Acute Heart Failure Syndromes in Patients With Coronary Artery Disease

Initial management of patients with acute heart failure

Pressure exists to manage patients with acute decompensated heart failure (ADHF) efficiently in the acute-care environment. Although most patients present with worsening of chronic heart failure, some may present with undifferentiated dyspnea and new-onset heart failure. Others have significant comorbidities that complicate both the diagnosis and treatment. The treatment of patients with ADHF is prioritized based on vital signs and presenting phenotype. The risk stratification of patients is the subject of ongoing evaluation. The disposition of patients to areas other than a monitored inpatient bed, such as an emergency department-based observation unit, may prove effective.

Incidence of heart failure and mortality after acute coronary syndromes

BACKGROUND

The long-term incidence of heart failure (HF) in ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), or unstable angina (UA) patients is uncertain. We examined the 1-year incidence of HF and its association with mortality among patients surviving their first acute coronary syndrome (ACS) hospitalization.

METHODS AND RESULTS

A retrospective cohort study of patients, aged ≥20 years, with no prior HF, hospitalized for the first time with ACS between April 1, 2002, and December 31, 2008, in Alberta, Canada, and followed up for 1 year. Index HF was defined as HF that developed as a complication during the index ACS hospitalization, and post-discharge HF, as HF developing after discharge from the index ACS hospitalization. Among 9,406 STEMI, 11,008 NSTEMI, and 4,910 UA patients, 13.6%, 14.8%, and 5.2% had index HF, respectively (P < .01). At 1-year, cumulative HF rates were 23.4% in STEMI, 25.4% in NSTEMI, and 16% in UA patients. Among hospital survivors, 1-year mortality rate was 13.9% in patients with index HF, 10.6% in patients with postdischarge HF, and 2.4% in patients with no HF. In multivariable analysis, both index HF (adjusted hazard ratio 3.2, 95% CI 2.7-3.7) and postdischarge HF (adjusted hazard ratio 4.6, 95% CI 3.9-5.4) were associated with 1-year mortality.

CONCLUSIONS

There are significant differences in the incidence of HF among STEMI, NSTEMI, and UA patients. The increased mortality risk associated with index HF and postdischarge HF suggests a need for vigilant follow-up of all ACS patients for prompt detection and treatment of HF.

Gender does not affect postdischarge outcomes in patients hospitalized for worsening heart failure with reduced ejection fraction (from the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan [EVEREST] Trial)

Women have traditionally been underrepresented in heart failure (HF) trials, and their baseline characteristics and outcomes after hospitalization for HF are unclear. We retrospectively analyzed the clinical characteristics and outcomes of patients according to gender in the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial. EVEREST randomized 4,133 patients hospitalized for HF and ejection fraction of ≤40% to tolvaptan or placebo, in addition to standard therapy. The median follow-up was 9.9 months. Log-rank tests and multivariate Cox regression models were used to compare the hazards of all-cause mortality and cardiovascular mortality or HF hospitalization. Women constituted 1,058 (26%) of the study population. The baseline characteristics were similar except that the women were older with more hypertension and diabetes and less chronic renal insufficiency, previous myocardial infarction, previous coronary revascularization, and baseline defibrillator implantation (all p <0.001). The baseline use of evidence-based HF medical therapies was similar between genders (all p >0.30). Despite a high event rate, no difference was seen in all-cause mortality (men 27% vs women 24%, multivariate hazard ratio 1.04, p = 0.61) or cardiovascular mortality plus HF hospitalization (men 42% vs women 39%, multivariate hazard ratio 1.11, p = 0.10) on univariate analysis or after adjusting for baseline covariates. In conclusion, women hospitalized for worsening HF with an ejection fraction of ≤40% were older, had more hypertension, and had received fewer procedure-based interventions than men but had relatively similar HF medication usage and clinical findings. After hospitalization for HF, women have a similarly high risk of long-term HF morbidity and mortality compared with men.

Lifetime analysis of hospitalizations and survival of patients newly admitted with heart failure

BACKGROUND

Hospital readmissions for heart failure (HF) contribute to increased morbidity and resource burden. Predictors of hospitalization and patterns of cardiovascular events over the lifetime of patients with HF have not been elucidated.

