Survival of heart failure patients with preserved versus impaired systolic function: the prognostic implication of blood pressure

Differential Impact of Systolic and Diastolic Heart Failure on In-Hospital Treatment, Outcomes, and Cost of Patients Admitted for Pneumonia

Background

Patients admitted with pneumonia and heart failure (HF) have increased mortality and cost compared to those without HF, but it is not known whether outcomes differ between systolic and diastolic HF. Management of concomitant pneumonia and HF is complicated because HF treatments can worsen complications of pneumonia.

Methods

This is a retrospective cohort study from the Premier Database among patients admitted with pneumonia between 2010-2015. Patients were categorized based on systolic, diastolic, and combined HF using ICD-9 codes. The primary outcome was in-hospital mortality. Secondary outcomes included use of HF medications, length of stay, cost, intensive care unit (ICU) admission, as well as use of invasive mechanical ventilation (IMV), vasopressors and inotropes. Multivariable logistic regression was used to describe associations of these outcomes with type of HF.

Results

Of 123,211 patients with pneumonia and HF, 41,196 (33.4%) had systolic HF, 69,982 (56.8%) diastolic HF, and 12,033 (9.8%) had combined HF. Compared to patients with diastolic HF, after multivariable adjustment systolic HF was associated with higher in-hospital mortality (OR 1.15; 95% CI:1.11-1.20), ICU admission, and use of IMV and vasoactive agents, but not with increased length of stay or cost. Among patients with systolic HF, 80% received a loop diuretic, 72% a beta blocker, 48% angiotensin converting enzyme inhibitor or angiotensin receptor blocker, and 12.5% a mineralocorticoid receptor antagonist.

Conclusion

Systolic HF is associated with added risk in pneumonia compared to diastolic HF. There may also be an opportunity to optimize medications in systolic HF prior to discharge.

The other side of the medallion in heart failure: Reverse metabolic syndrome

BACKGROUND AND AIMS

Lower levels of cardiovascular risk factors are associated with an increase in mortality in H.F. To explain this paradox, the term reverse metabolic syndrome (RMetS) has recently been proposed. We suggest defining these patients with lower levels of three risk factors can be combined under the heading "RMetS." We aimed to investigate the effect of MetS and RMetS on hemodynamic parameters and prognosis in patients with H.F. and reduced ejection fraction (HFrEF).

METHODS AND RESULTS

We included 304 patients who were performed right heart catheterization and followed up for a median of 16 (0-48) months. We first grouped patients according to the presence of MetS or not, then we added the RMetS category and stratified patients into three groups as MetS, RMetS, and metabolic healthy. Compared with not MetS group, Pulmonary arterial pressures and VO₂ were higher in MetS group. In the second step, LVEF, CI, VO₂I, O₂ delivery, and LVSWI were lowest in RMetS, pulmonary artery pressures were higher in MetS group. In multivariate Cox regression analysis, being in RMetS group was associated with 2.4 times and 1.8 times increased risk for composite end point (CEP) and all-cause mortality, respectively. In Kaplan Meier analysis, RMetS had the highest all-cause mortality and CEP.

CONCLUSIONS

We determined that RMetS patients had the worst prognosis with unfavorable hemodynamic profile. Hence, a better understanding of the pathophysiology of RMetS may help refine the treatment targets of CV risk factors, may yield new interventions targeting catabolic syndrome.

Age-dependent differences in clinical phenotype and prognosis in heart failure with mid-range ejection compared with heart failure with reduced or preserved ejection fraction

BACKGROUND

HFmrEF has been recently proposed as a distinct HF phenotype. How HFmrEF differs from HFrEF and HFpEF according to age remains poorly defined. We aimed to investigate age-dependent differences in heart failure with mid-range (HFmrEF) vs. preserved (HFpEF) and reduced (HFrEF) ejection fraction.

METHODS AND RESULTS

42,987 patients, 23% with HFpEF, 22% with HFmrEF and 55% with HFrEF, enrolled in the Swedish heart failure registry were studied. HFpEF prevalence strongly increased, whereas that of HFrEF strongly decreased with higher age. All cardiac comorbidities and most non-cardiac comorbidities increased with aging, regardless of the HF phenotype. Notably, HFmrEF resembled HFrEF for ischemic heart disease prevalence in all age groups, whereas regarding hypertension it was more similar to HFpEF in age ≥ 80 years, to HFrEF in age < 65 years and intermediate in age 65-80 years. All-cause mortality risk was higher in HFrEF vs. HFmrEF for all age categories, whereas HFmrEF vs. HFpEF reported similar risk in ≥ 80 years old patients and lower risk in < 65 and 65-80 years old patients. Predictors of mortality were more likely cardiac comorbidities in HFrEF but more likely non-cardiac comorbidities in HFpEF and HFmrEF with < 65 years. Differences among HF phenotypes for comorbidities were less pronounced in the other age categories.

CONCLUSION

HFmrEF appeared as an intermediate phenotype between HFpEF and HFrEF, but for some characteristics such as ischemic heart disease more similar to HFrEF. With aging, HFmrEF resembled more HFpEF. Prognosis was similar in HFmrEF vs. HFpEF and better than in HFrEF.

Prognostic value of daytime heart rate, blood pressure, their products and quotients in chronic heart failure

BACKGROUND

Chronic heart failure (CHF) is an important epidemiological and therapeuthic issue with poor prognosis. The aim of the study was to estimate the prognostic value of daytime heart rate (HR), blood pressure (BP), their products and quotients in patients with CHF.

METHODS

The study included 80 stable patients with CHF and reduced left ventricular ejection frac- tion (LVEF ≤ 35%). Physical examination, laboratory blood tests, electrocardiogram, chest X-ray, echocardiography, 6-minute walk test, telemetry monitoring and BP measurements were performed in all participants. We estimated mean daytime: BP, HR, their products and quotients. The follow-up period was 6 months. Major adverse cardiac events (MACE) included: death, cardiovascular death, hospitalization due to CHF exacerbation.

RESULTS

The analysis involved all recruited patients with CHF (91% men) aged 59 ± 12 years, in New York Heart Association class 2.15 ± 0.57 and reduced LVEF (mean LVEF: 23 ± 6%). The 3-month and 6-month mortality rates were 4% and 6%, respectively. There was a significant correlation between diastolic blood pressure (DBP), all-cause mortality (p = 0.048) and CHF decompensation (p = 0.0004) after 3-month observation period. No relationship was found between HR or systolic blood pressure (SBP) and MACE. Both higher SBP × HR and DBP × HR products were related to lower risk of heart failure exacerbations during 6-month follow-up. None of the analyzed products or ratios had an impact on mortality in this study group.

CONCLUSIONS

Diastolic blood pressure, SBP × HR and DBP × HR products may be useful in sub- sequent heart failure exacerbation risk stratification. Moreover, DBP value may predict short-term mortality in patients with CHF.

Is ambulatory blood pressure measurement a new indicator for survival among advanced heart failure cases

BACKGROUND

Ambulatory blood pressure monitoring (ABPM) in heart failure is not well defined. However, from the limited studies available, ABPM may be used to optimize heart failure therapy, and as a prognostic marker in this patient group. We analyzed the ABPM values with survival in advanced heart failure with reduced ejection fraction (HFrEF) patients who are on optimal guideline directed medical therapy (GDMT).

