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.

The role of cardiac biomarkers for predicting left ventricular dysfunction and cardiovascular mortality in acute exacerbations of COPD

The presence of cardiovascular comorbidities is frequently associated with poor outcomes in chronic obstructive pulmonary disease (COPD). No clear role has been defined for cardiac biomarkers in acute exacerbations of COPD (AECOPD). The aim of this systematic review was to examine the prognostic value of brain natriuretic peptide (BNP) and troponins in patients with AECOPD. Two independent authors searched the PubMed and Cochrane Library to collect clinical trials, observational studies and meta-analyses studying the prognostic value of cardiac biomarkers in AECOPD. The reference lists of all the included studies were also reviewed. A total of 14 studies were included in the review, of which 10 measured troponins, 7 measured BNP or NT-proBNP, and 3 measured both. Of the studies that used mortality in AECOPD as an end point, some but not all found that elevated BNP and/or troponins were associated with increased mortality. Of the studies that used left ventricular (LV) dysfunction in AECOPD as an end point, all found a significant association between elevated BNP and troponins in the diagnosis of LV dysfunction. In summary, it appears that there may be a link between an elevated level of BNP or NT-proBNP and increased cardiovascular mortality in AECOPD, although the data currently available are not conclusive. The inconsistencies in biomarkers measured, time points of measurements and the variability in outcome measured preclude more robust analysis.

β-Blockers in hypertension, diabetes, heart failure and acute myocardial infarction: a review of the literature

β-Blockers (BBs) are an essential class of cardiovascular medications for reducing morbidity and mortality in patients with heart failure (HF). However, a large body of data indicates that BBs should not be used as first-line therapy for hypertension (HTN). Additionally, new data have questioned the role of BBs in the treatment of stable coronary heart disease (CHD). However, these trials mainly tested the non-vasodilating β₁ selective BBs (atenolol and metoprolol) which are still the most commonly prescribed BBs in the USA. Newer generation BBs, such as the vasodilating BBs carvedilol and nebivolol, have been shown not only to be better tolerated than non-vasodilating BBs, but also these agents do not increase the risk of diabetes mellitus (DM), atherogenic dyslipidaemia or weight gain. Moreover, carvedilol has the most evidence for reducing morbidity and mortality in patients with HF and those who have experienced an acute myocardial infarction (AMI). This review discusses the cornerstone clinical trials that have tested BBs in the settings of HTN, HF and AMI. Large randomised trials in the settings of HTN, DM and stable CHD are still needed to establish the role of BBs in these diseases, as well as to determine whether vasodilating BBs are exempt from the disadvantages of non-vasodilating BBs.

Exercise-based rehabilitation for heart failure: systematic review and meta-analysis

OBJECTIVE

To update the Cochrane systematic review of exercise-based cardiac rehabilitation (CR) for heart failure.

METHODS

A systematic review and meta-analysis of randomised controlled trials was undertaken. MEDLINE, EMBASE and the Cochrane Library were searched up to January 2013. Trials with 6 or more months of follow-up were included if they assessed the effects of exercise interventions alone or as a component of comprehensive CR programme compared with no exercise control.

RESULTS

33 trials were included with 4740 participants predominantly with a reduced ejection fraction (<40%) and New York Heart Association class II and III. Compared with controls, while there was no difference in pooled all-cause mortality between exercise CR with follow-up to 1 year (risk ratio (RR) 0.93; 95% CI 0.69 to 1.27, p=0.67), there was a trend towards a reduction in trials with follow-up beyond 1 year (RR 0.88; 0.75 to 1.02, 0.09). Exercise CR reduced the risk of overall (RR 0.75; 0.62 to 0.92, 0.005) and heart failure-specific hospitalisation (RR 0.61; 0.46 to 0.80, 0.0004) and resulted in a clinically important improvement in the Minnesota Living with Heart Failure questionnaire (mean difference: -5.8 points, -9.2 to -2.4, 0.0007). Univariate meta-regression analysis showed that these benefits were independent of the type and dose of exercise CR, and trial duration of follow- up, quality or publication date.

CONCLUSIONS

This updated Cochrane review shows that improvements in hospitalisation and health-related quality of life with exercise-based CR appear to be consistent across patients regardless of CR programme characteristics and may reduce mortality in the longer term. An individual participant data meta-analysis is needed to provide confirmatory evidence of the importance of patient subgroup and programme level characteristics (eg, exercise dose) on outcome.

