140/90 mm Hg and to less than 130/80 mm Hg in older persons with diabetes mellitus or chronic renal insufficiency. Elderly persons with diastolic hypertension should have their diastolic blood pressure reduced to 80 to 85 mm Hg. Diuretics should be used as initial drugs in the treatment of older persons with hypertension and no associated medical conditions. The selection of antihypertensive drug therapy in persons with associated medical conditions depends on their associated medical conditions. If the blood pressure is more than 20/10 mm Hg above the goal blood pressure, drug therapy should be initiated with 2 antihypertensive drugs, one of which should be a thiazide-type diuretic. Other coronary risk factors must be treated in patients with hypertension.

Inotropic drugs and neurohormonal antagonists in the treatment of HF in the elderly

Heart failure (HF) is the most common reason for hospital admission among individuals over age 65 years and results in more than 1 million admissions each year. The overall annual death rate for HF is approximately 20%. HF results from decreased contractile function of the heart, and neurohormonal dysregulation plays a major part in the morbidity and mortality of the heart. The purpose of this article is to review recent studies on inotropic drugs and neurohormonal antagonists used in the treatment of patients who have HF, especially the elderly.

Heart failure-complicating acute myocardial infarction

This article addresses issues related to acute myocardial infarction (MI) complicated by heart failure, particularly in elderly patients. Findings have shown that acute MI complicated by congestive heart failure (CHF) is associated with a high mortality, and that women with acute MI are more likely to be older and to develop CHF than men with acute MI. In general, management of CHF complicating acute MI is similar in older and younger patients. Actions discussed include hemodynamic monitoring; the administration of oxygen; and the use of morphine, diuretics, nitroglycerin, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, spironolactone, beta-blockers, calcium channel blockers, magnesium, digoxin, and positive inotropic drugs. The article also discusses measures for treating arrhythmias and for diagnosing mechanical complications.

Cardiovascular drug therapy in the elderly

Pharmacokinetic considerations in the elderly include absorption, bioavailablility, drug distribution, half-life, drug metabolism, and drug excretion. There are numerous physiologic changes with aging that affect pharmacodynamics with alterations in end-organ responsiveness. This article discusses use of cardiovascular drugs in the elderly including digoxin, diuretics, beta-adrenergic blockers, angiotensin-converting enzyme inhibitors, angiotensin-II receptor blockers, nitrates, calcium channel blockers, alpha-adrenergic blockers, antiarrhythmic drugs, lipid-lowering drugs, and anticoagulants. This article also discusses the adverse effects of cardiovascular drugs in the elderly, medications best to avoid in the elderly, and the prudent use of medications in the elderly.

Inotropic drugs and neurohormonal antagonists in the treatment of HF in the elderly

HF (HF) is the most common reason for hospital admission among individuals over age 65 years and results in more than 1 million admissions each year. The overall annual death rate for HF is approximately 20%. HF results from decreased contractile function of the heart, and neurohormonal dysregulation plays a major part in the morbidity and mortality of the heart. The purpose of this article is to review recent studies on inotropic drugs and neurohormonal antagonists used in the treatment of patients who have HF, especially the elderly.

Heart-failure-complicating acute myocardial infarction

This article addresses issues related to acute myocardial infarction(MI) complicated by heart failure, particularly in elderly patients. Findings have shown that acute MI complicated by congestive heart failure (CHF) is associated with a high mortality, and that women with acute MI are more likely to be older and to develop CHF than men with acute MI. In general, management of CHF-complicating acute MI is similar in older and younger patients. Actions discussed include hemodynamic monitoring; the administration of oxygen; and the use of morphine, diuretics, nitroglycerin,angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, spironolactone, beta-blockers, calcium channel blockers, magnesium, digoxin, and positive inotropic drugs. The article also discusses measures for treating arrhythmias and for diagnosing mechanical complications.

Treatment of heart failure with normal left ventricular ejection fraction

Underlying causes and precipitating causes of heart failure (HF) should be treated when possible. Persons with HF and normal left ventricular ejection fraction (LVEF) should have maintenance of sinus rhythm, treatment of hypertension, myocardial ischemia, dyslipidemia, and anemia, slowing of the ventricular rate below 90 bpm, and reduction of salt overload. First-line drug treatment in the management of these persons is the use of loop diuretics combined with beta blockers and angiotensin-converting enzyme (ACE) inhibitors. If persons are unable to tolerate ACE inhibitors because of cough, angioneurotic edema, rash, or altered taste sensation, angiotensin II type I receptor antagonists (ARBs) should be given. If HF persists despite diuretics, beta blockers, and ACE inhibitors or ARBs, isosorbide dinitrate plus hydralazine should be administered. Beta blockers, verapamil, diltiazem, and digoxin may be used to slow a rapid ventricular rate in persons with supraventricular tachyarrhythmias. Digoxin should not be used in persons with HF in sinus rhythm with normal LVEF. Exercise training should be encouraged in persons with mild to moderate HF to improve functional status and to decrease symptoms.