METHODS AND RESULTS

We examined recurrent hospitalizations, cardiovascular events, and survival among newly discharged (April 1999-March 2001) patients with HF in the Enhanced Feedback For Effective Cardiac Treatment phase 1 study. During 10-year follow-up, we examined all new cardiovascular hospitalizations and selected predictors of readmission. Among 8543 patients (mean age, 77.4±10.5 years; 51.6% women) followed for 22 567 person-years, 60.7% had ischemic etiology, and 67.3% had HF with reduced ejection fraction (left ventricular ejection fraction ≤45% versus >45% [HF with preserved ejection fraction]). Overall, 10-year mortality was 98.8%, with 35 966 hospital readmissions occurring over the lifetime of the cohort. Adjusted hazards ratios (HRs) for first cardiovascular hospitalization were 1.36 for ischemic HF (95% CI, 1.28-1.44; P<0.001), 1.10 for HF with reduced ejection fraction (95% CI; 1.00-1.20; P=0.045), and 1.00 for men (95% CI, 0.94-1.06; P=0.979). On repeated-events time-to-event analysis, ischemic HF was a predictor of cardiovascular (HR, 1.24; 95% CI, 1.18-1.29), HF (HR, 1.20; 95% CI, 1.13-1.27), and coronary heart disease (HR, 2.01; 95% CI, 1.81-2.24) hospitalizations (all P<0.001). Of all recurrent HF hospitalizations, 26.8% occurred in the first and 39.8% in the last deciles of cohort survival duration. Similarly, 29.7% and 52.3% of all cardiovascular readmissions occurred in the first and last deciles of the cohort survival duration, respectively.

CONCLUSIONS

Among newly discharged patients with HF, cardiovascular events were clustered at early postdischarge and prefatal time periods, and were increased among those with ischemic etiology.

Soluble ST2 as a Diagnostic and Prognostic Marker for Acute Heart Failure Syndromes

OBJECTIVES: We investigated the association of sST2 with diagnostic and prognostic outcomes and assessed whether it aids B-natriuretic peptide (BNP) in diagnosing and predicting outcomes in emergency department (ED) patients with suspected AHFS. METHODS: We recruited patients who presented to the ED of 3 tertiary hospitals with signs or symptoms of AHFS and met modified Framingham criteria for AHFS. Outcome measures were a final diagnosis of AHFS and 5-and 30-day adverse events. RESULTS: In the 295 subjects with sST2 available, the median sST2 was 0.20 ng/ml (IQR=0.10, 0.34). Although unadjusted analyses indicated sST2 was significantly associated with the diagnosis of AHFS (p=0.02), this was not so in the adjusted analysis (p=0.33). Moderately low diagnostic utility was noted with an AUC of 0.62 (95% CI=0.56, 0.69). Similar sST2 test characteristics were seen when BNP was restricted between 100 and 500 pg/ml. While sST2 was associated with AHFS readmission at 30-days (p=0.04), in the adjusted analyses it was not associated with adverse events. CONCLUSION: In patients with signs or symptoms of AHFS, unadjusted analyses indicated that sST2 was significantly associated with the diagnosis of AHFS and with 30-day AHFS recidivism. However, the associations did not carry over to adjusted analyses, and sST2 did not add significant information with regard to explaining the diagnostic and prognostic variability of BNP.

Acute decompensated heart failure - treatments and challenges -

Acute decompensated heart failure (ADHF) is a major public health problem throughout the world and its importance is continuing to grow. This article reviews the epidemiology of ADHF and the profile of patients suffering from this condition. It describes factors used in assessing prognosis and presents treatment options. Although no currently available treatments have been shown to favorably affect long-term outcomes, there are a variety of strategies and approaches to management that are expected to reduce morbidity and mortality following discharge after ADHF hospitalization. In particular, the clinician is alerted to the need to identify factors that trigger decompensation as well as to optimize treatments for chronic heart failure. The importance of the transition from hospital to the outpatient setting is described. Particular attention should be focused on providing health education to the patient and their family at an appropriate level of medical literacy as well as ensuring early follow-up evaluation after hospital discharge.

A Turkish perspective on coronary artery bypass surgery and percutaneous coronary artery intervention in chronic heart failure patients

The impact of coronary revascularization methods (coronary artery bypass graft [CABG] surgery and stent implantation) on clinical outcome has not been determined yet in patients with systolic heart failure (SHF). We examined outcomes in patients discharged from our hospital after hospitalization for decompensated SHF. Of 637 patients with SHF (mean age, 64 ± 13 years; mean ejection fraction, 26.5% ± 9%), 402 patients (63%) had coronary artery disease (CAD) and 235 patients (37%) had no CAD; 223 patients (35%) died because of cardiovascular reasons during follow-up. Patients who had stenting alone and patients who had CABG surgery and stenting had better prognosis than patients with CAD but no revascularization procedure (P < .001 and P = .013, respectively). In the patients with SHF having CAD who had stenting and CABG surgery + stenting may have better prognosis compared with patients with CAD who had no revascularization procedure in their past.