METHODS AND RESULTS

Hundred patients of advanced HFrEF were followed up for one year. Baseline left ventricular ejection fraction (LVEF), left ventricular end diastolic diamension (LVEDD) and ABPM values were measured and they were analyzed with survival. Deceased patients (n=36) have lower ABPM values and are dippers as compared to living patients (n=64) [24hr systolic blood pressure (SBP24hr)=97.6±12.5mmHg, 24hr diastolic BP (DBP24hr)=64.6±10.2mmHg, decrement in systolic BP (dipSBP)=9.9±5.2mmHg and decrement in diastolic BP (dipDBP)=11.1±6.5mmHg Vs SBP24hr=109.4±16.9mmHg, DBP24hr=71.7±17mmHg, dipSBP=1.6±5.9mmHg and dipDBP=2.7±6.3mmHg] and they were statistically significant with p values<0.001, 0.025, <0.001, and <0.001 respectively. A logistic regression analysis was done to predict one year survival using age, sex, LVEF, LVEDD, SBP24hrs, DBP24hrs, dipSBP, dipDBP and dipMAP as independent predictors. When SBP24hrs is raised by one unit the chances of survival are 1.145 times more(Exp(B)=1.145). One unit dip in SBP and DBP will reduce the chances of survival by 0.697 times and 0.586 times respectively.

CONCLUSION

In advanced HFrEF patients with Lower SBP & DBP and dippers have lesser survival compared to those with higher SBP & DBP and non-dippers.

The obesity paradox in ICU patients

Excessive weight is connected with an increased risk of certain life-threatening diseases. However, some evidence shows that among patients with chronic diseases such as heart failure (HF) chronic kidney disease (CKD) and COPD, increased weight is paradoxically associated with a decreased risk of mortality. This counterintuitive phenomenon is referred to as the obesity paradox. The obesity paradox has been mostly observed among certain cohorts of patients with HF, but not specific to patients in the Intensive Care Unit (ICU) setting. This paper studies the relationship between obesity and mortality of ICU patients with and without HF and presents evidence supporting the existence of this paradox. The results provide helpful insights for developing more patient-centric care in ICUs. Additionally, we use both the MIMIC-II and (recently available) MIMIC-III databases, for which few comparative studies exist to date. We demonstrate an aspect of consistency between the databases, providing a significant step towards validating the use of the newly announced MIMIC-III in broader studies.

Heart failure with preserved ejection fraction has a better long-term prognosis than heart failure with reduced ejection fraction in old patients in a 5-year follow-up retrospective study

BACKGROUND

The issue of whether prognosis is similar between heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) remains unresolved. Because of the problem of inconsistency in the diagnostic criteria and because there is currently no lifesaving therapy available for HFpEF, it seems to be the right time to study the outcome of a clearly defined HFpEF compared with HFrEF in contemporary heart failure (HF) therapy. This study investigates 5-year-mortality and its prognostic factors in old patients with HFpEF compared with those with HFrEF.

METHODS

This is a retrospective study. Patients hospitalized at Sahlgrenska University Hospital/Ostra for HF were consecutively included between May 2007 and April 2008. Diagnosis were reviewed and re-evaluated for each patient. The outcome measure was all-cause mortality and collected from May 2007 and 2013.

RESULTS

Mean age of the study population (n=289) was 79±7years. One third of the HF cohort had HFpEF. When adjusted for age HFrEF patients had a 42% higher 5-year mortality than HFpEF. By logistic regression analysis age, female sex, pulmonary disease, renal dysfunction, loop diuretics and aldosterone receptor antagonist were negatively associated with prognosis in HFpEF, whereas angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARBs) and Statins were positive prognostic factors. In HFrEF age, atrial fibrillation, NT-proBNP and loop diuretics were negative predictive factors, while treated hypertension, percutaneous coronary intervention, ACEi/ARBs and beta-blockers were positive factors for survival.

CONCLUSION

HFpEF proved to have a better long-term prognosis than HFrEF and a distinct prognostic risk profile.

Genetics of diastolic heart failure

Heart failure explains a large portion of heart diseases. Molecular mechanisms determining cardiac function, by inference dysfunction in heart failure, are incompletely understood, especially in the common (or congestive) systolic (SHF) and diastolic heart failure (DHF). Limited genome-wide association studies (GWASs) in humans are reported on SHF and no GWAS has been performed on DHF. Genetic analyses in a rodent model of true DHF, Dahl salt-sensitive (DSS) rats, have begun to unravel the genetic components determining diastolic function. Diastolic dysfunction of DSS rats can be ameliorated or even normalized by distinct quantitative trait loci (QTLs), designated as diastolic function/blood pressure QTLs (DF/BP QTLs), which also affect blood pressure (BP). However, an improvement in diastolic dysfunction is merely transitory from a single DF/BP QTL, despite a permanent lowering of BP. A long-term protection against diastolic dysfunction can be realized only through combining specific DF/BP QTLs. Moreover, the worsening diastolic dysfunction with age can also be reversed in a different combination of DF/BP QTLs. Thus, distinct genes in combinations must be involved in the physiological mechanisms ameliorating or reversing diastolic dysfunction. As not all the QTLs that influence BP can affect diastolic function, it is not BP reduction itself that restores diastolic function, but rather specific genes that are uniquely integrated into the pathways of blood pressure homeostasis as well as diastolic function. Thus, the elucidation of pathophysiological mechanisms causal to hypertensive diastolic dysfunction will not only provide new diagnostic tools, but also novel therapeutic targets and strategies in reducing, curing, and even reversing DHF.

Evolving approaches to the management of heart failure with preserved ejection fraction in patients with coronary artery disease

OPINION STATEMENT

Coronary artery disease (CAD) is a major cause of heart failure with preserved ejection fraction (HFpEF). In studies of HFpEF, the reported prevalence of CAD varies widely, which may be the result of inconsistent definitions of CAD, geographic and ethnic differences in CAD burden, varying definitions of HFpEF (including different cutoffs for "preserved ejection fraction"), and differences in study design. Despite these limitations, pooled analysis of prospective HFpEF studies demonstrates that CAD is common in HFpEF, with an estimated prevalence of approximately 50%. Based on available data, patients with signs and symptoms of heart failure who have preserved left ventricular ejection fraction and evidence of CAD (HFpEF-CAD) most likely comprise a distinct etiologic and pathophysiologic subset of HFpEF. Therefore, future clinical trials in HFpEF should a priori stratify by CAD or specifically target patients with CAD, strategies that may improve the disappointing track record of therapies tested in HFpEF. The combination of systematic evaluation and management of CAD in HFpEF, along with promising future therapies for HFpEF-CAD, may lead to improved outcomes for this challenging clinical syndrome.

Influence of admission blood pressure on mortality in patients with acute decompensated heart failure

OBJECTIVES

To determine the relationship between admission blood pressure (BP) and prognosis in patients hospitalized for acute decompensated heart failure (HF).

BACKGROUND

The relationship between BP admission blood pressure and outcomes in decompensated HF is controversial. It has been suggested that this presentation may be a specific disorder, but their mechanisms and clinical relationships are poorly defined.

METHODS

We evaluated the association between initial BP (systolic, diastolic and mean BP) with readmission and mortality, as well as potential interactions with age, clinical characteristics, renal function, left ventricular dysfunction, comorbidities and treatment. By using Cox regression models the association between each outcome and BP was tested.

RESULTS

A total of 581 patients (77.5-years-old, range 51-100) were included. At admission, mean BP in quartiles was 77.09 mm Hg (53.3-85.0) (Q1); 91.46 mm Hg (85.0-96.7) (Q2); 103.41 mm Hg (96.7-109.9) (Q3) and 124.79 mm Hg (109.9-209.0) (Q4). Median duration of follow-up was 8 months [95% confidence interval (CI) 5.2-11.1]. Mortality was 15.5% (Q1), 9.2% (Q2), 12.6% (Q3) and 7.3% (Q4). Interquartile hazard ratio (95% CIs) for mortality was 0.40 (0.19-0.85) P=0.017. Body mass index (BMI) was higher in Q4 29.59 k/m2 than in Q1 28.25 k/m2 (P=0.018). There were no differences in age, clinical antecedents, renal function, comorbidities or severity of HF between groups.

