ECG in patients with acute heart failure can predict in-hospital and long-term mortality

Abnormal electrocardiogram and poor prognosis in heart failure with preserved ejection fraction

PURPOSE

Electrocardiogram (ECG) is generally performed in patients with heart failure with preserved ejection fraction (HFpEF), but the prognostic value of abnormal ECG is not fully understood. We aim to explore the prognostic value of abnormal ECG at baseline in HFpEF using data from the TOPCAT trial.

METHODS

A total of 1736 patients from TOPCAT-Americas were included and divided into normal versus abnormal ECG groups. Survival analyses were performed for the following outcomes: the primary endpoint [a composite of cardiovascular death, heart failure (HF) hospitalization, and aborted cardiac arrest], all-cause death, cardiovascular death, and HF hospitalization.

RESULTS

Abnormal ECG was significantly associated with higher risks of the primary endpoint [hazard ratio (HR): 1.480, P = 0.001] and HF hospitalization (HR: 1.400, P = 0.015), and borderline significantly with cardiovascular death (HR: 1.453, P = 0.052) in patients with HFpEF after multivariate adjustment. As for specific ECG abnormalities, bundle branch block was associated with the primary endpoint (HR: 1.278, P = 0.020) and HF hospitalization (HR: 1.333, P = 0.016), whereas atrial fibrillation/flutter was associated with all-cause death (HR: 1.345, P = 0.051) and cardiovascular death (HR: 1.570, P = 0.023), but ventricular paced rhythm, pathological Q waves, and left ventricular hypertrophy were not of prognostic significance. Besides, other unspecific abnormalities together were associated with the primary endpoint (HR: 1.213, P = 0.032).

CONCLUSION

Abnormal ECG at baseline could be associated with poor prognosis in patients with HFpEF. Physicians are encouraged to pay more attention to HFpEF patients who present an abnormal ECG instead of ignoring those obscure abnormalities. Key messages What is already known on this topic Electrocardiogram (ECG) is a basic and easily accessible examination for patients with heart failure with preserved ejection fraction (HFpEF). Some findings from ECG such as frontal QRS-T angle, QTc interval, and the Cornell product have been shown to be associated with the prognosis of HFpEF but these results are from studies with relatively small sample sizes. What this study adds Using data from TOPCAT-Americas, this study found that an overall estimation of abnormal ECG significantly predicted poor prognosis in patients with HFpEF. As for specific abnormalities in ECG, bundle branch block mainly predicted heart failure hospitalization and atrial fibrillation mainly predicted death. How this study might affect research, practice, or policy This study reminds physicians to pay more attention to HFpEF patients who present an abnormal ECG.

ECG and Biomarker Profile in Patients with Acute Heart Failure: A Pilot Study

Background: Biomarkers, electrocardiogram (ECG) and Holter ECG are basic, accessible and feasible cardiac investigations. The combination of their results may lead to a more complex predictive model that may improve the clinical approach in acute heart failure (AHF). The main objective was to investigate which ECG parameters are correlated with the usual cardiac biomarkers (prohormone N-terminal proBNP, high-sensitive cardiac troponin I) in patients with acute heart failure, in a population from Romania. The relationship between certain ECG parameters and cardiac biomarkers may support future research on their combined prognostic value. Methods: In this prospective case-control study were included 49 patients with acute heart failure and 31 participants in the control group. For all patients we measured levels of prohormone N-terminal proBNP (NT-proBNP), high-sensitive cardiac troponin I (hs-cTnI) and MB isoenzyme of creatine phosphokinase (CK-MB) and evaluated the 12-lead ECG and 24 h Holter monitoring. Complete clinical and paraclinical evaluation was performed. Results: NT-proBNP level was significantly higher in patients with AHF (p < 0.001). In patients with AHF, NT-proBNP correlated with cQTi (p = 0.027), pathological Q wave (p = 0.029), complex premature ventricular contractions (PVCs) (p = 0.034) and ventricular tachycardia (p = 0.048). Hs-cTnI and CK-MB were correlated with ST-segment modification (p = 0.038; p = 0.018) and hs-cTnI alone with complex PVCs (p = 0.031). Conclusions: The statistical relationships found between cardiac biomarkers and ECG patterns support the added value of ECG in the diagnosis of AHF. We emphasize the importance of proper ECG analysis of more subtle parameters that can easily be missed. As a non-invasive technique, ECG can be used in the outpatient setting as a warning signal, announcing the acute decompensation of HF. In addition, the information provided by the ECG complements the biomarker results, supporting the diagnosis of AHF in cases of dyspnea of uncertain etiology. Further studies are needed to confirm long-term prognosis in a multi-marker approach.

Patient characteristics, short-term and long-term outcomes after incident heart failure admissions in a regional Australian setting

AIMS

This study aims to (1) define the characteristics of patients with a first admission for heart failure (HF), stratified by type (reduced (HFrEF) vs preserved (HFpEF) ejection fraction) in a regional Australian setting; (2) compare the outcomes in terms of mortality and rehospitalisation and (3) assess adherence to the treatment guidelines.

METHODS

We identified all index hospitalisations with HF to John Hunter Hospital and Tamworth Rural Referral Hospital in the Hunter New England Local Health District over a 12 months. We used the recent Australian HF guidelines to classify HFrEF and HFpEF and assess adherence to guideline-directed therapy. The primary outcome of the study was to compare short-term (1 year) and long-term all-cause mortality and the composite of all-cause hospitalisation or all-cause mortality of patients with HFrEF and HFpEF.

