Electrocardiographic left ventricular hypertrophy Cornell product is a feasible predictor of cardiac prognosis in patients with chronic heart failure

Growth Differentiation Factor 15 and Clinical Outcomes in Japanese Patients With Heart Failure

BACKGROUND

Heart failure (HF) is an increasing health problem associated with a high mortality rate. Growth differentiation factor (GDF) 15, a stress response cytokine belonging to the transforming growth factor-β superfamily, is associated with poor clinical outcomes in a broad spectrum of cardiovascular diseases. However, the prognostic usefulness of GDF15 in Japanese patients with HF remains unclear.

METHODS AND RESULTS

We measured serum concentrations of GDF15 and B-type natriuretic peptide (BNP) in 1,201 patients with HF. All patients were prospectively followed for a median period of 1,309 days. In all, 319 HF-related events and 187 all-cause deaths occurred during the follow-up period. Kaplan-Meier analysis demonstrated that, among GDF15 tertiles, the highest tertile group had the greatest risk of HF-related events and all-cause mortality. Multivariate Cox proportional hazard regression analysis demonstrated that the serum GDF15 concentration was an independent predictor of HF-related events and all-cause deaths after adjusting for confounding risk factors. Serum GDF15 improved the prediction capacity for all-cause deaths and HF-related events with a significant net reclassification index and integrated discrimination improvement. Subgroup analysis in patients with HF with preserved ejection fraction also showed the prognostic usefulness of GDF15.

CONCLUSIONS

Serum GDF15 concentrations were associated with HF severity and clinical outcomes, indicating that GDF15 could provide additional clinical information to track the health status of patients with HF.

Incidence and Predictors of Progression in Asymptomatic Patients With Stable Heart Failure

Data from previous heart failure (HF) trials suggest that patients with mild symptoms (NYHA II) actually have a poor clinical outcome. However, these studies did not assess clinical stability and rarely included patients in NYHA I. We sought to determine the incidence of short-term clinical progression in supposedly stable HF patients in NYHA I. In addition, we aimed to investigate the predictive value of widely available electrocardiographic and echocardiographic parameters for short-term disease progression. This is a retrospective study including 153 consecutive patients with HF with reduced and mid-range ejection fraction (HFrEF: LVEF<40%; HFmrEF: LVEF 40-49%) in NYHA I with no history of decompensation within the previous 6 months. All patients underwent comprehensive baseline echocardiographic and electrocardiographic assessment. The primary endpoint was the composite of cardiovascular death, hospitalization and need for intensification of HF treatment within a 12 month follow-up period. The cumulative incidence of HF progression was 17.8%, with a median time to event of 193 days. Death and hospitalization due to HF accounted for three-quarters of the events. QRS duration ≥120ms and mitral regurgitation grade >1 showed to be significant predictors of HF progression (HR: 8.92, p<0.001; and HR: 4.10, p<0.001, respectively). Patients without these risk factors had a low incidence of clinical events (3.8%). In conclusion, almost one in five supposedly stable HF patients in NYHA I experience clinical progression in short-term follow-up. Simple electrocardiographic and echocardiographic predictors may be useful for risk stratification and could help to improve individual HF patient management and outcomes.

Cornell product is an ECG marker of heart failure with preserved ejection fraction

Objective

ECG markers of heart failure (HF) with preserved ejection fraction (HFpEF) are lacking. We hypothesised that the Cornell product (CP) is a risk marker of HFpEF and has prognostic utility in HFpEF.

Methods

CP =[(amplitude of R wave in aVL+depth of S wave in V3)×QRS] was measured on baseline 12-lead ECG in a prospective Asian population-based study of 606 healthy controls (aged 55±10 years, 45% men), 221 hypertensive controls (62±9 years, 58% men) and 242 HFpEF (68±12 years, 49% men); all with EF ≥50% and followed for 2 years for all-cause mortality and HF hospitalisations.

Results

CP increased across groups from healthy controls to hypertensive controls to HFpEF, and distinguished between HFpEF and hypertension with an optimal cut-off of ≥1800 mm*ms (sensitivity 40%, specificity 85%). Age, male sex, systolic blood pressure (SBP) and heart rate were independent predictors of CP ≥1800 mm*ms, and CP was associated with echocardiographic E/e' (r=0.27, p<0.01) and left ventricular mass index (r=0.46, p<0.01). Adjusting for clinical and echocardiographic variables and log N-terminal pro B-type natriuretic peptide (NT-proBNP), CP ≥1800 mm*ms was significantly associated with HFpEF (adjusted OR 2.7, 95% CI 1.0 to 7.0). At 2-year follow-up, there were 29 deaths and 61 HF hospitalisations, all within the HFpEF group. Even after adjusting for log NT-proBNP, clinical and echocardiographic variables, CP ≥1800 mm*ms remained strongly associated with a higher composite endpoint of all-cause mortality and HF hospitalisations (adjusted HR 2.1, 95% CI 1.2 to 3.5).