Current challenges in palliative care provision for heart failure in the UK: a survey on the perspectives of palliative care professionals

OBJECTIVE

Palliative care (PC) in heart failure (HF) is beneficial and recommended in international HF guidelines. However, there is a perception that PC is underutilised in HF in the UK. This exploratory study aims to investigate, from a PC perspective, this perceived underutilisation and identify problems with current practice that may impact on the provision of PC in HF throughout the UK.

METHODS

A prospective survey was electronically sent to PC doctors and nurses via the UK Association for Palliative Medicine and adult PC teams listed in the UK Hospice directory.

RESULTS

We received 499 responses (42%-PC consultants). Although PC provision for patients with HF was widespread, burden on PC services was low (47% received less than 10 referrals annually). While PC was acknowledged to have a role in end-stage HF, there were differing views about the optimal model of care. Levels of interdisciplinary collaboration (58%) and mutual education (36%) were low. There were frequent reports that end-of-life matters were not addressed by cardiology prior to PC referral. Moreover, 24% of respondents experienced difficulties with implantable cardioverter defibrillator deactivation.

CONCLUSIONS

Low HF referrals despite widespread availability of PC services and insufficient efforts by cardiology to address PC issues may contribute to the perception that PC is underutilised in HF. The challenges facing PC and HF identified here need to be further investigated and addressed. These findings will hopefully promote awareness of PC issues in HF and encourage debate on how to improve PC support for this population.

Classification of left ventricular size: diameter or volume with contrast echocardiography?

Background

Left ventricular (LV) size is an important clinical variable, commonly assessed at echocardiography by measurement of the internal diameter in diastole (IDD). However, this has recognised limitations and volumetric measurement from apical views is considered superior, particularly with the use of echocardiographic contrast. We sought to determine the agreement in classification of LV size by different measures in a large population of patients undergoing echocardiography.

Methods and results

Data were analysed retrospectively from consecutive patients (n=2008, 61% male, median 62 years) who received echocardiographic contrast for LV opacification over 3 years in a single institution. Repeat studies were not included. LVIDD was measured, and LV end-diastolic volume (LVEDV) calculated using Simpson's biplane method. Both measures were indexed (i) to body surface area and categorised according to the American Society of Echocardiography (ASE) guidelines as normal, mild, moderate or severely dilated. Of 320 patients with a severely dilated LVEDVi, only 95 (30%) were similarly classified by LVIDD, with 86 patients (27%) measuring in the normal range. LVIDDi agreement was poorer, with only 43 patients (13%) classified as being severely dilated, and 173 (54%) measuring in the normal range.

Conclusions

Currently recommended echocardiographic measures of LV size show limited agreement when classified according to currently recommended cut-offs. LV diameter should have a limited role in the assessment of LV size, particularly where a finding of LV dilation has important diagnostic or therapeutic implications.

Heart failure risk prediction in the Multi-Ethnic Study of Atherosclerosis

OBJECTIVE

Heart failure (HF) is a leading cause of mortality especially in older populations. Early detection of high-risk individuals is imperative for primary prevention. The purpose of this study was to develop a HF risk model from a population without clinical cardiac disease.

METHODS

The Multi-Ethnic Study of Atherosclerosis is a multicentre observational cohort study following 6814 subjects (mean age 62±10 years; 47% men) who were free of clinical cardiovascular disease at baseline. Median follow-up was 4.7 years. HF events developed in 176 participants. Cox proportional hazards models and regression coefficients were used to determine independent risk factors and generate a 5-year risk score for incident HF. Bootstrapping with bias correction was used for internal validation.

RESULTS

Independent predictors for HF (HR, p value) were age (1.30 (1.10 to 1.50) per 10 years), male gender (2.27 (1.53 to 3.36)), current smoking (1.97 (1.15 to 3.36)), body mass index (1.40 (1.10 to 1.80) per 5 kg/m(2)), systolic blood pressure (1.10 (1.00 to 1.10) per 10 mm Hg), heart rate (1.30) (1.10 to 1.40) per 10 bpm), diabetes (2.27 (1.48 to 3.47)), N-terminal pro-B-type natriuretic peptide (NT proBNP) (2.48 (2.16 to 2.84) per unit log increment) and left ventricular mass index (1.40 (1.30 to 1.40) per 10 g/m(2)). A parsimonious model based on age, gender, body mass index, smoking status, systolic blood pressure, heart rate, diabetes and NT proBNP natriuretic peptide predicted incident HF risk with a c-statistic of 0.87.