CONCLUSION

Higher mean BP at admission is associated with significantly lower mortality during follow-up, in patients hospitalized for HF. With the exception of BMI, positively correlated with blood pressure, this relationship is independent of other clinical factors and medications.

Change in blood pressure during hospitalisation for acute heart failure predicts mortality

OBJECTIVE

In patients with acute heart failure (HF) there is an inverse relation between blood pressure (BP) and mortality but the prognostic impact of the change in BP between admission and discharge is not known. The primary objective was to study the impact of the change in BP during a hospitalisation for acute HF on prognosis.

DESIGN

We studied 208 consecutive patients admitted with acute heart failure and discharged alive, age 77 ± 10 years, 49.5% women.

RESULTS

BP at admission was 145 ± 35/85 ± 9 mmHg compared to 132 ± 24/76 ± 13 mmHg at discharge. The average number of BP lowering medications at admission and discharge was 2.1 ± 1.2 and 2.8 ± 1.0 respectively. The average number of BP lowering medications with dose increased at discharge compared to admission was 0.3 ± 0.5. Univariate predictors of all-cause mortality at 12 and/or 40 months were admission SBP and DBP, discharge DBP, decrease in SBP and DBP during hospitalisation, age, eGFR, number of added BP-lowering medications during the hospitalisation and left ventricular ejection fraction (LVEF). Multivariate predictors at 12 and/or 40 month were admission DBP, decrease in DBP, age, eGFR, LVEF and number of new BP-lowering medications added during the hospitalisation.

CONCLUSIONS

A decrease in BP during hospitalisation for acute heart failure was a predictor of all cause mortality. A higher admission BP and the tolerability of added medications probably played a role, and our findings need confirmation in larger studies.

Exercise testing and prescription in patients with congenital heart disease

The present paper provides a review of the literature regarding exercise testing, exercise capacity, and the role of exercise training in patients with congenital heart disease (CHD). Different measures of exercise capacity are discussed, including both simple and more advanced exercise parameters. Different groups of patients, including shunt lesions, pulmonary valvar stenosis, patients after completion of Fontan circulation, and patients with pulmonary arterial hypertension are discussed separately in more detail. It has been underscored that an active lifestyle, taking exercise limitations and potential risks of exercise into account is of utmost importance. Increased exercise capacity in these patients is furthermore correlated with an improvement of objective and subjective quality of life.

The prognostic significance of heart failure with preserved left ventricular ejection fraction: a literature-based meta-analysis

AIMS

Heart failure (HF) with normal or preserved left ventricular (LV) ejection fraction (HFPEF) has been reported to be associated with similar outcome as HF with reduced EF (HFREF) in registry-based and epidemiological analyses, but many of these studies excluded patients who did not have EF measurements. Conversely, prior prospective studies have reported better outcome for patients with HFPEF. We performed a meta-analysis of prospective observational studies comparing all-cause mortality in patients with HFREF and HFPEF.

METHODS AND RESULTS

We searched several online databases for studies comparing outcome in HFREF and HFPEF, published before 2007.

INCLUSION CRITERIA

prospective, clinical HF, near complete EF data, and mortality outcome. Review Manager version 4.2.3 software was used for the analysis. Overall, 24 501 patients [9299 deaths (38%)] from 17 studies are included. Average follow-up was 47 months; the HFPEF group was older (69 vs. 66 years) and more likely to be female (44% vs. 26%). Of the 7688 patients with HFPEF 2468 died (32.1%), compared with 6831 of the 16 813 patients with HFREF (40.6%): odds ratio 0.51 (95% CI: 0.48, 0.55).

CONCLUSION

This literature-based meta-analysis demonstrates that mortality among patients with HFPEF was half that observed in those with HFREF, in contrast to previous reports suggesting that mortality may be similar between both groups.

Distinct genomic replacements from Lewis correct diastolic dysfunction, attenuate hypertension, and reduce left ventricular hypertrophy in Dahl salt-sensitive rats

BACKGROUND

Hypertension and diastolic heart failure are two common cardiovascular diseases that inflict heavy morbidity and mortality, yet relatively little is understood about their pathophysiology. The identification of quantitative trait loci for blood pressure is important in unveiling the causes of polygenic hypertension. Although Dahl salt-sensitive strain is also an excellent model for the study of diastolic heart failure, virtually nothing is known about the quantitative trait loci determining diastolic heart failure. Diastolic dysfunction often represents the onset of diastolic heart failure.

METHODS

We first characterized the cardiac phenotype of Dahl salt-sensitive strain and normotensive Lewis control rats by echocardiography to ascertain diastolic function. We then analyzed corresponding features of four newly developed and two existing congenic strains, each of which carries a specific chromosome substitution of Dahl salt-sensitive strain by its Lewis homologue and each lowering blood pressure.

RESULTS

Dahl salt-sensitive strain displayed diastolic dysfunction that was rectified in two of six congenic strains, designated as positive congenic strains, which represent the first rodent models exhibiting functional normalization of diastolic dysfunction caused by naturally occurring genetic variants. The two positive congenic strains also showed a reduction in left ventricular mass. In contrast, four of six congenic strains did not change diastolic function despite their blood pressure-lowering effects.

CONCLUSION

Genes present in the replaced chromosome segments of the two positive congenic strains are not commonly known to affect blood pressure, diastolic function or left ventricular mass. Consequently, novel prognostic, diagnostic and therapeutic strategies for hypertensive diastolic heart failure likely emerge from this work.

Treatment of hypertension in heart failure with preserved ejection fraction: role of the kidney

Heart failure can present clinically as primarily diastolic or systolic dysfunction or both. There is an increasing awareness that heart failure can occur in the presence of a normal left ventricular ejection fraction. Heart failure with normal left ventricular ejection fraction is frequently referred to as diastolic heart failure because of the presence of diastolic left ventricular dysfunction evident from impaired left ventricular relaxation. This article focuses on the treatment of hypertension and the role the kidney plays in selecting appropriate agents.

Chronic systolic heart failure, guideline-directed medical therapy, and systemic hypotension-less pressure but maybe more risk (does this clinical scenario need more discussion?)

Many clinical trials have demonstrated the survival benefit of medication regimens that modulate the neurohormonal activation that occurs with chronic heart failure (HF). These medications, however, also commonly lower systemic blood pressure (BP). Low arterial BP in patients with chronic HF has been shown to be an independent predictor of increased mortality. Given this apparent paradox in therapeutic goals (treat aggressively but keep BP from going too low), how low should we allow systemic BP to go as a result of our medication regimens before we compromise the proven benefits of such drug therapy? Or is the association between the BP-lowering effects of standard therapy and outcomes in HF even meaningful clinically? It is from this perspective that the merits, potential clinical implications, and the relevant published literature pertaining to this patient and practice management issue will be discussed.

Association of blood pressure and its evolving changes with the survival of patients with heart failure

OBJECTIVE

The association between low blood pressure (BP) levels and increased mortality has been established in several studies of heart failure (HF). Although many drugs administered to these patients decrease BP, the relationship between changes in BP and survival has not been investigated. Nor have previous analyses distinguished among different forms of death. We investigated the influence of baseline BP and changes in BP during a 1-year period on the survival of patients with HF, distinguishing among sudden cardiac death, nonsudden cardiac death, and noncardiac death. We also identified the possible relationship with the baseline values of and changes in other clinical and treatment variables, including pharmacologic treatments.