Racial Differences in the Characteristics of Patients Admitted for Acute Decompensated Heart Failure and Their Relation to Outcomes: Results From the OPTIME-CHF Trial

BACKGROUND

Recent data suggest that differences in response to therapy and survival exist between African Americans and Caucasians with heart failure. Whether these differences exist in acute decompensated heart failure (ADHF) is uncertain.

METHODS AND RESULTS

We analyzed data from the OPTIME-CHF (Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure) study, a randomized trial of intravenous milrinone versus placebo in 949 patients hospitalized with ADHF. We evaluated differences in clinical characteristics, outcomes, and response to milrinone therapy in African American patients compared with Caucasians. The primary end point of OPTIME-CHF was days hospitalized for cardiovascular causes or death within 60 days of randomization. Thirty-three percent (n = 310) of patients were African American. African American patients were younger (57 vs. 70 years, P < .0001) and more likely to have non-ischemic cardiomyopathy (74% vs. 36%, P < .0001). In unadjusted analysis, African American patients had a lower 60-day mortality (5% vs. 12%, P = .0004) and tended to have better overall clinical outcomes. After adjustment for baseline differences, however, these differences were no longer significant. We found no differential effect of milrinone therapy by race.

CONCLUSION

African American patients with acute decompensated heart failure present with a different clinical profile than Caucasian patients. Although unadjusted clinical outcomes are better for African Americans presenting with ADHF, these differences diminished after adjustment for baseline characteristics.

Heart disease and aging

CAD is the most common cause of death in older persons and was present in 43% of 1,160 men and in 41% of 2,464 women, mean age 81 years. Hypertension was present in 60% of these older women and in 57% of these older men. The prevalence of valvular aortic stenosis, aortic regurgitation, mitral regurgitation, and MAC increases with age in older men and in older women. The prevalence and incidence of CHF increase with age. CHF is the most common cause of hospitalization in persons aged 65 years and older. The prevalence of normal LV ejection fraction associated with CHF increases with age and is higher in older women than in older men. The prevalence of chronic atrial fibrillation increases with age and was present in 16% of 1,160 older men and in 13% of 2,464 older women. Atrial fibrillation is an independent predictor of new coronary events and thromboembolic stroke in older persons. Older persons who have unexplained syncope should have 24-hour ambulatory electrocardiograms to determine whether pauses of longer than 3 seconds are present that require permanent pacemaker implantation.

Predictors of mortality and hospitalization in women with heart failure in the Digitalis Investigation Group trial

We performed a retrospective follow-up study of 1926 women with heart failure who participated in the Digitalis Investigation Group trial. Adjusted hazard ratios and 95% confidence intervals for covariates that were significant independent predictors of all-cause mortality were age in years (1.02; 1.01-1.03; P<0.001), NYHA class IH-IV (1.56; 1.31-1.87), diabetes (1.63; 1.36-1.95), glomerular filtration rate in mL/min/1.73 m(2) (0.99; 0.98-4).996; P=0.001), pulmonary congestion by chest x-ray (1.57; 1.22-2.02), left ventricular ejection fraction (LVEF) (0.99; 0.98-0.993; P<0.001), and use of digoxin (1.20; 1.02-1.42). Covariates that were significant independent predictors of hospitalization due to worsening heart failure were: nonwhite race (1.28; 1.03-1.58), NYHA class III-IV (1.55; 1.30-1.84), diabetes (1.75; 1.47-2.09), glomerular filtration rate as mL/min/1.73 m(2) (0.99; 0.986-0.996; P<0.001), pulmonary congestion by chest x-ray (1.42; 1.12-1.81), and use of ACE inhibitors (0.67; 0.49-0.91). Longer duration of heart failure, higher NYHA classes, diabetes, chronic kidney disease, pulmonary congestion, and lower LVEF were significant independent predictors of all-cause mortality, all-cause hospitalization, and hospitalization for heart failure in women with heart failure.

