Anemia and associated clinical outcomes in patients with heart failure due to reduced left ventricular systolic function

Exercise training outcomes in patients with chronic heart failure with reduced ejection fraction depend on patient background

Background

The aim of this study was to identify significant factors affecting the effectiveness of exercise training using information of the HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) study.

Methods

Background factors influencing the effect of exercise training were comprehensively surveyed for 2,130 patients by multivariable Cox regression analysis with the stepwise variable selection, and only significant factors were selected that were statistically distinguished from dummy noise factors using the Boruta method.

Results

The analysis suggested that the use of beta-blockers, pulse pressure, hemoglobin level, electrocardiography findings, body mass index, and history of stroke at baseline potentially influenced the exercise effect on all-cause death (AD). Therefore, a hypothetical score to estimate the effect of exercise training was constructed based on the analysis. The analysis suggested that the score is useful in identifying patients for whom exercise training may be significantly effective in reducing all-caused death and hospitalization (ADH) as well as AD. Such a subpopulation accounted for approximately 40% of the overall study population. On the other hand, in approximately 45% of patients, the effect of exercise was unclear on either AD or ADH. In the remaining 15% of patients, it was estimated that the effect of exercise might be unclear for ADH and potentially rather increase AD.

Conclusions

This study is the first analysis to comprehensively evaluate the effects of various factors on the outcome of exercise training in chronic heart failure, underscoring the need to carefully consider the patient's background before recommending exercise training. However, it should be noted that exercise training can improve many outcomes in a wide variety of diseases. Therefore, given the limitations involved in post-hoc analyses of a single clinical trial, the characteristics of patients to whom the results of this analysis can be applied need attention, and also further research is necessary on the relationship between the degree of exercise and the outcomes. A new clinical trial would be needed to confirm the factors detected and the appropriateness of the score.

Decreased Haemoglobin Level Measured at Admission Predicts Long Term Mortality after the First Episode of Acute Pulmonary Embolism

Background: Decreased hemoglobin concentration was reported to predict long term prognosis in patients various cardiovascular diseases including congestive heart failure and coronary artery disease. We hypothesized that hemoglobin levels may be useful for post discharge prognostication after the first episode of acute pulmonary embolism. Therefore, the aim of the current study was to evaluate a potential prognostic value of a decreased hemoglobin levels measured at admission due to the first episode of acute PE for post discharge all cause mortality during at least 2 years follow up. Methods: This was a prospective, single-center, follow-up, observational, cohort study of consecutive survivors of the first PE episode. Patients were managed according to ESC current guidelines. After the discharge, all PE survivors were followed for at least 24 months in our outpatient clinic. Results: During 2 years follow-up from the group of 402 consecutive PE survivors 29 (7.2%) patients died. Non-survivors were older than survivors 81 years (40−93) vs. 63 years (18−97) p < 0.001 presented higher sPESI 2 (0−4) vs. 1 (0−5), p < 0.001 driven by a higher frequency of neoplasms (37.9% vs. 16.6%, p < 0.001); and had lower hemoglobin (Hb) level at admission 11.7 g/dL (6−14.8) vs. 13.1 g/dL (3.1−19.3), p < 0.001. Multivariable analysis showed that only Hb and age significantly predicted all cause post-discharge mortality. ROC analysis for all cause mortality showed AUC for hemoglobin 0.688 (95% CI 0.782−0.594), p < 0.001; and for age 0.735 (95% CI 0.651−0.819) p < 0.001. A group of 59 subjects with hemoglobin < 10.5 g/dL showed mortality rate of 16.9% (OR for mortality 4.19 (95% CI 1.82−9.65), p-value < 0.00, while among 79 patients with Hb > 14.3 g/dL only one death was detected. Interestingly, patients in age > 64 years hemoglobin levels < 13.2 g/dL compared to patients in the same age but with >13.2 g/dL showed OR 3.6 with 95% CI 1.3−10.1 p = 0.012 for death after the discharge. Conclusions: Lower haemoglobin measured in the acute phase especially in patients in age above 64 years showed significant impact on the prognosis and clinical outcomes in PE survivors.

Association of Baseline Anemia with Mid-Term Clinical Outcomes in Patients Who Underwent Trans-Radial Primary Percutaneous Coronary Intervention