Heart failure and non-ST-segment elevation myocardial infarction: a review for a widespread situation

Up to 15% of patients with NSTEMI present at admission with heart failure. Scientific evidence for its management is limited but much progress has been made during the last years. Our purpose was to review the last data concerning heart failure in NSTEMI and perform an update on the subject, with the following findings as main highlights. As Killip classes III and IV, Killip class II onset in the context of NSTEMI has also proven bad prognosis significance. Beta-blocker therapy has proven benefit to patients with Killip class II in observational studies and small trials. Angiotensin-converting enzyme inhibitor therapy shows stronger evidence of benefit in patients with heart failure than in patients without it. Eplerenone is indicated for patients with left ventricular dysfunction and heart failure or diabetes mellitus. Implantable cardioverter defibrillators improve survival in patients with severe ventricular dysfunction after a myocardial infarction. Cardiac resynchronization therapy indications must be carefully assessed due to the high rate of implants that do not fulfill guidelines indications. In conclusion, heart failure during a NSTEMI is a common and meaningful situation which warrants careful management and further investigation to reach stronger evidence for clinical recommendations.

Magnetic resonance imaging/magnetic resonance spectroscopy biomarkers evaluation of stunned myocardium in canine model

OBJECTIVES

To evaluate whether dynamic alterations in high-energy phosphate (HEP) occur in postischemic "stunned" myocardium (SM) in canine model and to investigate the correlation between HEP and cardiac function, using cine magnetic resonance imaging (cine-MRI) and phosphorus-31 magnetic resonance spectroscopy (31P-MRS).

MATERIALS AND METHODS

Dogs (n = 13) underwent cine MRI and 31P-MRS at 60 minutes, 8 days after 10 minutes full left anterior descending occlusion followed by reperfusion. The same MRI/MRS experiments were repeated on 5 reference animals (dogs without ischemic reperfusion) at the same time points to serve as internal reference myocardium (RM). After MR data acquisitions, the SM dogs (n = 3 at 60 minutes; n = 10 at 60 minutes and day 8) and RM dogs (n = 5) were euthanized and myocardial tissues were sampled for histologic study by triphenyltetrazolium chloride staining, hematoxylin and eosin staining, and electron microscopic examination.

RESULTS

The myocardial stunning at 60 minutes was confirmed by electron microscopy examinations from the 3 randomly chosen animals with SM. The phosphocreatine (PCr)/β- adenosine triphosphate (ATP) ratio of SM was significantly lower at 60 minutes than that at day 8 (1.07 ± 0.20 vs. 1.97 ± 0.28, P < 0.05). However, no significant difference was found between 60 minutes and day 8 in RM group (1.91 ± 0.14 at 60 minutes vs. 1.89 ± 0.16 at day 8, P > 0.05). At 60 minutes, the PCr/β-ATP ratio has significant difference between SM and RM groups; while at day 8, the ratio shows no significant difference between the 2 groups. The same results were obtained for left ventricle ejection fraction (LVEF). In SM group, LVEF has good correlation with myocardial PCr/β-ATP ratios at 60 minutes (R2 = 0.71, P < 0.05) and at day 8 (R2 = 0.73, P < 0.05), respectively.

CONCLUSIONS

The HEP alterations were confirmed by 31P-MRS in SM and there is a good correlation between PCr/β-ATP ratio and LVEF for SM at 60 minutes and recovered myocardium at day 8. The combined MRS/MRI method offers the potential to systematically assess the cardiac function, morphology, and metabolism of SM. These MRS/MRI biomarker datasets could be used to dynamically monitor therapeutic efficiency and predict cardiac events.

Intramyocardial BNP gene delivery improves cardiac function through distinct context-dependent mechanisms

BACKGROUND

B-type natriuretic peptide (BNP) is an endogenous peptide produced under physiological and pathological conditions mainly by ventricular myocytes. It has natriuretic, diuretic, blood pressure-lowering, and antifibrotic actions that could mediate cardiorenal protection in cardiovascular diseases. In the present study, we used BNP gene transfer to examine functional and structural effects of BNP on left ventricular (LV) remodeling.