CONCLUSIONS

A clinical algorithm based on risk factors readily available in the primary care setting can used to identify individuals with high likelihood of developing HF without pre-existing cardiac disease.

Vitamin B12 and folate deficiency in chronic heart failure

OBJECTIVE

To determine the prevalence, clinical correlates and the effects on outcome of vitamin B12 and folic acid levels in patients with chronic heart failure (HF).

METHODS

We studied an international pooled cohort comprising 610 patients with chronic HF. The main outcome measure was all-cause mortality.

RESULTS

Mean age of the patients was 68±12 years and median serum N-terminal prohormone brain natriuretic peptide level was 1801 pg/mL (IQR 705-4335). Thirteen per cent of the patients had an LVEF >45%. Vitamin B12 deficiency (serum level <200 pg/mL), folate deficiency (serum level <4.0 ng/mL) and iron deficiency (serum ferritin level <100 µg/L, or 100-299 µg/L with a transferrin saturation <20%) were present in 5%, 4% and 58% of the patients, respectively. No significant correlation between mean corpuscular volume and vitamin B12, folic acid or ferritin levels was observed. Lower folate levels were associated with an impaired health-related quality of life (p=0.029). During a median follow-up of 2.10 years (1.31-3.60 years), 254 subjects died. In multivariable proportional hazard models, vitamin B12 and folic acid levels were not associated with prognosis.

CONCLUSIONS

Vitamin B12 and folate deficiency are relatively rare in patients with chronic HF. Since no significant association was observed between mean corpuscular volume and neither vitamin B12 nor folic acid levels, this cellular index should be used with caution in the differential diagnosis of anaemia in patients with chronic HF. In contrast to iron deficiency, vitamin B12 and folic acid levels were not related to prognosis.

A meta-analysis of proinflammatory cytokines in chronic heart failure

BACKGROUND

Previous studies suggested that inflammation was involved in chronic heart failure (CHF), but their sample sizes were small.

OBJECTIVE

To summarise the clinical cytokine data systematically and emphasise the importance of proinflammatory cytokines in the pathogenesis of CHF, we conducted a meta-analysis of relevant literatures.

METHODS

Articles about cytokines and CHF were searched in Pubmed, EMBASE, Cochrane Library, Chinese National Knowledge Infrastructure and Chinese Wanfang Database. The pooled effects were measured by weighted mean difference (MD) and 95% CI, which were calculated by RevMan 5.1 software.

RESULTS

Finally, a total of 28 studies were included. Compared with normal control subjects, concentrations of tumour necrosis factor-α (TNF-α), interleukin-6 (IL-6), IL-1β and C reactive protein (CRP) in the peripheral blood in CHF patients are significantly increased. The overall MDs with 95% CIs for TNF-α, IL-6, CRP and IL-1β were 2.59 pg/ml (2.14∼3.05, p<0.00001), 5.49 pg/mL (4.68∼6.29, p<0.00001), 11.45 mg/dL (7.68∼15.23, p<0.00001) and 0.11 pg/mL (0.09∼0.14, p<0.00001). The mortality of elevated IL-6 group was significantly higher than control group (OR=6.73, 95% CI 2.39∼18.93, p=0.0003).

CONCLUSIONS

Concentrations of TNF-α, IL-6, IL-1β and CRP are significantly higher in CHF patients than in control subjects. Proinflammatory cytokines play an import role in the pathogenesis of CHF.

Trends in left ventricular assist device use and outcomes among Medicare beneficiaries, 2004-2011

Objective

To characterise the trends in the left ventricular assist device (LVAD) implantation rates and outcomes between 2004 and 2011 in the Medicare population. Since the approval of the HeartMate II in 2008, the use of LVADs has steadily climbed. Given the increase in LVAD use, issues around discharge disposition, post-implant hospitalisations and costs require further understanding.

Methods

We examined LVAD implantation rates and short-term and long-term outcomes among Medicare fee-for-service beneficiaries hospitalised for LVAD implantation. We also conducted analyses among survivors 1-year post-discharge to examine rehospitalisation rates. Lastly, we reported Centers for Medicare & Medicaid Services (CMS) payments for both index hospitalisation and rehospitalisations 1 year post-discharge.