RESULTS

There were 664 patients who had an index HF admission to John Hunter and Tamworth hospitals in 2014. The median age was 80 years, 47% were female and 22 (3%) were Aboriginal. In terms of HF type, 29% had HFrEF, 37% had HFpEF, while the remainder (34%) did not have an echocardiogram within 1 year of admission and could not be classified. The median follow-up was 3.3 years. HFrEF patients were predominantly male (64%) and in 48% the aetiology was ischaemic heart disease. The 1-year all-cause mortality was 23% in HFpEF subgroup and 29% in HFrEF subgroup (p=0.15). Five-year mortality was 61% in HFpEF and HFrEF patients. Of the HFrEF patients, only 61% were on renin-angiotensin-aldosterone blockers, 74% were on β-blockers and 39% were on aldosterone antagonist.

CONCLUSION

HF patients are elderly and about evenly split between HFrEF and HFpEF. In this regional cohort, both HF types are associated with similar 1-year and 5-year mortality following incident HF hospitalisation. Echocardiography and guideline-directed therapies were underused.

Diagnosis of Acute Heart Failure in the Emergency Department: An Evidence-Based Review

Heart failure is a common presentation to the emergency department (ED), which can be confused with other clinical conditions. This review provides an evidence-based summary of the current ED evaluation of heart failure. Acute heart failure is the gradual or rapid decompensation of heart failure, resulting from either fluid overload or maldistribution. Typical symptoms can include dyspnea, orthopnea, or systemic edema. The physical examination may reveal pulmonary rales, an S3 heart sound, or extremity edema. However, physical examination findings are often not sensitive or specific. ED assessments may include electrocardiogram, complete blood count, basic metabolic profile, liver function tests, troponin, brain natriuretic peptide, and a chest radiograph. While often used, natriuretic peptides do not significantly change ED treatment, mortality, or readmission rates, although they may decrease hospital length of stay and total cost. Chest radiograph findings are not definitive, and several other conditions may mimic radiograph findings. A more reliable modality is point-of-care ultrasound, which can facilitate the diagnosis by assessing for B-lines, cardiac function, and inferior vena cava size. These modalities, combined with clinical assessment and gestalt, are recommended.

Automated analysis of breathing waveforms using BreathMetrics: a respiratory signal processing toolbox

Nasal inhalation is the basis of olfactory perception and drives neural activity in olfactory and limbic brain regions. Therefore, our ability to investigate the neural underpinnings of olfaction and respiration can only be as good as our ability to characterize features of respiratory behavior. However, recordings of natural breathing are inherently nonstationary, nonsinusoidal, and idiosyncratic making feature extraction difficult to automate. The absence of a freely available computational tool for characterizing respiratory behavior is a hindrance to many facets of olfactory and respiratory neuroscience. To solve this problem, we developed BreathMetrics, an open-source tool that automatically extracts the full set of features embedded in human nasal airflow recordings. Here, we rigorously validate BreathMetrics' feature estimation accuracy on multiple nasal airflow datasets, intracranial electrophysiological recordings of human olfactory cortex, and computational simulations of breathing signals. We hope this tool will allow researchers to ask new questions about how respiration relates to body, brain, and behavior.

Diagnosis and management of acute heart failure

Acute heart failure (AHF) is a life threatening clinical syndrome with a progressively increasing incidence in general population. Turkey is a country with a high cardiovascular mortality and recent national statistics show that the population structure has turned to an 'aged' population.As a consequence, AHF has become one of the main reasons of admission to cardiology clinics. This consensus report summarizes clinical and prognostic classification of AHF, its worldwide and national epidemiology, diagnostic work-up, principles of approach in emergency department,intensive care unit and ward, treatment in different clinical scenarios and approach in special conditions and how to plan hospital discharge.

Prognostic significance of ECG abnormalities for mortality risk in acute heart failure: insight from the Sub-Saharan Africa Survey of Heart Failure (THESUS-HF)

OBJECTIVE

The aim of this study was to assess the predictive utility of 12-lead electrocardiogram (ECG) abnormalities among Africans with acute heart failure (HF).

METHODS AND RESULTS

We used the Sub-Saharan Africa Survey of Heart Failure, a multicenter prospective cohort study of 1,006 acute HF patients, and regression models to relate baseline ECG findings to all-cause mortality and readmission during a 6-month follow-up period. Of 814 ECGs available, 523 (49.0% male) were obtained within 15 days of admission, among which 97.7% showed abnormalities. Mean age was 52.0 years and median follow-up was 180 days, with 77 deaths (Kaplan-Meier 17.5%) through day 180 and 63 patients with death or readmission to day 60. QRS width, QT duration, bundle branch block, and ischemic changes were not associated with outcomes. Increasing ventricular rate was associated with increasing risk of both outcomes (hazard ratio [HR] 1.07 per 5 beats/min increase for 60-day death or readmission, 95% confidence interval [CI] 1.02-1.12; P = .0047), and the presence of sinus rhythm was associated with lower risk (HR 0.58, 95% CI 0.34-0.97; P = .0385). There was a strong association between survival and heart rate in patients in sinus rhythm, with heart rate >119 beats/min conveying the worst mortality risk.

CONCLUSIONS

ECG abnormalities are almost universal among Africans with acute HF, which may add to the immediate diagnosis of patients presenting with dyspnea. Although some ECG findings have prognostic value for risk of adverse outcomes, most of them are nonspecific and add little to the risk stratification of these patients.