Accuracy of bedside tissue Doppler echocardiography for the prediction of in-hospital mortality in elderly patients with acute heart failure with preserved left ventricular systolic function. comparison with B-type natriuretic peptide measurement

Incremental Prognostic Value of Conventional Echocardiography in Patients with Acutely Decompensated Heart Failure

BACKGROUND

Acutely decompensated heart failure (ADHF) presents high morbidity and mortality in spite of therapeutic advance. Identifying factors of worst prognosis is important to improve assistance during the hospital phase and follow-up after discharge. The use of echocardiography for diagnosis and therapeutic guidance has been of great utility in clinical practice. However, it is not clear if it could also be useful for risk determination and classification in patients with ADHF and if it is capable of adding prognostic value to a clinical score (OPTIMIZE-HF).

OBJECTIVE

To identify the echocardiographic variables with independent prognostic value and to test their incremental value to a clinical score.

METHODS

Prospective cohort of patients consecutively admitted between January 2013 and January 2015, with diagnosis of acutely decompensated heart failure, followed up to 60 days after discharge. Inclusion criteria were raised plasma level of NT-proBNP (> 450 pg/ml for patients under 50 years of age or NT-proBNP > 900 pg/ml for patients over 50 years of age) and at least one of the signs and symptoms: dyspnea at rest, low cardiac output or signs of right-sided HF. The primary outcome was the composite of death and readmission for decompensated heart failure within 60 days.

RESULTS

Study participants included 110 individuals with average age of 68 ± 16 years, 55% male. The most frequent causes of decompensation (51%) were transgression of the diet and irregular use of medication. Reduced ejection fraction (<40%) was present in 47% of cases, and the NT-proBNP median was 3947 (IIQ = 2370 to 7000). In multivariate analysis, out of the 16 echocardiographic variables studied, only pulmonary artery systolic pressure remained as an independent predictor, but it did not significantly increment the C-statistic of the OPTMIZE-HF score.

CONCLUSION

The addition of echocardiographic variables to the OPTIMIZE-HF score, with the exception of left ventricular ejection fraction, did not improve its prognostic accuracy concerning cardiovascular events (death or readmission) within 60 days.

[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]

OBJECTIVE

To address the clinical relevance of serum albumin and B-type natriuretic peptide (BNP) concentration in the prediction of in-hospital death in elderly patients with acute severe heart failure.

PATIENTS AND METHODS

Seventy-four consecutive patients >70 years of age admitted for acute heart failure in NYHA class IV were prospectively included. BNP concentration was measured on admission and serum albumin concentration after clinical stabilization.

RESULTS

Mean age was 86.6+/-5.7 years. Sixty-five percent of patients had a normal left ventricular ejection fraction. Eighteen patients died during the in-hospital stay. Those patients who died were older, had higher blood urea nitrogen and BNP concentration, had lower systolic blood pressure and serum albumin concentration than patients who survived. Heart rate, rhythm, left ventricular ejection fraction, serum creatinine and hemoglobin did not differ according to outcome. By multivariate analysis, albumin (p=0.0017), BNP (p=0.016) and age (p=0.03) were independent predictors of in-hospital death. Serum troponin I measured on admission in 71 patients was predictive of in-hospital death (p=0.01), as well as serum total cholesterol measured after stabilization in 66 patients (p=0.004). However, these two variables no longer predicted outcome in multivariate models, unlike serum albumin and BNP.

CONCLUSION

Serum albumin and BNP offer independent, additional information for the prediction of in-hospital death in elderly patient with acute severe heart failure regardless of left ventricular ejection fraction.

Cardiac asthma in elderly patients: incidence, clinical presentation and outcome

Background

Cardiac asthma is common, but has been poorly investigated. The objective was to compare the characteristics and outcome of cardiac asthma with that of classical congestive heart failure (CHF) in elderly patients.

Methods

Prospective study in an 1,800-bed teaching hospital.

Results

Two hundred and twelve consecutive patients aged ≥ 65 years presenting with dyspnea due to CHF (mean age of 82 ± 8 years) were included. Findings of cardiac echocardiography and natriuretic peptides levels were used to confirm CHF. Cardiac asthma patients were defined as a patient with CHF and wheezing reported by attending physician upon admission to the emergency department. The CHF group (n = 137) and the cardiac asthma group (n = 75), differed for tobacco use (34% vs. 59%, p < 0.05), history of chronic obstructive pulmonary disease (16% vs. 47%, p < 0.05), peripheral arterial disease (10% vs. 24%, p < 0.05). Patients with cardiac asthma had a significantly lower pH (7.38 ± 0.08 vs. 7.43 ± 0.06, p < 0.05), and a higher PaCO₂ (47 ± 15 vs. 41 ± 11 mmHg, p < 0.05) at admission. In the cardiac asthma group, patients had greater distal airway obstruction: forced expiratory volume in 1 second of 1.09 vs. 1.33 Liter (p < 0.05), and a forced expiratory flow at 25% to 75% of vital capacity of 0.76 vs. 0.99 Liter (p < 0.05). The in-hospital (23% vs. 19%) and one year mortality (48% vs. 43%) rates were similar.

Conclusion

Patients with cardiac asthma represented one third of CHF in elderly patients. They were more hypercapnic and experienced more distal airway obstruction. However, outcomes were similar.