METHODS AND RESULTS

Human BNP was overexpressed by using adenovirus-mediated gene delivery in normal rat hearts and in hearts during the remodeling process after infarction and in an experimental model of angiotensin II-mediated hypertension. In healthy hearts, BNP gene delivery into the anterior wall of the LV decreased myocardial fibrosis (P<0.01, n=7 to 8) and increased capillary density (P<0.05, n=7 to 8) associated with a 7.3-fold increase in LV BNP peptide levels. Overexpression of BNP improved LV fractional shortening by 22% (P<0.05, n=6 to 7) and ejection fraction by 19% (P<0.05, n=6 to 7) after infarction. The favorable effect of BNP gene delivery on cardiac function after infarction was associated with normalization of cardiac sarcoplasmic reticulum Ca(2+)-ATPase expression and phospholamban Thr17-phosphorylation. BNP gene delivery also improved fractional shortening and ejection fraction in angiotensin II-mediated hypertension as well as decreased myocardial fibrosis and LV collagen III mRNA levels but had no effect on angiogenesis or Ca(2+)-ATPase expression and phospholamban phosphorylation.

CONCLUSIONS

Local intramyocardial BNP gene delivery improves cardiac function and attenuates adverse postinfarction and angiotensin II-induced remodeling. These results also indicate that myocardial BNP has pleiotropic, context-dependent, favorable actions on cardiac function and suggest that BNP acts locally as a key mechanical load-activated regulator of angiogenesis and fibrosis.

ACE gene insertion/deletion polymorphism has a mild influence on the acute development of left ventricular dysfunction in patients with ST elevation myocardial infarction treated with primary PCI

Background

We evaluated the associations among angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism, ACE activity and post-myocardial infarction (MI) left ventricular dysfunction and acute heart failure (AHF) early after presentation with MI with ST-segment elevation (STEMI).

Methods

A total of 556 patients with STEMI treated by primary PCI (421 patients without AHF and 135 patients with AHF) were the study population. The activity of BNP, NT-ProBNP and ACE were measured at hospital admission and 24 h after MI onset. Left ventricular angiography was done before PCI; echocardiography was undertaken between the third and fifth day after MI.

Results

In comparison with the II genotypes group, the DD/ID group had a higher level of ACE activity upon hospital admission (p < 0.001). We found a significantly higher level of ACE activity in patients with moderate LV dysfunction (EF 40-54%) in comparison both with patients with preserved LV function (EF ≥55%) and with patients with severe LV dysfunction (p = 0.028). A non-significant trend towards a higher incidence of mild AHF (22.1% vs. 16.02%, p = 0,093), a significantly higher value of end-systolic volume (ESV/BSA) (30.0 ± 12.3 vs. 28.5 ± 13.0; p < 0.05) and lower EF (50.2 ± 11.1 vs. 52.7 ± 11.7; p < 0.05) in the DD/ID genotypes group was noted. Even after multiple adjustments according to multivariate models, the EF for the DD/ID group remained significantly lower (p = 0,033). The DD/ID genotypes were associated with a significantly higher risk of EF <45% (OR 2.04 [95% CI 1.28; 3.25]).

Conclusions

These results suggest that the I/D polymorphism of ACE is associated with the development of LV dysfunction in the acute phase after STEMI. We demonstrated for the first time an association of the low ACE activity with the severe LV dysfunction, although patients with moderate LV dysfunction had higher level ACE activity than patients with preserved LV function.

Effect of acute heart failure following discharge in patients with non-ST-elevation acute coronary syndrome on the subsequent risk of death or acute myocardial infarction

INTRODUCTION AND OBJECTIVES

Little is known about how prognosis is influenced by readmission for acute heart failure (AHF) following non-ST-segment elevation acute coronary syndrome (NSTEACS). The aim of this study was to determine the prognostic effect of a first admission for AHF on the risk of acute myocardial infarction (AMI) or death in patients who survived an episode of high-risk NSTEACS.

METHODS

The study involved 972 consecutive patients with high-risk NSTEACS who survived after hospital admission. Readmission for AHF was selected as the main exposure variable, and its association with subsequent AMI or all-cause death was assessed using Cox proportional hazards models for time-dependent covariates that also included adjustment for competing risks.

RESULTS

After a median follow-up period of 30 [interquartile range, 12-48] months, 82 patients (8.4%) were admitted for AHF, 146 (15%) had an AMI, and 202 (20.8%) died. The median time to readmission for AHF was 203 [56-336] days after NSTEACS. Patients readmitted for AHF had an increased risk of subsequent death (hazard ratio [HR]=1.67; 95% confidence interval [CI], 1.13-2.45; P=.009) or AMI (HR=2.15; 95% CI, 1.41-3.27; P< .001), which was independent of baseline prognostic and time-dependent variables.

CONCLUSIONS

Readmission for AHF after high-risk NSTEACS was associated with an increased risk of subsequent death or AMI.