METHOD AND RESULTS

A total of 1062 patients with chronic HF included in the Spanish National Registry of Sudden Death (mean age of 64.5 +/- 11.8 years, 72% were men, and 21% were in New York Heart Association class III with a mean left ventricular ejection fraction of 36.7% +/- 14.2%) were prospectively investigated for a mean of 1.9 +/- 0.6 years. A multivariable Cox proportional hazards model adjusting for clinical and therapeutic variables showed an independent association between low baseline systolic blood pressure (SBP) and nonsudden cardiac death (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.93-0.98), but changes in SBP during the following year did not influence survival, regardless of the baseline SBP level (P = .55). Contrariwise, baseline diastolic BP was not associated with mortality, but an increase in diastolic BP during the following year showed a borderline independent significant association with lower nonsudden cardiac death (HR 0.90, 95% CI 0.82-1.00). Treatment with angiotensin-converting enzyme inhibitors or beta-blockers at baseline was also associated with lower nonsudden cardiac mortality, as was an increase in left ventricular ejection fraction during the following year (HR 0.69, 95% CI 0.51-0.93; P = .015).

CONCLUSION

Among patients with stable HF, low SBP is associated with a greater risk of nonsudden cardiac death. The change in SBP during a 1-year period has no prognostic value. Because the beneficial effects of drugs associated with increased survival (in this study, angiotensin-converting enzyme inhibitors and beta-blockers) thus seem to be independent of their effects on BP, changes in BP should probably not influence the decision to use such drugs or continue their administration.

Effect of antecedent hypertension and follow-up blood pressure on outcomes after high-risk myocardial infarction

The influence of blood pressure on outcomes after high-risk myocardial infarction is not well characterized. We studied the relationship between blood pressure and the risk of cardiovascular events in 14 703 patients with heart failure, left ventricular systolic dysfunction, or both after acute myocardial infarction in the Valsartan in Myocardial Infarction Trial. We assessed the relationship between antecedent hypertension and outcomes and the association between elevated (systolic: >140 mm Hg) or low blood pressure (systolic: <100 mm Hg) in 2 of 3 follow-up visits during the first 6 months and subsequent cardiovascular events over a median 24.7 months of follow-up. Antecedent hypertension independently increased the risk of heart failure (hazard ratio [HR]: 1.19; 95% CI: 1.08 to 1.32), stroke (HR: 1.27; 95% CI: 1.02 to 1.58), cardiovascular death (HR: 1.11; 95% CI: 1.01 to 1.22), and the composite of death, myocardial infarction, heart failure, stroke, or cardiac arrest (HR: 1.13; 95% CI: 1.06 to 1.21). While low blood pressure in the postmyocardial infarction period was associated with increased risk of adverse events, patients with elevated blood pressure (n=1226) were at significantly higher risk of stroke (adjusted HR: 1.64; 95% CI: 1.17 to 2.29) and combined cardiovascular events (adjusted HR: 1.14; 95% CI: 1.00 to 1.31). Six months after a high-risk myocardial infarction, elevated systolic blood pressure, a potentially modifiable risk factor, is associated with an increased risk of subsequent stroke and cardiovascular events. Whether aggressive antihypertensive treatment can reduce this risk remains unknown.

Incidence and predictors of sudden cardiac death in patients with diastolic heart failure

INTRODUCTION

Although it is known that patients with diastolic heart failure are at an increased risk of death, their mode of death has not been clearly defined. We conducted this study to examine the incidence and predictors of sudden cardiac death (SCD) in patients with isolated diastolic heart failure.

METHODS AND RESULTS

Using the Duke Databank for Cardiovascular Disease, we identified patients with a history of congestive heart failure (CHF) and an ejection fraction of greater than 50% who were enrolled in the database from 1995 through 2004. Mode of death was adjudicated by two independent reviewers. Of the 1,941 patients who met our inclusion criteria, 548 (28%) died (40 were SCD). Using a Cox proportional hazards model, five variables were found to be independently associated with a significant increase in the risk of SCD. These variables include diabetes mellitus (P < 0.01), the presence of mild mitral regurgitation (P < 0.01), severity of CHF (P < 0.01), the occurrence of a myocardial infarction within 3 days prior to the date of the index cardiac catheterization (P = 0.01), and severity of coronary artery disease (P = 0.02).

CONCLUSIONS

SCD is not uncommon in patients with isolated diastolic heart failure. We identified some clinical variables that are associated with a significant increase in the risk of SCD and that may be used in the risk stratification of patients for SCD. Studies are needed to validate our findings.

Strong and independent prognostic value of peak circulatory power in adults with congenital heart disease

BACKGROUND

The identification of patients with adult congenital heart disease (ACHD) who are at higher risk of death is challenging. Peak circulatory power (CircP; expressed as peak exercise oxygen uptake multiplied for peak mean arterial blood pressure) is a strong predictor of death in adults with acquired heart disease. We sought to establish the distribution and the prognostic value of peak CircP across a wide spectrum of patients with ACHD.

METHODS

Four hundred thirty-two consecutive patients with ACHD of varying diagnosis underwent cardiopulmonary exercise testing at a single laboratory between 1996 and 2005. Patient age was 32 +/- 10 years.

RESULTS

A gradual variation in peak CircP was found across the spectrum of congenital heart defects (P < .0001 at analysis of variance). Reduced peak CircP values were associated with the presence of heart failure symptoms (P < .0001), absence of sinus rhythm (P = .010), and use of antiarrhythmic medications (P = .0013). At a follow-up of 4.4 +/- 2.4 years, 23 patients (5.3%) had died. Peak CircP was a strong predictor of mortality when univariate analysis was used and the strongest independent predictor of mortality among exercise parameters. A peak CircP < or = 1476 mm Hg mlO2 min(-1) kg(-2) was associated with a 15.4-fold increase in the 4-year risk of death.

CONCLUSIONS

Peak CircP is abnormal across the spectrum of ACHD. Peak CircP appears as the strongest predictor of adverse outcome in ACHD.

Ejection fraction and blood pressure are important and interactive predictors of 4-week mortality in severe acute heart failure

BACKGROUND

In acute heart failure syndromes (AHFS), the prognostic value of left ventricular ejection fraction (LVEF), although widely accepted, has been recently challenged. In contrast, blood pressure is increasingly gaining ground over LVEF as predictor of mortality. Therefore, it is not clear whether both LVEF and mean arterial pressure (MAP) are independent risk factors in patients with AHFS.

METHODS AND RESULTS

The EFICA study enrolled 581 AHFS patients admitted to 60 CCU/ICUs. Survival at 4 weeks was analyzed for all cases with echocardiographic LVEF available on admission (n=355). Four-week mortality was 23%. Multivariable analysis identified lower LVEF, lower MAP and serum creatinine >1.5 mg/dl as independent correlates of mortality (respectively, OR: 1.27 per 10% decrease, CI: 1.05-1.53, p=0.012; OR: 1.30 per 10 mmHg decrease, CI: 1.15-1.48, p<0.0001; OR: 2.84, CI: 1.64-4.93, p=0.0002). LVEF interacted significantly with MAP (p<0.0001) and the subgroup analysis showed that reduced LVEF was a strong risk factor in patients with MAP <or=90 mmHg (OR: 2.73, CI: 1.23-5.98, p=0.01) but did not reach statistical significance in patients with MAP >90 mmHg.

CONCLUSIONS

Both LVEF and MAP are important predictors of death in severe AHFS. LVEF can provide additional prognostic information on top of MAP but mainly in patients with low MAP (<or=90 mmHg) at admission.