Radial access is recommended for primary percutaneous coronary intervention (PCI), because it has fewer bleeding complications than trans-femoral PCI. However, even if trans-radial PCI is chosen, patients with ST-elevation myocardial infarction (STEMI) presenting with anemia on admission might have poor clinical outcomes. The aim of this retrospective study was to investigate whether anemia on admission was associated with mid-term clinical outcomes in patients who underwent trans-radial primary PCI. The primary endpoint was a composite of all-cause death, recurrent acute myocardial infarction, and readmission for heart failure. A total of 288 consecutive patients with STEMI who underwent trans-radial primary PCI were divided into an anemia group (n = 79) and a non-anemia group (n = 209). The median follow-up duration was 301 days. The anemia group was significantly older than the non-anemia group (77.3 ± 11.9 versus 64.4 ± 12.7 years, respectively; P < 0.001). There were significantly more females in the anemia group than in the non-anemia group (36.7% versus 14.4%, respectively; P < 0.001). Kaplan-Meier analysis revealed that the composite outcome-free survival was significantly worse in the anemia group than in the non-anemia group (P < 0.001). Multivariate Cox hazard model analysis revealed that hemoglobin levels on admission were significantly associated with the composite outcome (per 1 g/dL increase: hazard ratio 0.76, 95% confidence interval 0.66-0.88, P < 0.001) after controlling for confounding factors. In conclusion, baseline anemia was significantly associated with poor clinical outcomes. Patients with STEMI presenting with anemia should be managed carefully, even if trans-radial primary PCI is chosen.

Association of serum hemoglobin level with the risk of carotid plaque beyond metabolic abnormalities among asymptomatic adults without major adverse clinical events: a cross-sectional cohort study

BACKGROUND

The serum hemoglobin (Hb) level is closely related to adverse clinical outcomes. However, data on the association of Hb levels with subclinical atherosclerosis beyond metabolic abnormalities are limited.

METHODS

This study evaluated the association among serum Hb level, metabolic syndrome (MetS), and the risk of carotid plaque formation in asymptomatic adults without a history of major adverse clinical events.

RESULTS

A total of 2560 participants (mean age: 60 ± 8 years, 32.9% men) were stratified into four groups based on Hb quartiles, as follows: ≤ 12.8 g/dL (group I), 12.9-13.6 g/dL (group II), 13.7-14.5 g/dL (group III), and ≥ 14.6 g/dL (group IV). The overall prevalence of MetS and carotid plaque was 37.2% and 33.4%, respectively. The prevalence of MetS increased with increasing Hb level (group I: 27.4% vs. group II: 35.9% vs. group III: 42.6% vs. group IV: 44.1%, p < 0.001). The prevalence of carotid plaque was 34.3%, 28.1%, 32.8%, and 39.5% in groups I, II, III, and IV, respectively. Univariate logistic regression analysis showed that MetS was associated with an increased risk of carotid plaque (odds ratio [OR] 1.568, 95% confidence interval [CI] 1.326-1.856, p < 0.001). Only group II showed a lower risk of carotid plaque than group I (OR 0.750, 95% CI 0.596-0.943, p = 0.014). Multiple logistic regression models showed consistent results after adjusting for clinical factors, including MetS and its individual components.

CONCLUSION

Serum Hb level is associated with the risk of carotid plaque beyond MetS and its components in a relatively healthy adult population.

Prevalence, clinical correlates, and outcomes of anaemia in multi-ethnic Asian patients with heart failure with reduced ejection fraction

Aims

Recent international heart failure (HF) guidelines recognize anaemia as an important comorbidity contributing to poor outcomes in HF, based on data mainly from Western populations. We sought to determine the prevalence, clinical correlates, and prognostic impact of anaemia in patients with HF with reduced ejection fraction across Asia.

Methods and results

We prospectively studied 3886 Asian patients (60 ± 13 years, 21% women) with HF (ejection fraction ≤40%) from 11 regions in the Asian Sudden Cardiac Death in Heart Failure study. Anaemia was defined as haemoglobin <13 g/dL (men) and <12 g/dL (women). Ethnic groups included Chinese (33.0%), Indian (26.2%), Malay (15.1%), Japanese/Korean (20.2%), and others (5.6%). Overall, anaemia was present in 41%, with a wide range across ethnicities (33–54%). Indian ethnicity, older age, diabetes, and chronic kidney disease were independently associated with higher odds of anaemia (all P < 0.001). Ethnicity modified the association of chronic kidney disease with anaemia (P_interaction = 0.045), with the highest adjusted odds among Japanese/Koreans [2.86; 95% confidence interval (CI) 1.96–4.20]. Anaemic patients had lower Kansas City Cardiomyopathy Questionnaire scores (P < 0.001) and higher risk of all‐cause mortality and HF hospitalization at 1 year (hazard ratio = 1.28, 95% CI 1.08–1.50) compared with non‐anaemic patients. The prognostic impact of anaemia was modified by ethnicity (P_interaction = 0.02), with the greatest hazard ratio in Japanese/Koreans (1.82; 95% CI 1.14–2.91).

Conclusions

Anaemia is present in a third to more than half of Asian patients with HF and adversely impacts quality of life and survival. Ethnic differences exist wherein prevalence is highest among Indians, and survival is most severely impacted by anaemia in Japanese/Koreans.

