Predictors of mortality in medically treated patients with congestive heart failure of nonrheumatic etiology and reduced systolic function

Impact of Tricuspid Regurgitation in Patients With Heart Failure and Mitral Valve Disease from a Nationwide Cohort Study

Concomitant heart failure (HF) and mitral valve disease (MVD) portend significant morbidity and mortality. Although associated Tricuspid regurgitation (TR) is a common occurrence in this scenario, it is not well known whether there are additional prognostic implications. We sought to assess whether coexistent TR is associated with higher readmission rates or increased mortality in patients with HF and MVD. We identified 1,520,871 encounters with a primary diagnosis of HF in the 2013 to 2014 Nationwide Readmission Database. We excluded patients without MVD, patients <18 years old, those with rheumatic heart disease and infective endocarditis. We also excluded patients who were discharged in December, hospital transfers, and cases where follow-up or outcomes were missing. Logistic regression was used to evaluate the association between baseline characteristics (including the presence of tricuspid valve disease), mortality as well as 30-day readmission rates. A total of 221,127 admissions with HF and MVD were identified. Median age was 79 years (IQR, 67 to 87), 55% were female, 2.7% died during hospitalization, and the 30-day readmission rate was 20.3%. Nearly 1/3 had concomitant TR (n = 78,356, 35%). The presence of TR was neither associated with elevated risk of mortality (hazard ratio 0.98, 95% confidence interval 0.93 to 1.04) nor 30-day readmission rate (odds ratio 1.01, 95% confidence interval 0.98 to 1.03). HF accounted for 33% of 30-day readmissions, while combined cardiac causes accounted for 54%. In conclusion concomitant TR in patients with HF and MVD was not associated with worse short-term outcomes in terms of inpatient hospital mortality and 30-day readmission rates.

Ten-year survival and prognostic markers in one thousand patients with advanced heart failure. A single-centre analysis

AIM

Patients with advanced heart failure (HF) represent a pool of candidates for heart transplantation and long-term mechanical circulatory support devices. The aim of our study was to determine simple and reliable markers of one-year mortality for selection of the most suitable patients for heart replacement therapy.

METHODS AND RESULTS

One thousand consecutive patients with HF (mean age 49 ± 10.9 years; 86.8% males) referred to a single tertiary centre from January 1998 to January 2010 in order to assess the indication for heart transplantation were enrolled. Kaplan-Meier survival analysis was performed. Independent mortality predictors were established using logistic regression analysis. The mean follow-up was 4.3 ± 2.7 years (range 1-12 years). Cumulative survival was as follows: 1-year survival 83%, 3-year 63%, 5-year 50%, 7-year 39%, and 10-year 23%. Independent predictors of 1-year mortality included coronary artery disease, left ventricular diastolic diameter >79 mm, plasma sodium <135 mmol/L, the need for intravenous treatment at hospital admission (diuretics and/or inotropes), and furosemide dose at discharge >240 mg/day.

CONCLUSIONS

Short-term prognosis of HF patient can be estimated based on simple parameters. Patients with signs of poor prognosis should be referred to tertiary centres to be considered for heart replacement therapy.

Gender related predictors of limited exercise capacity in heart failure

AIM

The aim of this study was to investigate the impact of gender on the prediction of limited exercise capacity in heart failure (HF) patients assessed by 6 minute walk test (6-MWT).

METHODS

In 147 HF patients (mean age 61 ± 11 years, 50.3% male), a 6-MWT and a Doppler echocardiographic study were performed in the same day. Conventional cardiac measurements were obtained and global LV dyssynchrony was indirectly assessed using total isovolumic time - t-IVT [in s/min; calculated as: 60 - (total ejection time - total filling time)] and Tei index (t-IVT/ejection time). Patients were divided into two groups according to gender, which were again divided into two subgroups based on the 6-MWT distance (Group I: ≤ 300 m, and Group II: > 300 m).

RESULTS

Female patients were younger (p = 0.02), and had higher left ventricular (LV) ejection fraction - EF (p = 0.007) but with similar 6-MWT distance to male patients (p = 68). Group I male patients had lower hemoglobin level (p = 0.02) and lower EF (p = 0.03), compared with Group II, but none of the clinical or echocardiographic variables differed between groups in female patients. In multivariate analysis, only t-IVT [0.699 (0.552-0.886), p = 0.003], and LV EF [0.908 (0.835-0.987), p = 0.02] in males, and NYHA functional class [4.439 (2.213-16.24), p = 0.02] in females independently predicted poor 6-MWT distance (< 300 m).