Epidemiology of dialysis patients and heart failure patients

The epidemiology of maintenance dialysis patients and heart failure patients has striking similarities. Both groups have a high prevalence of comorbid conditions, a high hospitalization rate, a low self-reported quality of life, and an excessively high mortality risk, mostly because of cardiovascular causes. Observational studies in both dialysis and heart failure patients have indicated the lack of a significant association between the traditional cardiovascular risk factors and mortality, or the existence of a paradoxic or reverse association, in that obesity, hypercholesterolemia, and hypertension appear to confer survival advantages. The time discrepancy between the 2 sets of risk factors, that is, overnutrition (long-term killer) versus undernutrition (short-term killer) may explain the overwhelming role of malnutrition, inflammation, and cachexia in causing the reverse epidemiology, which may exist in more than 20 million Americans. We have reviewed the opposing views about the concept of reverse epidemiology in dialysis and heart failure patients, the recent Die Deutsche Diabetes Dialyze study findings, and the possible role of racial disparities. Contradictory findings on hyperhomocysteinemia in dialysis patients are reviewed in greater details as a possible example of publication bias. Additional findings related to intravenous iron and serum ferritin, calcium, and leptin levels in dialysis patients may enhance our understanding of the new paradigm. The association between obesity and increased death risk in kidney transplanted patients is reviewed as an example of the reversal of reverse epidemiology. Studying the epidemiology of dialysis patients as the archetypical population with such paradoxic associations may lead to the development of population-specific guidelines and treatment strategies beyond the current Framingham cardiovascular risk factor paradigm.

Determination of optimal atrioventricular delay for cardiac resynchronization therapy using acute non-invasive blood pressure

AIMS

In this study, we apply non-invasive blood pressure (BP) monitoring, by continuous finger photoplethysmography (Finometer), to detect directly haemodynamic responses during adjustment of the atrioventricular (AV) delay of cardiac resynchronization therapy (CRT), at different heart rates.

METHODS AND RESULTS

Twelve patients were studied with six re-attending for reproducibility assessment. At each AV delay, systolic BP relative to a reference AV delay of 120 ms (SBPrel) was calculated. We found that at higher heart rates, altering the AV delay had a more pronounced effect on BP (average range of SBPrel=17.4 mmHg) compared with resting rates (average range of SBPrel=6.5 mmHg), P<0.0001. Secondly, peak AV delay differed between patients (minimum 120 ms, maximum 200 ms). Thirdly, small changes in AV delay had significant BP effects: programming AV delay 40 ms below the peak AV delay reduced SBPrel by 4.9 mmHg (P<0.003); having it 40 ms above the peak decreased SBPrel by 4.4 mmHg (P<0.0005). Finally, the peak AV delay is highly reproducible both on the same day and at 3 months (Bland-Altman difference: 3+/-8 ms).

CONCLUSIONS

Continuous non-invasive arterial pressure monitoring demonstrates that even small changes in AV delay from its haemodynamic peak value have a significant effect on BP. This peak varies between individuals, is highly reproducible, and is more pronounced at higher heart rates than resting rates.

The association between blood pressure and mortality in patients with heart failure

BACKGROUND

The association between low blood pressure and prognosis in the general population has been controversial, with some reports suggesting an increased mortality for patients with the lowest blood pressures. Whereas many standard heart failure therapies decrease blood pressure, the relationship between mortality and blood pressure in patients with heart failure has not been previously evaluated.

METHODS

We used the Digitalis Investigation Group trial database to evaluate retrospectively the relationship among systolic blood pressure (SBP), diastolic blood pressure (DBP), and survival among 5747 patients with New York Heart Association class II or III heart failure and left ventricular ejection fraction < or = 0.45. Cox proportional hazards models were used to identify covariates predictive of long-term mortality.

RESULTS

The adjusted all-cause mortality rate during the entire study period for patients in the lowest SBP group (< 100 mm Hg) was 50% and was significantly higher than that of the reference group of patients with SBP of 130 to 139 mm Hg, which had a mortality rate of 32% (hazard ratio 1.65, 95% CI 1.25-2.17, P < .001). The relationship between SBP and mortality was significant (P < .001) and nonlinear (P = .009). The relationship between DBP and mortality was significant (P < .001), with the highest mortality seen in patients with DBP < 60 mm Hg.

CONCLUSIONS

In patients with systolic dysfunction (left ventricular ejection fraction < or = 0.45) and New York Heart Association classes II and III symptoms, lower SBPs and DBPs were associated with greater mortality.

Poor prognosis of Japanese patients with chronic heart failure following myocardial infarction--comparison with nonischemic cardiomyopathy

BACKGROUND

Myocardial infarction (MI) is one of the major etiologies of chronic heart failure (CHF) in Japan.

METHODS AND RESULTS

The prognoses of CHF patients after MI (n=283) were investigated by comparing them with those of CHF patients with nonischemic cardiomyopathy (NICM, n=310) from the CHF registry (CHART; n=1,154). The Kaplan-Meier (KM) analyses revealed that the 3-year all-cause mortality was significantly higher in the MI cohort compared with the NICM cohort (29.0% vs 12.4%, p<0.0005). Age/gender/treatment-adjusted KM analysis revealed significant differences only in the cohorts with preserved left ventricular ejection fraction (LVEF), defined as LVEF >45%, or in less symptomatic patients (New York Heart Association I or II). Multivariate Cox regression analysis showed that beta-blocker (BB) was associated with a significant reduction in mortality from cardiac causes, and either angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEI/ARB) was significantly related to the improvement of survival in the MI cohort (adjusted hazard ratio: 0.222 and 0.497, p<0.05), even though these medicines were used significantly less often in the MI cohort.

CONCLUSIONS

Underlying MI has a significant impact on the survival of Japanese CHF patients, especially those with preserved LVEF or with fewer symptoms. The appropriate expansion of ACEI/ARB or BB therapy might be necessary to improve their survival.

Ventricular reverse remodeling and 6-month outcomes in patients receiving cardiac resynchronization therapy: analysis of the MIRACLE study

OBJECTIVE

The objective of this analysis was to determine if there were differences in ventricular reverse remodeling and 6-month outcome with cardiac resynchronization therapy (CRT) among specific subgroups enrolled in the Multicenter InSync Randomized Clinical Evaluation (MIRACLE) Study.

BACKGROUND

Analysis of major subgroups receiving CRT is important in determining who may be most likely to benefit, since all patients who receive CRT do not demonstrate improvement.

METHODS

Differences in response to CRT between subgroups based on baseline echocardiographic parameters, New York Heart Association (NYHA) class, age, gender, beta blocker use, and etiology of heart failure (HF) were analyzed for the clinical end points of the study as well as 6-month HF re-hospitalization or death.

RESULTS

The benefit of CRT over control was similar in all subgroups with respect to all clinical endpoints. However, non-ischemic HF patients had greater improvements with CRT compared to ischemic HF patients in left ventricular end diastolic volume (P < 0.001) and ejection fraction (EF) (6.7% increase vs. 3.2% [P < 0.001]). Greater improvements in EF were also seen in those patients with less severe baseline mitral regurgitation (MR) (P < 0.001). Women but not men receiving CRT were more likely to be event-free from first HF hospitalization or death compared to the control group (Hazard Ratio = 0.157).

CONCLUSIONS

The benefits of CRT with respect to EF and reverse remodeling were greater in patients with non-ischemic HF and less severe MR. Women may also derive more benefit than men with respect to the occurrence of HF hospitalization or death.

Influence of diabetes on the survival of patients hospitalized with heart failure: A 12-year study

AIM

To investigate the influence of diabetes mellitus (DM) on the prognosis of heart failure (HF) patients, focussing specifically on aetiology and patients with preserved left ventricular systolic function (LVSF), which to date has not been fully investigated.