Results

A total of 2152 LVAD implantations were performed with numbers increasing from 107 in 2004 to 612 in 2011. The 30-day mortality rate decreased from 52% to 9%, and 1-year mortality rate decreased from 69% to 31%. We observed no change in overall length of stay, but post-procedure length of stay increased. We also found an increase in home discharge dispositions from 26% to 53%. Between 2004 and 2010, the rehospitalisation rate increased and the number of hospital days decreased. The adjusted CMS payment for the index hospitalisation increased from $188 789 to $225 697 over time but decreased for rehospitalisation from $60 647 to $53 630.

Conclusions

LVAD implantations increased over time. We found decreasing 30-day and 1-year mortality rates and increasing home discharge disposition. The proportion of patients rehospitalised among 1-year survivors remained high with increasing index hospitalisation cost, but decreasing post-implantation costs over time.

Clinical use of multimodality imaging in the assessment of dilated cardiomyopathy

Learning objectives: =To understand the use of cardiovascular imaging for diagnosis, evaluation of prognosis and for supporting treatment decisions and monitoring therapy in patients with dilated cardiomyopathy by providing morphologic, functional and etiologic information, including refined assessment of ventricular function. =To provide to the clinical cardiologist the information on what to expect from each imaging modality and how to work together with the cardiovascular imaging expert to fully explore the potential of complementary imaging techniques. = To provide a look into the future role of new imaging modalities such as molecular imaging.

Prognosis after a first hospitalisation for acute myocardial infarction and congestive heart failure by country of birth

OBJECTIVE

To investigate differences in 28-day and 5-year mortality and 5-year readmission after a first hospitalisation for acute myocardial infarction (AMI) and congestive heart failure (CHF) between first generation ethnic minority groups (henceforth, migrants) and the ethnic Dutch population.

METHODS

Nationwide prospective cohorts of first hospitalised AMI (N=213 630) and CHF patients (N=189 069) between 1998 and 2010 were built. Differences in 28-day and 5-year mortality and in 5-year AMI/CHF readmission between migrants (Surinamese, Moroccan, Turkish, Antillean, Indonesian, Chinese and South Asian) and the ethnic Dutch population were investigated using Cox proportional hazard regression models.

RESULTS

After the first AMI hospitalisation, mortality and AMI/CHF readmission were higher in the majority of migrant groups compared with ethnic Dutch. For example, HRs (adjusted for age, sex, marital status, degree of urbanisation and year of event) with 95% CIs among Surinamese (mainly of African or South-Asian origin) were 1.16 (1.02 to 1.32) for 28-day mortality, 1.44 (1.30 to 1.60) for 5-year mortality, 1.33 (1.08 to 1.63) for AMI readmission and 2.09 (1.82 to 2.40) for CHF readmission. After a first CHF hospitalisation, mortality rates among migrants were more diverse, with lower 28-day mortality among Moroccan and Turkish migrants and higher 5-year mortality among Surinamese, Chinese and South Asians. Readmission after CHF was often higher among migrant groups.

CONCLUSIONS

Prognosis after a first AMI hospitalisation was worse among most migrant groups compared with the ethnic Dutch population. Ethnic inequalities in prognosis after a first CHF hospitalisation were more diverse. Efforts should be made to disentangle the underlying factors of the results.

Β-adrenergic blockade combined with subcutaneous B-type natriuretic peptide: a promising approach to reduce ventricular arrhythmia in heart failure?

AIMS

Clinical studies failed to prove convincingly efficiency of intravenous infusion of neseritide during heart failure and evidence suggested a pro-adrenergic action of B-type natriuretic peptide (BNP). However, subcutaneous BNP therapy was recently proposed in heart failure, thus raising new perspectives over what was considered as a promising treatment. We tested the efficiency of a combination of oral β1-adrenergic receptor blocker metoprolol and subcutaneous BNP infusion in decompensated heart failure.