Conclusion

The Cornell product is an easily applicable ECG marker of HFpEF and predicts poor prognosis by reflecting the severity of diastolic dysfunction and LV hypertrophy.

Influence of sex and pregnancy on survival in patients admitted with heart failure: Data from a prospective multicenter registry

BACKGROUND

Female sex is an independent predictor of better survival in patients with heart failure (HF), but the mechanism of this association is unknown. On the other hand, pregnancies have a strong influence on the cardiovascular system.

HYPOTHESIS

Sex and previous gestations might have a prognostic impact on 1-year mortality in patients admitted with HF.

METHODS

We conducted an observational, prospective, consecutive, multicenter registry of 1831 patients (756 females [41.2%]) admitted with HF.

RESULTS

Females had a more advanced age (75.2 ±11.4 vs 70.4 ±12.2 years), less ischemic heart disease (167 [25.3%] vs 446 [47.3%]), and higher left ventricular ejection fraction (52.0% ±16.6% vs 41.1% ±17.0%) than did men (all P values <0.001). During 1-year follow-up, 373 (20.4%) patients died (151 females and 222 males). Female sex was an independent predictor for survival (hazard ratio: 0.79, 95% confidence interval: 0.64-0.98, P = 0.03). In 504 women (65.9%), the exact number of previous pregnancies could be determined; 62 women (12.3%) had no previous pregnancies, 288 (57.1%) women had 1 or 2 pregnancies, and 154 women (30.6%) had ≥3 pregnancies. We found an association between the number of previous gestations and better survival (hazard ratio: 0.878, 95% confidence interval: 0.773-0.997, P = 0.045).

CONCLUSIONS

In patients admitted with HF, female sex and the number of previous pregnancies are independently associated with better 1-year survival.

Association of plasma xanthine oxidoreductase activity with severity and clinical outcome in patients with chronic heart failure

BACKGROUND

Oxidative stress due to purine degradation is associated with the development of chronic heart failure (CHF). Xanthine oxidoreductase (XOR) is a rate-limiting enzyme of purine degradation that plays a key role in uric acid (UA) production with a resultant increase in reactive oxygen species. However, the relationship between plasma XOR activity and CHF severity and clinical outcome remains unclear.

METHODS AND RESULTS

We measured XOR activity in 440 patients with CHF and 44 control subjects. Abnormally high and low XOR activities were identified based on the results for 95% of the control subjects (high and low XOR activities ≥120 and <33pmol/100μL/h, respectively). The prevalence rates of high and low XOR activities increased with advancing New York Heart Association functional class. There were 158 cardiac events during a median follow-up period of 1034days. Multivariate Cox proportional hazard regression analysis showed that both high and low XOR activities were significantly associated with cardiac events in patients with CHF after adjustment for confounding risk factors including serum UA and loop diuretic use. Kaplan-Meier analysis revealed that the cardiac event rate was significantly higher in patients with either high or low XOR activity. The net reclassification index was significantly improved by adding XOR activity to the basic risk factors.

CONCLUSIONS

We provide the first evidence of an association of plasma XOR activity with CHF severity and clinical outcome. Plasma XOR activity could be used to identify high-risk CHF patients and could be a therapeutic target for XOR inhibitors.

Investigating the role of acute mental stress on endothelial dysfunction: a systematic review and meta-analysis

Chronic stress is a known risk factor for both endothelial dysfunction and cardiovascular disease (CVD), but less is known of how acute mental stress affects the vasculature. In this systematic review and meta-analysis, we analyzed the impact of acute mental stress on flow-mediated dilation (FMD), an indicator of endothelial function. We searched the Medline, Cochrane, EMBASE, and ISI Web of Knowledge databases through May 2014, to identify publications in English-language journals. The primary outcome was the change in FMD from baseline to the time of measurement. We also assessed the risk of bias and the heterogeneity of included studies. Our search identified eight prospective studies, which displayed significant heterogeneity. Four studies measured FMD while the subject was performing the task; six measured FMD after the task had been completed. The total number of participants was 164. The pooled results indicate that FMD did not change significantly while the task was being performed (pooled difference in means: -0.853; 95 % confidence interval (CI), -3.926/2.220; P = 0.586); however, FMD measured after the task was completed was significantly less than baseline (pooled difference in means: -2.450; 95 %CI, -3.925/-0.975; P = 0.001). In conclusions, our findings provide evidence that an acute stressful experience has a delayed, negative impact on the function of the endothelium. Repeated exposure to short-term stress may lead to permanent injury of the vasculature. Therefore, assessment of patients' exposure to both repeated acute mental stress and chronic stress may be useful in determining their risk of developing CVD.