METHOD AND RESULTS

1659 Patients hospitalized for HF between 1991 and 2002 in the Cardiology Department of a tertiary hospital, aged 69+/-12 years, 60% male were studied prospectively. Arterial hypertension was present in 54% of patients, DM in 26% and ischaemic cardiomyopathy in 51%. A survival analysis performed in April 2003 showed that DM worsens the prognosis of the whole group (median survival (MS): 3.6 vs. 5.4 years; p<0.001), of ischaemic and non-ischaemic patients (MS: 3.8 vs. 4.9 years; p=0.13 and 3.6 vs. 6.0 years; p<0.001, respectively). A similar effect of DM was shown in patients with preserved LVSF (MS: 3.8 vs. 5.8 years; p=0.03) and in patients with impaired LVSF (3.6 vs. 6.3 years; p<0.0001).

CONCLUSION

DM increases mortality among HF patients with preserved and impaired LVSF and those without ischaemic cardiomyopathy.

Reverse epidemiology of hypertension and cardiovascular death in the hemodialysis population: the 58th annual fall conference and scientific sessions

Maintenance hemodialysis patients in the United States have a high prevalence (approximately 80%) of systolic hypertension and a high mortality (approximately 20% per year). Some reports indicate a paradoxical association between hypertension and mortality in hemodialysis patients (ie, a normal to low blood pressure is associated with poor outcome), whereas high pressure confers survival advantages, a phenomenon referred to as "reverse epidemiology." We hypothesized that malnutrition-inflammation complex syndrome may be a cause of this paradoxical association. We studied a 15-month cohort of 40 933 hemodialysis patients in the United States whose predialysis and postdialysis blood pressure values were recorded routinely during each hemodialysis treatment. Patients were 59.8+/-15.3 years old; 54% were women and 46% diabetics. Cox proportional hazard models were used for blood pressure categories (systolic <110, > or =190 mm Hg; diastolic <50, > or =110; and increments of 10 mm Hg in between). Unadjusted, case-mix and dialysis dose-adjusted, and additional malnutrition-inflammation-adjusted hazard ratios of all-cause and cardiovascular death showed progressively increasing all-cause and cardiovascular death risk for decreasing blood pressure values. The lowest mortality was associated with predialysis systolic pressure of 160 to 189 mm Hg, whereas normal to low predialysis pressure values were associated with significantly increased mortality. Adjustment for the malnutrition-inflammation mitigated only a small portion of paradoxical associations between the low blood pressure and mortality. Predialysis systolic hypertension remained a significant predictor of highest all-cause and cardiovascular survival rate. Although these associations may not be causal, they call into question whether treatment goals for the general population can be applied to dialysis patients or other similar populations.

Outcomes and Prognostic Factors of Systolic as Compared With Diastolic Heart Failure in Urban America

We sought to describe a large heart failure (HF) population with respect to systolic and diastolic abnormalities in terms of demographics, echocardiographic parameters, and survival. Using data abstracted from the Resource Utilization Among Congestive Heart Failure (REACH) study, a targeted subpopulation of 3471 patients had electrocardiographic, echocardiographic, and clinical data taken from automated sources during the first year of diagnosis. Among the HF population, 1811 (52.2%) had diastolic HF. Prevalence of diastolic HF trended with age, from 46.4% in those less than 45 years to 58.7% in those 85 years or older (p=0.001 for trend). Patients with diastolic HF had a higher mean ejection fraction (55.7% vs. 28.0%), lower left ventricular end-systolic diameter (3.11 vs. 4.74 cm), and lower left atrium:aortic outlet ratio (1.28 vs. 1.38) (p=0.001 for each comparison). Annualized age, sex, and race-adjusted mortality were 11.2% and 13.0% for those with diastolic and systolic HF, respectively (p=0.001). In a large, racially mixed, urban HF population, those with diastolic HF predominate and enjoy better-adjusted survival than counterparts with systolic HF.

The epidemiological enigma of heart failure with preserved systolic function

BACKGROUND

Current epidemiological evidence suggests that the prevalence of preserved systolic function in patients with heart failure varies widely from 13 to 74%. This inconsistency suggests a lack of consensus as to what this condition really is and how it has been characterised for epidemiological studies.

AIMS

In this review, we summarise and discuss the current understanding of the epidemiology of heart failure with preserved systolic function and the challenges that this raises.

METHODS

Studies were identified from Medline and Embase Literature Database searches using the subject headings heart failure, diastolic heart failure, epidemiology, incidence, prevalence, diagnosis, prognosis and mortality.

RESULTS

Sixty-one studies of congestive heart failure with preserved systolic function were reviewed. There is great diversity in the criteria used to determine whether heart failure is present, the patient population, the setting of the study and methods of evaluating left ventricular function. This makes epidemiological studies of prevalence, morbidity and mortality impossible to compare.

CONCLUSIONS

The diagnosis of this syndrome might be better defined in terms of symptoms, elevated neuro hormones and impaired cardiac workload. This would allow accurate identification of cases so that further research could be conducted to measure outcome and assess therapeutic benefit.

Reverse epidemiology of conventional cardiovascular risk factors in patients with chronic heart failure

Traditional risk factors of a poor clinical outcome and mortality in the general population, including body mass index (BMI), serum cholesterol, and blood pressure (BP), are also found to relate to outcome in patients with chronic heart failure (CHF), but in an opposite direction. Obesity, hypercholesterolemia, and high values of BP have been demonstrated to be associated with greater survival among CHF patients. These findings are in contrast to the well-known associations of over-nutrition, hypercholesterolemia, and hypertension with a poor outcome in the general population. The association between traditional cardiovascular risk factors and an adverse clinical outcome in CHF patients is referred to as "reverse epidemiology." The mechanisms for this inverse association in CHF is not clear. There are other populations with a similar risk factor reversal phenomenon, including patients with end-stage renal disease receiving dialysis, those with advanced malignancies, and individuals with advanced age. Several possible causes are hypothesized: the time discrepancy of the competing risk factors may play a role; the presence of the "malnutrition-inflammation complex syndrome" in CHF patients may explain the existence of reverse epidemiology; and a decreased level of lipoprotein molecules may distort their endotoxin-scavenging role, predisposing CHF patients with a low serum cholesterol level to inflammatory consequences of endotoxemia. It is possible that new goals for such traditional risk factors as BMI, serum cholesterol, and BP should be developed for CHF. Reverse epidemiology of conventional cardiovascular risk factors is observed in CHF and may have a bearing on the management of these patients; thus, it deserves further investigation.

Influence of pretreatment systolic blood pressure on the effect of carvedilol in patients with severe chronic heart failure: the Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) study

OBJECTIVES

We sought to evaluate the influence of pretreatment systolic blood pressure (SBP) on the efficacy and safety of carvedilol in patients with chronic heart failure (CHF).

BACKGROUND

Although beta-blockers reduce the risk of death in CHF, there is little reported experience with these drugs in patients with a low pretreatment SBP, who may respond poorly to beta-blockade.

METHODS

We studied 2,289 patients with severe CHF who participated in the Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) trial.

RESULTS

Compared with placebo, carvedilol improved the clinical status and reduced the risk of death and the combined risk of death or hospitalization for any reason, for a cardiovascular reason, or for worsening heart failure (p < 0.001 for all). The relative magnitude of these benefits did not vary as a function of the pretreatment SBP (all interaction: p > 0.10). However, because patients with the lowest SBP were at highest risk of an event, they experienced the greatest absolute benefit from treatment with carvedilol. The lower the pretreatment SBP, the more likely that patients would report an adverse event, be intolerant of high doses of the study drug, or require permanent withdrawal of treatment (p < 0.001 for all). However, these risks were primarily related to the severity of the underlying illness and not to treatment with carvedilol.

CONCLUSIONS

The current study provides little support for concerns about using beta-blockers (particularly those with vasodilatory actions) in patients with severe CHF who have a low SBP. Pretreatment blood pressure can identify patients who have the greatest need for risk reduction with carvedilol.