METHODS AND RESULTS

The effects of metoprolol or/and BNP were studied on cardiac remodelling, excitation-contraction coupling and arrhythmias in an experimental mouse model of ischaemic heart failure following postmyocardial infarction. We determined the cellular and molecular mechanisms involved in anti-remodelling and antiarrhythmic actions. As major findings, the combination was more effective than metoprolol alone in reversing cardiac remodelling and preventing ventricular arrhythmia. The association of the two molecules improved cardiac function, reduced hypertrophy and fibrosis, and corrected the heart rate, sympatho-vagal balance (low frequencies/high frequencies) and ECG parameters (P to R wave interval (PR), QRS duration, QTc intervals). It also improved altered Ca(2+) cycling by normalising Ca(2+)-handling protein levels (S100A1, SERCA2a, RyR2), and prevented pro-arrhythmogenic Ca(2+) waves derived from abnormal Ca(2+) sparks in ventricular cardiomyocytes. Altogether these effects accounted for decreased occurrence of ventricular arrhythmias.

CONCLUSIONS

Association of subcutaneous BNP and oral metoprolol appeared to be more effective than metoprolol alone. Breaking the deleterious loop linking BNP and sympathetic overdrive in heart failure could unmask the efficiency of BNP against deleterious damages in heart failure and bring a new potential approach against lethal arrhythmia during heart failure.

Clinical and echocardiographic profile and outcomes of peripartum cardiomyopathy: the Philippine General Hospital experience

BACKGROUND

Peripartum cardiomyopathy (PPCM) is a rare disease entity of unknown aetiology. High rates of mortality or poor overall clinical outcome are reported in women with this condition. Certain characteristics are risk factors for this disease. In Asia, there are limited data, especially in the Southeast Asian region. In the Philippines, no data exist regarding the prevalence or risk factors.

OBJECTIVES

To determine the prevalence, profile and outcomes of PPCM in Philippine General Hospital and to describe their echocardiographic findings.

METHODS

All patients diagnosed with PPCM in the period of 1 January 2009-31 December 2010 were seen and examined. Demographic data and echocardiogram of the patients were reviewed.

RESULTS

9 were diagnosed with PPCM during the study period. The prevalence is 1 in 1270 live births. Mean age was 29. 78% presented with moderate to severe heart failure symptoms in the prepartum period. Among purported risk factors for PPCM, obesity, multiparity and pre-eclampsia were seen in most. Conversely, only one patient admitted to having more than a single sexual partner. Only one patient had multifetal pregnancy. None were smokers. 44% underwent caesarean section for maternal indication. No mortality was seen. Fetal outcomes were good with all resulting in live births and most were appropriate for gestational age. Echocardiographic findings showed global wall motion abnormalities in the majority, mean ejection fraction of 34% and mean fractional shortening of 20%.

CONCLUSIONS

PPCM is rare in the Philippines. Compared with international data, our patients are younger with low percentages of promiscuity, multifetal pregnancy, smoking history and tocolytic use. Similar to previous studies, obesity, multiparity and pre-eclampsia were also present in our PPCM patients. Immediate maternal and fetal outcomes were generally good. Adherence to standard heart failure management is high.

Recent advances in the epidemiology, pathogenesis and prognosis of acute heart failure and cardiomyopathy in Africa

This review addresses recent advances in the epidemiology, pathogenesis and prognosis of acute heart failure and cardiomyopathy based on research conducted in Africa. We searched Medline/PubMed for publications on acute decompensated heart failure and cardiomyopathy in Africa for the past 5 years (ie, 1 January 2008 to 31 December 2012). This was supplemented with personal communications with colleagues from Africa working in the field. A large prospective registry has shown that acute decompensated heart failure is caused by hypertension, cardiomyopathy and rheumatic heart disease in 90% of cases, a pattern that is in contrast with the dominance of coronary artery disease in North America and Europe. Furthermore, acute heart failure is a disease of the young with a mean age of 52 years, occurs equally in men and women, and is associated with high mortality at 6 months (∼18%), which is, however, similar to that observed in non-African heart failure registries, suggesting that heart failure has a dire prognosis globally, regardless of aetiology. The molecular genetics of dilated cardiomyopathy, hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy in Africans is consistent with observations elsewhere in the world; the unique founder effects in the Afrikaner provide an opportunity for the study of genotype-phenotype correlations in large numbers of individuals with cardiomyopathy due to the same mutation. Advances in the understanding of the molecular mechanisms of peripartum cardiomyopathy have led to promising clinical trials of bromocriptine in the treatment of peripartum heart failure. The key challenges of management of heart failure are the urgent need to increase the use of proven treatments by physicians, and the control of hypertension in primary care and at the population level.

"Cardiac" or congestive cirrhosis of liver

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