Epidemiology and patterns of care of patients admitted to Italian Intensive Cardiac Care units: the BLITZ-3 registry

BACKGROUND

Intensive cardiac care units (ICCUs) have shifted from the observation of patients with myocardial infarction to the care of different acute cardiac diseases. However, few data on such an evolution are available.

METHODS AND RESULTS

From 7 to 20 April 2008, 6986 consecutive patients admitted to 81% of Italian ICCUs were prospectively enrolled. Patients observed were mainly elderly men (median age 72 years) with several co-morbidities. Most of them were triaged to ICCU from the emergency room, but 15% of admissions were transfer-in from other hospitals. Several diagnostic and therapeutic procedures were applied (78% had echocardiography and 35% coronary angiography) during the ICCU stay [median length 4 days, interquartile range (IQR) 2-5]. The discharge diagnosis was ST-elevation acute coronary syndrome (ACS) in 21%, non-ST-elevation ACS in 31%, acute heart failure (AHF) in 14% and other acute non-ACS, non-AHF cardiac diseases in 34%. Of those with ST-elevation ACS, 60% received reperfusion (15% fibrinolysis and 45% primary percutaneous coronary intervention). The overall in-ICCU crude mortality was 3.3%.

CONCLUSION

The BLITZ-3 survey provides a unique snapshot of current epidemiology and patterns of care of patients admitted to ICCUs. Although ACS still remains the most frequent admission diagnosis, the number of non-ACS patients is substantial. However, the correct standard of care for these non-ACS patients has to be defined.

Coronary artery disease, coronary revascularization, and outcomes in chronic advanced systolic heart failure

BACKGROUND

Associations between coronary artery disease (CAD) and outcomes in systolic heart failure (HF) and that between coronary artery bypass graft (CABG) surgery and outcomes in patients with HF and CAD have not been examined using propensity-matched designs.

METHODS

Of the 2707 patients with advanced chronic systolic HF in the Beta-Blocker Evaluation of Survival Trial (BEST), 1593 had a history of CAD, of whom 782 had prior CABG. Using propensity scores for CAD we assembled a cohort of 458 pairs of CAD and no-CAD patients. Propensity scores for prior CABG in those with CAD were used to assemble 500 pairs of patients with and without CABG. Matched patients were balanced on 68 baseline characteristics.

RESULTS

All-cause mortality occurred in 33% and 24% of matched patients with and without CAD respectively, during 26 months of median follow-up (hazard ratio {HR} when CAD was compared with no-CAD, 1.41; 95% confidence interval {CI}, 1.11-1.81; P=0.006). HR's (95% CIs) for CAD-associated cardiovascular mortality, HF mortality, and sudden cardiac death (SCD) were 1.53 (1.17-2.00; P=0.002), 1.44 (0.92-2.25; P=0.114) and 1.76 (1.21-2.57; P=0.003) respectively. CAD had no association with hospitalization. Among matched patients with HF and CAD, all-cause mortality occurred in 32% and 39% of those with and without prior CABG respectively (HR for CABG, 0.77; 95% CI, 0.62-0.95; P=0.015).

CONCLUSIONS

In patients with advanced chronic systolic HF, CAD is associated with increased mortality, and in those with CAD, prior CABG seems to be associated with reduced all-cause mortality but not SCD.

Relation of the ankle brachial index to left ventricular ejection fraction

Low and high ankle brachial index (ABI) values are both a marker of peripheral arterial disease and associated with greater cardiovascular disease event rates. The objective of the present study was to determine whether the ABI is associated with left ventricular (LV) systolic function. We studied 175 patients (age 67 +/- 13 years, 58% men) referred for ABI determination who had had the LV ejection fraction (EF) determined using echocardiography within 14 days. The mean LVEF was 47 +/- 13%, mean ABI for the right leg was 0.93 +/- 0.32, and the mean ABI for the left leg was 0.94 +/- 0.26. Of the 175 patients, 91 (52%) had a low, 69 (39%) had a normal, and 15 (9%) had a high ABI. The mean LVEF increased in a stepwise manner from the low, to normal, to abnormally high ABI groups (43 +/- 13% vs 51 +/- 12% vs 57 +/- 5%, respectively; p <0.01). On ordinal regression analysis, ABI status was independently related to LVEF. For each 1% increase in LVEF, the odds of being in the higher category of ABI increased by 1.08 (95% confidence interval 1.02 to 1.12, p = 0.002). No significant interaction was seen between coronary artery disease and LVEF on the ABI (p = 0.48). In conclusion, the ABI might be influenced by LV systolic function, independent of coronary disease. LVEF should be considered when ABI values are used to evaluate and monitor cardiovascular risk in patients.