Prevalence, clinical characteristics, quality of life, and prognosis of patients with congestive heart failure and isolated left ventricular diastolic dysfunction

Prevalence of isolated left ventricular (LV) diastolic dysfunction has been reported to be as high as one-third of all heart failure (HF) cases, with an increasing prevalence in the elderly population. However, there is a paucity of prospective data about the prevalence and prognosis of isolated LV diastolic dysfunction in an unselected population of patients hospitalized with HF. Therefore, we prospectively evaluated 179 consecutive patients discharged from our hospital with HF to assess the prevalence of systolic versus diastolic LV dysfunction among patients hospitalized with HF and to compare their demographics, clinical features, self-perceived quality of life (QOL), and 6-month readmission rate and mortality. Among them, 133 (59% men, median age 74 years) showed in sinus rhythm and had no significant primary valvular disease. LV diastolic dysfunction was diagnosed on the basis of the European Study Group on Diastolic HF echocardiographic criteria. QOL was assessed at hospital discharge and 6-month follow-up visit using the Minnesota Living with HF questionnaire. Survival of patients with HF was compared with that of age- and sex-matched general population. In all, 29 patients (22%) had isolated LV diastolic dysfunction and 102 (78%) had prevalent LV systolic dysfunction (ie, LV ejection fraction </= 45%). There was no difference in age, sex, or New York Heart Association functional class between patients with LV diastolic or systolic dysfunction. QOL scores were similar between the 2 patient groups with HF both at discharge (39.4 and 34) and at 6-month visit (10.4 and 10.4). Both 6-month readmission rate (48% and 48%) and median inhospital length-of-stay during readmissions (10 days and 10 days) were similar between the 2 patient groups with HF. Finally, 6-month survival, adjusted for age and sex, was similar between patients with LV diastolic or systolic dysfunction (hazard ratio 0.68; 95% confidence interval 0.20-2.35). Using standardized echocardiographic criteria, isolated LV diastolic dysfunction among unselected patients hospitalized with HF was less than previously reported. Patients with HF and isolated diastolic dysfunction showed similar clinical symptoms, self-perceived QOL, readmission rate, and 6-month mortality to patients with prevalent LV systolic dysfunction.

The association of left ventricular ejection fraction, mortality, and cause of death in stable outpatients with heart failure

OBJECTIVES

The aim of this study was to assess the prognostic importance of left ventricular ejection fraction (LVEF) in stable outpatients with heart failure (HF).

BACKGROUND

Although LVEF is an accepted prognostic indicator of prognosis in HF patients, the relationship of LVEF and mortality across the full spectrum of LVEF is incompletely understood.

METHODS

We examined the association of LVEF and outcomes among 7,788 stable HF patients enrolled in the Digitalis Investigation Group trial.

RESULTS

During mean follow-up of 37 months, mortality was substantial in all LVEF groups (range, LVEF <or= 15%, 51.7%, LVEF > 55%, 23.5%). Among patients with LVEF <or= 45%, mortality decreased in a near linear fashion across successively higher LVEF groups (LVEF < 15%, 51.7%; LVEF 36% to 45%, 25.6%; p < 0.0001). This association was present after multivariable adjustment, although the magnitude of this associated risk was reduced (LVEF <or= 15%: hazard ratio [HR] 1.77, 95% confidence interval [CI] 1.48 to 2.11; LVEF 16% to 25%: HR 1.44, 95% CI 1.28 to 1.61; LVEF 26% to 35%: HR 1.10, 95% CI 0.98 to 1.28; LVEF 36% to 45%: referent). In contrast, mortality rates were comparable among patients with LVEF > 45% both before (LVEF 46% to 55%: 23.3%; LVEF > 55%: 23.5%; p = 0.25), and after multivariable adjustment (LVEF 46% to 55%: HR 0.92, 95% CI 0.77 to 1.10; LVEF > 55%: HR 0.88, 95% CI 0.71 to 1.09; LVEF 36% to 45%: referent). Patients with lower LVEF were at increased absolute risk of death due to arrhythmia and worsening HF, but these were leading causes of death in all LVEF groups.

CONCLUSIONS

Among HF patients in sinus rhythm, higher LVEFs were associated with a linear decrease in mortality up to an LVEF of 45%. However, increases above 45% were not associated with further reductions in mortality.

Predictors of mortality in younger and older patients with heart failure and preserved or reduced left ventricular ejection fraction

BACKGROUND

Although half of elderly patients with heart failure have preserved left ventricular ejection fraction (LVEF), little is known about predictors of mortality in this group.

METHODS

We reviewed the charts of 400 patients hospitalized at an academic medical center in 1999 with a principal discharge diagnosis of heart failure. Patients were divided into 4 groups on the basis of age > or =75 or <75 years and the presence of preserved or reduced LVEF. Vital status was ascertained as of October 2001.

RESULTS

A total of 373 patients (mean age 69.1 years, 56.0% female, 47.5% nonwhite) underwent echocardiography to assess LVEF. Of these, 216 patients were <75 years of age (81 with preserved LVEF [group 1, 21.7%] and 135 with reduced LVEF [group 2, 36.2%]), and 157 were > or =75 years of age (81 with preserved LVEF [group 3, 21.7%] and 76 with reduced LVEF [group 4, 19.6%]). After a mean follow-up of 25 months, independent predictors of mortality among the 4 groups differed substantially: group 1, male sex, prescription of a calcium-channel blocker, and diuretic dose at discharge; group 2, blood urea nitrogen (BUN), lower hemoglobin level, and not being prescribed a beta-blocker at discharge; group 3, BUN; and group 4, older age, history of myocardial infarction, severity of reduced LVEF, and diuretic dose.

CONCLUSION

In patients with heart failure, predictors of mortality vary by age and by the presence of preserved or reduced LVEF. Traditional predictors of mortality in patients with reduced LVEF may not apply to elderly patients with preserved LVEF.

Incident cases of heart failure in a community cohort: importance and outcomes of patients with preserved systolic function

BACKGROUND

The clinical presentation and outcomes of patients with heart failure and preserved systolic function have not been well characterized in the outpatient setting.

METHODS

This was a retrospective cohort study of 403 patients with new-onset heart failure in a large regional health maintenance organization between July 1996 and December 1996. The clinical characteristics and treatment of patients with preserved ejection fractions (PrEF; >45%) were compared with those of patients with with reduced left ventricular function (Low EF) after excluding patients with terminal comorbidities. The main outcome measure was the combination of death, cardiovascular (CV) hospitalization, or both, which was assessed for as long as 24 months (mean, 22 months) with proportional hazards models.

RESULTS

Sixty-five patients (16%) did not have an assessment of left ventricular (LV) function. Of the remaining 338 patients, 191(57%) had an EF <45% (Low EF group) and 147 (44%) had preserved LV function (PrEF group). Patients with PrEF tended to be older, more frequently women, have less coronary disease and myocardial infarction, and have more atrial fibrillation and other comorbid conditions. They had higher systolic blood pressures and pulse pressures and slower heart rates than the patients with reduced LV function on initial presentation. Overall, mortality and CV hospitalization rates were similar in the 2 groups; however, on multivariate analysis, which took into account baseline differences between groups, low EF was a significant independent predictor of the combined end point (hazard ratio, 1.9; 95% CI, 1.3-2.9).

CONCLUSIONS

Patients with preserved LV function constitute a significant portion of incident outpatient patients with heart failure and carry a better prognosis than patients with reduced LV function.

Outcomes in heart failure patients with preserved ejection fraction: mortality, readmission, and functional decline

OBJECTIVES

We evaluated the six-month clinical trajectory of patients hospitalized for heart failure (HF) with preserved ejection fraction (EF), as the natural history of this condition has not been well established. We compared mortality, hospital readmission, and changes in functional status in patients with preserved versus depressed EF.