[Management of anesthesia in endovascular interventions]

Cardiovascular diseases are one of the leading causes of morbidity and mortality in Germany. In these patients, the high-risk profile necessitates an interdisciplinary and multimodal approach to treatment. Endovascular interventions and vascular surgery have become established as an important element of this strategy in the past; however, the different anatomical localizations of pathological vascular alterations make it necessary to use a wide spectrum of procedural options and methods; therefore, the requirements for management of anesthesia are variable and necessitate a differentiated approach. Endovascular procedures can be carried out with the patient under general or regional anesthesia (RA); however, in the currently available literature there is no evidence for an advantage of RA over general anesthesia regarding morbidity and mortality, although a reduction in pulmonary complications could be found for some endovascular interventions. Epidural and spinal RA procedures should be carefully considered with respect to the risk-benefit ratio and consideration of the recent guidelines on anesthesia against the background of the current study situation and the regular use of therapy with anticoagulants. The following article elucidates the specific characteristics of anesthesia management as exemplified by some selected endovascular interventions.

Prevalence of anaemia among patients with heart failure at the Brazzaville University Hospital

BACKGROUND

Heart failure (HF) is a frequent cause of ospitalisation in cardiology. Its prognosis depends on several risk factors, one of which is anaemia.

OBJECTIVES

We aimed to determine the prevalence of anaemia in patients with heart failure, and evaluate its impact on their prognosis.

METHODS

This article describes a cross-sectional study with prospective collection of data, carried out from 1 January to 31 December 2010 in the Department of Cardiology at Brazzaville University Hospital, Congo. Patients admitted for heart failure were included. Anaemia was defined as a haemoglobin level < 12 g/dl for men and < 11 g/dl for women.

RESULTS

In total, 130 men (47.8%) and 142 women (52.2%) were recruited, mean age 56.9 ± 16.5 years. The prevalence of anaemia was 42%. Average levels of haemoglobin were 9.4 ± 1.8 and 13.8 ± 4.9 g/dl for the anaemic (A) and non-anaemic (NA) patients, respectively (p = 0.0001). Two hundred and forty-nine patients (91.5%) were in NYHA functional class III-IV. Forty-seven patients (17.3%) were on oral anticoagulation and 15 (5.5%) were on aspirin. The average duration of hospital stay was 19.1 ± 16.7 days, without a significant difference between the A and NA groups (19.4 ± 12 vs 18.8 ± 13.8 days; p = 0.79, respectively). Total mortality rate was 17%, with a significant difference between the A and NA groups (26 vs 10%; p = 0.001).

CONCLUSION

This preliminary study showed a high prevalence of anaemia in patients with heart failure, and it had a negative effect on the prognosis.

[Perioperative risk and mortality after major surgery]

Although anesthesia-associated mortality has been significantly reduced down to 0.00068-0.00082% over the last decades, recent studies have revealed a high perioperative mortality of 0.8- 4%. Apart from anesthesia and surgery-induced major complications, perioperative mortality is primarily negatively influenced by individual patient comorbidities. These risk factors predispose for acute critical incidents (e.g., myocardial infarction); however, the majority of fatal complications are a result of slowly progressing conditions, particularly infections or the sequelae of systemic inflammation. This implicates a broad window of opportunity for the detection and treatment of slow-onset complications to improve the perioperative outcome. The term "failure to rescue" (FTR), i.e., the proportion of patients who die from major complications compared to the number of all patients with complications, has been introduced as a valid indicator for the quality of perioperative care. Growing evidence has already shown that FTR is an underestimated factor in perioperative medicine accounting for or at least being involved in the development of postoperative mortality. While the incidence of severe postoperative complications amazingly does not show much variation between hospitals, FTR shows significant differences implying a major potential for improvement. With 14 million surgical procedures per year in Germany, a postoperative mortality of approximately 1% and an avoidable FTR rate of 40% mean that there are an estimated 60,000 preventable deaths per year. Hence, in the future it will be imperative to (1) identify patients at risk, (2) to prevent the development of postoperative complications with the use of adequate adjunctive therapeutic strategies, (3) to establish surveillance and monitoring systems for the early detection of postoperative complications and (4) to treat postoperative complications efficiently and in time when they arise.

A Second Look at the Association between Gender and Mortality on Antiretroviral Therapy

Objective

We assessed the association between gender and mortality on antiretroviral therapy (ART) using identical models with and without sex-specific categories for weight and hemoglobin.

Design

Cohort study of adult patients on ART.

Setting

GHESKIO Clinic in Port-au-Prince, Haiti.

Participants

4,717 ART-naïve adult patients consecutively enrolled on ART at GHESKIO from 2003 to 2008.

Main Outcome Measure

Mortality on ART; multivariable analyses were conducted with and without sex-specific categories for weight and hemoglobin.

Results

In Haiti, male gender was associated with mortality (OR 1.61; 95% CI: 1.30–2.00) in multivariable analyses with hemoglobin and weight included as control variables, but not when sex-specific interactions with hemoglobin and weight were used.

Conclusions

If sex-specific categories are omitted, multivariable analyses indicate a higher risk of mortality for males vs. females of the same weight and hemoglobin. However, because males have higher normal values for weight and hemoglobin, the males in this comparison would generally have poorer health status than the females. This may explain why gender differences in mortality are sometimes observed after controlling for differences in baseline variables when gender-specific interactions with weight and hemoglobin are omitted.