CONCLUSION

Despite similar limited exercise capacity, gender determines the pattern of underlying cardiac disturbances; ventricular dysfunction in males and subjective NYHA class in female heart failure patients.

Coexistence of dynamic mitral regurgitation and dynamic left ventricular dyssynchrony in a patient with repeated episodes of acute pulmonary edema: improvement with cardiac resynchronization therapy

A 69-year-old woman with idiopathic dilated cardiomyopathy and chronic heart failure experienced repeated hospital admissions for acute pulmonary edema with no recognizable precipitating factor. Worsening mitral regurgitation was triggered by exercise echocardiography and significant intraventricular dyssynchrony was elicited by low-dose dobutamine stress echocardiography. After cardiac resynchronization therapy she remained free of hospitalizations for 12 months. This case highlights the dynamic nature of both functional mitral regurgitation and left ventricular dyssynchrony and illustrates how in some patients stress echocardiography can help to clarify clinical scenarios and help with the challenging task of selecting patients who will benefit from cardiac resynchronization therapy.

Independent and incremental value of severely enlarged left atrium in risk stratification of very elderly patients with chronic systolic heart failure

The authors sought to assess the impact on survival of demographic, clinical, and echo-Doppler parameters in patients with chronic heart failure due to left ventricular systolic dysfunction divided according to age groups. This study included 734 patients (age 69±11 years) who were classified into tertiles of age: I (22-66 years), II (67-76 years), and III (77-94 years). Severely enlarged left atrial size was defined as ≥52 mm in men and ≥47 mm in women. Multivariable analysis identified male sex (P=.018) and severely enlarged left atrium (P=.024) as significant correlates of all-cause mortality in the very elderly cohort, while restrictive filling pattern (RFP) (P=.004) and New York Heart Association class III or IV (P=.005) among patients of the first tertile and RFP (P=.028) among patients in the second tertile were independently associated with mortality after 30±21 months of follow-up. At the interactive stepwise model in the very elderly population, a severely enlarged left atrium, added to the model after clinical parameters and ejection fraction, moved the chi-square value from 20.7 to 25.8 (P=.048). RFP emerged as the single best predictor of all-cause mortality in the younger and intermediate ranges, whereas severely enlarged left atrium was the best predictor in the very elderly.

Predictors of increased left ventricular filling pressure in dialysis patients with preserved left ventricular ejection fraction

AIM

To study the left and right ventricular function and to assess the predictors of increased left ventricular (LV) filling pressure in dialysis patients with preserved LV ejection fraction.

METHODS

This study included 63 consecutive patients (age 57+/-14 years, 57% women) with end-stage renal failure. Echocardiography, including tissue Doppler measurements, was performed in all patients. Based on the median value of the ratio of transmitral early diastolic velocity to early myocardial velocity (E/E' ratio), patients were divided into 2 groups: the group with high filling pressure (E/E'>10.16) and the group with low filling pressure (E/E'< or =10.16).

RESULTS

Compared with patients with low filling pressure, the group of patients with high filling pressure included a higher proportion of diabetic patients (41% vs 13%, P=0.022) and had greater LV mass index (211+/-77 vs 172+/-71 g/m3, P=0.04), lower LV lateral long axis amplitude (1.4+/-0.3 vs 1.6+/-0.3 cm, P=0.01), lower E wave (84+/-19 vs 64+/-18cm/s, P<0.001), higher systolic myocardial velocity (S': 8.6+/-1. 5 vs 7.0+/-1.3 cm/s, P<0.001), and lower diastolic myocardial velocities (E': 6.3+/-1.9 vs 9.5+/-2.9 cm/s, P<0.001; A': 8.4+/-1.9 vs 9.7+/-2.5 cm/s, P=0.018). Multivariate analysis identified LV systolic myocardial velocity - S' wave (adjusted odds ratio, 1.909; 95% confidence interval, 1.060-3.439; P=0.031) and age (1.053; 1.001-1.108; P=0.048) as the only independent predictors of high LV filling pressure in dialysis patients.

CONCLUSIONS

In dialysis patients with preserved left ventricular ejection fraction, reduced systolic myocardial velocity and elderly age are independent predictors of increased left ventricular filling pressure.