[Comparative value of B-type natriuretic peptide and serum albumin concentration in the prediction of in-hospital mortality in elderly patients admitted for acute severe heart failure]

Application of the Seattle heart failure model in patients >80 years of age enrolled in a tertiary care heart failure clinic

The Seattle Heart Failure Model (SHFM) is 1 of the most widely used tools to predict survival in patients with heart failure. However, it does not accommodate very elderly patients. We decided to assess the applicability of the SHFM in patients >80 years old enrolled in a tertiary care heart failure clinic. We evaluated the difference between observed survival and mean life expectancy as predicted by the SHFM on 261 patients >80 years old enrolled in a heart failure clinic at the Jewish General Hospital, Montreal, Quebec, Canada from January 2002 through March 2010. Average age of the patient population was 85 ± 4 years (range 80 to 105). Sixty-two percent of the population consisted of men, 63% had ischemic cardiomyopathy (ICM), and average ejection fraction was 36 ± 18%. Median observed survival was 1.91 years (interquartile range 0.68 to 5.53) for the total population (n = 261). The SHFM (predicted median survival 6.7 years, interquartile range 3.8 to 11.2) overestimated life expectancy by an average of 4.79 years. For patients with ICM (n = 164) versus non-ICM (n = 97), the score overestimated survival by 4.29 versus 5.69 years, respectively. In conclusion, the SHFM overestimates life expectancy in elderly patients followed in a tertiary care heart failure clinic. Further studies are needed to more accurately estimate prognosis in this patient population.

Gender differences in total cholesterol levels in patients with acute heart failure and its importance for short and long time prognosis

AIM

The purpose of this study was to evaluate whether there are gender differences in total cholesterol levels in patients with acute heart failure and if there is an association of this parameter with short and long time mortality.

METHODS

The AHEAD MAIN registry is a database conducted in 7 university hospitals, all with 24 h cath lab service, in 4 cities in the Czech Republic. The database included 4 153 patients hospitalised for acute heart failure in the period 2006-2009. 2 384 patients had a complete record of their total cholesterol levels. 946 females and 1437 males were included in this analysis. According to the admission total cholesterol levels, patients were divided into 5 groups: < 4.50 mmol/l (group A), 4.50-4.99 mmol/l (group B), 5.0-5.49 mmol/l (group C), 5.50-5.99 mmol/l (group D) and > 6.0 mmol/l (group E). The median total cholesterol levels were 4.24 in males and 4.60 in females (P<0.001). There were differences in the distribution of total cholesterol levels between men and women: group A 57.6 vs 45.0%, group B 13.8 vs 16.3%, group C 9.8 vs 12.5%, group D 7.7 vs 11.4%, group E 11.1 vs 14.8% respectively (all P<0.001). The median age of men was 68.7 vs 77.3 years in women (P<0.001). In all total cholesterol categories women were older than men: group A 77.7 vs 69.5 years, group B 78.6 vs 69.1 years, group C 77.3 vs 68.8 years, group D 76.8 vs 64.2 years, group E 75.6 vs 64.4 years (all P<0.001). For the calculation of long term mortality, the cohort was divided into three groups: total cholesterol levels below 4.50 mmol/l, 4.50-5.49 mmol/l and above 5.50 mmol/l. The log rank test was used for the analysis.

RESULTS

There were no differences in hospital mortality between male and female in general (9.2 vs 10.8%, P<0.202), or in total cholesterol levels in subgroups. Total cholesterol levels were associated with in-hospital mortality (P<0.002). In the long-term follow up (78 months) patients with total cholesterol levels below 4.5 mmol/l had the worst prognosis (P<0.001). An independent influence of total cholesterol level on mortality and survival was confirmed in the multivariate model as well.

CONCLUSIONS

Women with acute heart failure had higher total cholesterol levels than men in all ages. There was a higher percentage of women with total cholesterol levels above 6 mmol/l and lower percentage in the group below 4.5 mmol/l than in men. In all, total cholesterol categories women were older than men. Total cholesterol levels are important for in- hospital mortality and long term survival of patients admitted for acute heart failure.

[Serum albumin and heart failure: recent advances on a new paradigm]

Hypoalbuminemia is a common condition in patients with heart failure and is mainly related to the malnutrition-inflammation complex syndrome. Other causal factors can be involved, which include hemodilution, liver dysfunction, increased transcapillary escape rate, renal and enteral loss. Evidence is growing that hypoalbuminemia independently predicts incident heart failure in patients with end-stage renal disease and elderly patients, as well as mortality in patients with heart failure regardless of left ventricular ejection fraction and clinical presentation. Hypoalbuminemia induces a low plasma oncotic pressure, which facilitates pulmonary edema in patients without critical increase in pulmonary capillary hydrostatic pressures. Hypoalbuminemia may also contribute to the progression of heart failure by favoring myocardial edema, volume overload, diuretic resistance and exacerbation of oxidative stress and inflammation. If relevant, removal of subclinical excess of fluid and renutrition may be indicated in patients with heart failure and hypoalbuminemia. Additional research is warranted to determine the specific role of serum albumin in the pathophysiologic process of heart failure and the potential benefits of targeted therapeutic interventions.

Serum albumin and mortality in acutely decompensated heart failure

BACKGROUND

Although hypoalbuminemia has been associated with decreased survival in chronic systolic heart failure (HF), its role for prognosticating outcomes in those with acutely decompensated heart failure (ADHF) has not been established.

METHODS AND RESULTS

438 consecutive patients with ADHF (mean age 75±13 years, mean left ventricular ejection fraction 41%±20%) admitted to a large community hospital were studied. The mean serum albumin level for the group was 3.4 g/dL; quintile analysis demonstrated an inflection of risk for death below this value. Patients with hypoalbuminemia (defined as a serum albumin<3.4 g/dL; N=236, 54% overall) were more likely to have prior HF, more severe HF symptoms, more likely to be edematous, and had more prevalent prognostically meaningful laboratory abnormalities, such as a higher frequency of renal dysfunction and elevated B-type natriuretic peptide. Independent associations between anemia, hyponatremia, lack of therapy with vasodilators at presentation, prior history of obstructive airways disease, severe tricuspid regurgitation, low serum cholesterol, and the presence of a pleural effusion on chest radiography were found with reduced serum albumin; interestingly, body mass index was not predictive of albumin levels. In Cox proportional hazards analysis, hypoalbuminemia predicted 1-year mortality (hazard ratio [HR]adjusted=2.05, 95% CI 1.10-3.81, P=.001). Reduced serum albumin concentrations were prognostic across a wide range of body mass index but had highest HR in obese patients (HRadjusted=4.39 [95% CI=1.66 to 11.60], P=.003). As well, hypoalbuminemia was mainly predictive of outcomes among those with systolic HF (HRadjusted=5.00, 95% CI=2.17-11.5, P<.001).

CONCLUSION

Hypoalbuminemia is common among patients with ADHF and is independently associated with increased one year mortality in patients admitted with ADHF.