BACKGROUND

Although the poor prognosis of HF with depressed EF has been extensively documented, there are only limited and conflicting data concerning clinical outcomes for patients with preserved EF.

METHODS

We prospectively evaluated 413 patients hospitalized for HF to determine whether EF >or=40% was an independent predictor of mortality, readmission, and the combined outcome of functional decline or death.

RESULTS

After six months, 13% of patients with preserved EF died, compared with 21% of patients with depressed EF (p = 0.02). However, the rates of functional decline were similar among those with preserved and depressed EF (30% vs. 23%, respectively; p = 0.14). After adjusting for demographic and clinical covariates, preserved EF was associated with a lower risk of death (hazard ratio [HR] 0.49, 95% confidence interval [CI] 0.26 to 0.90; p = 0.02), but there was no difference in the risk of readmission (HR 1.01, 95% CI 0.72 to 1.43; p = 0.96) or the odds of functional decline or death (OR 1.01, 95% CI 0.59 to 1.72; p = 0.97).

CONCLUSIONS

Heart failure with preserved EF confers a considerable burden on patients, with the risk of readmission, disability, and symptoms subsequent to hospital discharge, comparable to that of HF patients with depressed EF.

The frequency of systolic versus diastolic heart failure in an Egyptian cohort

BACKGROUND

All factors predisposing for congestive heart failure (CHF), such as coronary artery disease (CAD), hypertension and diabetes are increasing in prevalence in Egypt. Despite this, no data about CHF in our country are available.

AIMS

To study the relative contribution of systolic vs. diastolic heart failure in Egyptians and the prevalence of risk factors in this population, as well as their prognosis.

METHODS

This was a retrospective study of patients with a diagnosis of CHF over a 3.5-year period in a general cardiology clinic. Demographic, ECG and echocardiographic data for left ventricular systolic and diastolic function were collected. The differential effect of systolic versus diastolic CHF was analyzed regarding hospitalization and mortality.

RESULTS

After exclusion of valvular diseases, we found 155 patients diagnosed with heart failure, 102 patients (66%) had systolic heart failure, and 53 (34%) had diastolic heart failure. Mean age was 60+/-10 and 63+/-11 years, respectively (P=0.13). Systolic CHF patients had significantly more CAD, while those with diastolic failure were mostly hypertensives (P<0.01) for both. There was no significant difference in the incidence of diabetes mellitus, cerebrovascular accidents or atrial fibrillation between the two groups. Patients with systolic failure required more hospitalization, P<0.05, and had a mortality rate of 17.6% vs. 11.3% for patients with diastolic heart failure (P=0.3).

CONCLUSION

Diastolic heart failure is present in one-third of cases of CHF in Egyptians. Hypertension is very common in this group. These patients require less hospitalization but have a similar mortality rate.

Diastolic heart failure in the community: clinical profile, natural history, therapy, and impact of proposed diagnostic criteria

BACKGROUND

Diastolic heart failure (DHF) has been broadly defined as "signs and symptoms of congestive heart failure (CHF) with normal/near normal systolic function." The clinical profile and natural history of the syndrome remain controversial. Furthermore, the frequency with which patients with CHF and normal ejection fraction (EF) fulfill recently proposed standardized diagnostic criteria for DHF is unclear. Our objective was to determine the clinical profile, Doppler echocardiographic features, current management, prognosis, and predictors of outcome of all patients with new onset CHF who had normal EF in Olmsted County, Minnesota, during 1996-1997. The frequency with which patients met recently proposed standardized criteria for diagnosis of DHF was assessed.

METHODS

Using the resources of the Rochester Epidemiology Project, all residents of Olmsted County, Minnesota, with a new diagnosis of CHF in 1996-1997, an ejection fraction >45%, and no valve disease (n = 83) were identified.

RESULTS

Patients were elderly (79 +/- 13 yr), predominantly female (76%), and had hypertension and/or coronary artery disease (85%). New-onset atrial fibrillation, ischemia, and medical comorbidities were frequently present at diagnosis. Although most patients (81%) met criteria for "probable DHF" by recently proposed clinical criteria, only half of patients met European criteria in which evidence of abnormal function/filling is required. The 1-, 2-, and 3-year mortality rates were 29%, 39%, and 60%, respectively. Angiotensin-converting enzyme inhibition (P =.0008) and beta-blocker (P =.02) therapy were independently associated with improved survival.

CONCLUSION

This population-based study provides a comprehensive clinical profile, current management, prognosis, and predictors of outcome of patients with new onset CHF who had normal ejection fraction.

Clinical characteristics and prognosis of hospitalised inpatients with heart failure and preserved or reduced left ventricular ejection fraction

OBJECTIVE

To determine the clinical and prognostic differences between patients with heart failure who had preserved or deteriorated systolic function, defined as a left ventricular ejection fraction of > 50% or < 50%, respectively, within two weeks of admission to hospital.

METHODS

The records of 229 patients with congestive heart failure were studied. There were 95 women and 134 men, mean (SD) age 66.7 (11.7) years, who had been admitted to a cardiology department for congestive heart failure in the period 1991 to 1994, and whose left ventricular systolic function had been evaluated echocardiographically within two weeks of admission. Data were collected on the main clinical findings, supplementary investigations, treatment, and duration of hospital admission. Follow up information was obtained in the spring of 1998 by searching the general archives of the hospital and by a telephone survey.

RESULTS

Left ventricular systolic function was preserved in 29% of the patients. The preserved and deteriorated groups differed significantly in the sex ratio (more women in the preserved group) and in the presence of a third heart sound, cardiomegaly, alveolar oedema, ischaemic cardiomyopathy, and treatment with angiotensin converting enzyme (ACE) inhibitors (all more in the deteriorated group). There were no significant differences in age, New York Heart Association functional class, rhythm disturbances, left ventricular hypertrophy, treatment with drugs other than ACE inhibitors, or survival. In the group as a whole, the survival rates after three months, one year, and five years were 92.6%, 80%, and 48.4%, respectively.

CONCLUSIONS

In view of the unexpectedly poor prognosis of patients with congestive heart failure and preserved left ventricular systolic function, controlled clinical trials should be carried out to optimise their treatment.

The burden of chronic congestive heart failure in older persons: magnitude and implications for policy and research

Heart failure disproportionately affects the older population. Approximately 80% of all cases of heart failure in the United States occur in persons aged 65 years and older. It is associated with very poor long-term survival, with a minority surviving 5 years after diagnosis. In the older population, heart failure accounts for more hospital admissions than any other single condition. Following hospitalization for heart failure, older persons are at high risk for re-hospitalization: nearly half are readmitted within 6 months. The economic impact of the condition is thus dramatic. Despite the importance of heart failure in the older population, there is a dearth of research specifically targeting this group. This review highlights the importance of heart failure in the older population and identifies the specific areas where research and policy initiatives may be instrumental in reducing the impact of the condition.

The burden of chronic congestive heart failure in older persons: magnitude and implications for policy and research

Heart failure disproportionately affects the older population. Approximately 80% of all cases of heart failure in the United States occur in persons aged 65 years and older. It is associated with very poor long-term survival, with a minority surviving 5 years after diagnosis. In the older population, heart failure accounts for more hospital admissions than any other single condition. Following hospitalization for heart failure, older persons are at high risk for re-hospitalization: nearly half are readmitted within 6 months. The economic impact of the condition is thus dramatic. Despite the importance of heart failure in the older population, there is a dearth of research specifically targeting this group. This review highlights the importance of heart failure in the older population and identifies the specific areas where research and policy initiatives may be instrumental in reducing the impact of the condition.