Epidemiology, pathophysiology, prognosis, and treatment of systolic and diastolic heart failure

Underlying causes, risk factors, and precipitating causes of heart failure (HF) should be treated. Drugs known to precipitate or aggravate HF such as nonsteroidal antiinflammatory drugs should be stopped. Patients with HF and a low left ventricular ejection fraction (systolic heart failure) or normal ejection fraction (diastolic HF) should be treated with diuretics if fluid retention is present, with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioneurotic edema, rash, or altered taste sensation, and with a beta blocker unless contraindicated. If severe systolic HF persists, an aldosterone antagonist should be added. If HF persists, isosorbide dinitrate plus hydralazine should be added. Calcium channel blockers should be avoided if systolic HF is present. Digoxin should be avoided in men and women with diastolic HF if sinus rhythm is present and in women with systolic HF. Digoxin should be given to men with systolic HF if symptoms persist, but the serum digoxin level should be maintained between 0.5 and 0.8 ng/mL.

Higher New York Heart Association classes and increased mortality and hospitalization in patients with heart failure and preserved left ventricular function

BACKGROUND

The association between higher New York Heart Association (NYHA) class and outcomes in patients with heart failure and preserved systolic function is not well known.

METHODS

We performed a retrospective follow-up study of 988 patients with heart failure with ejection fraction > 45% who participated in the DIG trial. Using Cox proportional hazard models, we estimated risks and all-cause mortality, heart failure mortality, all-cause hospitalization, and hospitalization due to worsening heart failure during a median follow-up of 38.5 months.

RESULTS

Patients had a median age of 68 years; 41.2% were women and 13.9%, nonwhites. Overall, 23.4% of patients died, and 19.9% were hospitalized because of worsening heart failure. Proportion of patients with NYHA classes I, II, III, and IV were 19.9%, 58.0%, 20.9%, and 1.2%, respectively, and 14.7%, 21.1%, 35.9%, and 58.3%, respectively, died of all causes (P < .001 for trend). Respective rates for heart failure-related hospitalizations were 14.2%, 17.1%, 32.5%, and 33.3% (P < .001 for trend). Compared with NYHA class I patients, adjusted hazard ratios (HRs) for all-cause mortality for class II, III, and IV patients were 1.54 (95% CI 1.02-2.32, P = .042), 2.56 (95% CI 1.64-24.01, P < .001), and 8.46 (95% CI 3.57-20.03, P < .001), respectively. Respective adjusted HRs (95% CI) for hospitalization due to heart failure for class II, III, and IV patients were 1.16 (0.76-1.77) (P = .502), 2.27 (1.45-3.56) (P < .001), and 3.71 (1.25-11.02) (P = 018). New York Heart Association classes II through IV were also associated with higher risk of all-cause hospitalization.

CONCLUSION

Higher NYHA classes were associated with poorer outcomes in patients with heart failure and preserved systolic function.

Association of diastolic dysfunction and outcomes in ambulatory older adults with chronic heart failure

BACKGROUND

Studies of patients with heart failure and preserved systolic function report variable outcomes compared with those of patients with impaired systolic function.

OBJECTIVE

To study outcomes of diastolic (vs systolic) heart failure in older adults with chronic heart failure.

METHODS

Patients were ambulatory chronic heart failure patients 65 years and older (N = 3984) who participated in the Digitalis Investigation Group trial. Of these, 3405 had systolic heart failure (ejection fraction < or =45%) and 579 had diastolic heart failure (ejection fraction >45%). By using a 1:1 match by age, sex, and race, 571 diastolic heart failure patients were matched with 571 systolic heart failure patients. Kaplan-Meier survival analyses and multivariable Cox proportional hazard analyses were used to estimate the risk of various outcomes between the groups.

RESULTS

During the 1044 mean days of follow up, compared with 41% of systolic heart failure patients, 27% of diastolic heart failure patients died (p <.001). Presence of diastolic heart failure was independently associated with a 27% decreased risk of all-cause death (adjusted hazard ratio [HR] = 0.73; 95% confidence interval [CI], 0.58-0.91) and a 32% reduction in risk of hospitalization due to heart failure (adjusted HR = 0.68; 95% CI, 0.52-0.88). There was no difference in overall hospitalization between the groups. However, compared with systolic heart failure patients, diastolic heart failure patients were more likely to be hospitalized due to noncardiovascular causes (adjusted HR = 1.38; 95% CI, 1.02-1.88).

CONCLUSIONS

Older adults with diastolic heart failure had lower risk of all-cause mortality and heart failure-related hospitalizations, but higher risk of noncardiovascular hospitalization.