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

Development and Validation of a Nomogram Model for Predicting the Risk of Readmission in Patients with Heart Failure with Reduced Ejection Fraction within 1 Year

The high incidence of readmission for patients with reduced ejection fraction heart failure (HFrEF) can seriously affect the prognosis. In this study, we aimed to build a simple predictive model to predict the risk of heart failure (HF) readmission in patients with HFrEF within one year of discharge from the hospital. This retrospective study enrolled patients with HFrEF evaluated in the Heart Failure Center of the Affiliated Hospital of Xuzhou Medical University from January 2018 to December 2020. The patients were allocated into the readmission or nonreadmission group, according to whether HF readmission occurred within 1 year of hospital discharge. Subsequently, all patients were randomly divided into training and validation sets in a 7 : 3 ratio. A nomogram was established according to the results of univariate and multivariate logistic regression analysis. Finally, the area under the receiver operating characteristic curve (AUC-ROC), calibration plot, and decision curve analysis (DCA) were used to validate the nomogram. Independent risk factors for HF readmission of patients with HFrEF within 1 year of hospital discharge were as follows: age, body mass index, systolic blood pressure, diabetes mellitus, left ventricular ejection fraction, and angiotensin receptor-neprilysin inhibitors. The AUC-ROC of the training and validation sets were 0.833 (95% confidence interval (CI): 0.793-0.866) and 0.794 (95% CI: 0.727-0.852), respectively, which have an excellent distinguishing ability. The predicted and observed values of the calibration curve also showed good consistency. DCA also confirmed that the nomogram had good clinical value. In conclusion, we constructed an accurate and straightforward nomogram model for predicting the 1-year HF readmission risk in patients with HFrEF. This nomogram can guide early clinical intervention and improve patient prognosis.

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.

Mortality in heart failure patients

Heart failure (HF) is a clinical syndrome, which is becoming a major public health problem in recent decades, due to its increasing prevalence, especially in the developed countries, mostly due to prolonged lifespan of the general population as well as the increased of HF patients. The HF treatment, particularly, new pharmacological and non-pharmacological agents, has markedly improved clinical outcomes of patients with HF including increased life expectancy and improved quality of life. However, despite the facts that mortality in HF patients has decreased, it still remains unacceptably high. This review of summarizes the evidence to date about the mortality of HF patients. Despite the impressive achievements in the pharmacological and non-pharmacological treatment of HF patients which has undeniably improved the survival of these patients, the mortality still remains high particularly among elderly, male and African-American patients. Patients with HF and reduced ejection fraction have higher mortality rates, most commonly due to cardiovascular causes, compared with patients HF and preserved ejection fraction.

FRAIL-HF, a study to evaluate the clinical complexity of heart failure in nondependent older patients: rationale, methods and baseline characteristics

The clinical scenario of heart failure (HF) in older hospitalized patients is complex and influenced by acute and chronic comorbidities, coexistent geriatric syndromes, the patient's ability for self-care after discharge, and degree of social support. The impact of all these factors on clinical outcomes or disability evolution is not sufficiently known. FRAIL-HF is a prospective observational cohort study designed to evaluate clinical outcomes (mortality and readmission), functional evolution, quality of life, and use of social resources at 1, 3, 6, and 12 months after admission in nondependent elderly patients hospitalized for HF. Clinical features, medical treatment, self-care ability, and health literacy were prospectively evaluated and a comprehensive geriatric assessment with special focus on frailty was systematically performed in hospital to assess interactions and relationships with postdischarge outcomes. Between May 2009 and May 2011, 450 consecutive patients with a mean age of 80 ± 6 years were enrolled. Comorbidity was high (mean Charlson index, 3.4 ± 2.9). Despite being nondependent, 118 (26%) had minor disability for basic activities of daily living, only 76 (16.2%) had no difficulty in walking 400 meters, and 340 (75.5%) were living alone or with another elderly person. In addition, 316 patients (70.2%) fulfilled frailty criteria. Even nondependent older patients hospitalized for HF show a high prevalence of clinical and nonclinical factors that may influence prognosis and are usually not considered in routine clinical practice. The results of FRAIL-HF will provide important information about the relationship between these factors and different postdischarge clinical, functional, and quality-of-life outcomes.

Outcomes of patients with anemia and acute decompensated heart failure with preserved versus reduced ejection fraction (from the ARIC study community surveillance)

Anemia is associated with poor prognosis in patients hospitalized with acute decompensated heart failure (ADHF). Whether the impact of anemia differs by heart failure with preserved ejection fraction (HFpEF) or heart failure with reduced ejection fraction (HFrEF) is uncertain. We examined hospital surveillance data captured by the Atherosclerosis Risk in Communities Study from January 1, 2005, to December 31, 2010. Diagnoses of ADHF were validated by standardized physician review of the medical record. Anemia was classified using the World Health Organization criteria (<12 g/dl for women and <13 g/dl for men), and HF type was determined by the ejection fraction (<40% for HFrEF and ≥40% for HFpEF). Hospital length of stay and 1-year mortality outcomes were analyzed by multivariable regression, weighted to account for the sampling design, and adjusted for demographics and clinical covariates. Over 6 years, 15,461 (weighted) hospitalized events for ADHF (59% HFrEF) occurred in the catchment of the Atherosclerosis Risk in Communities, based on 3,309 sampled events. Anemia was associated with a mortality hazard ratio of 2.1 (95% confidence interval [CI] 1.6 to 2.7) in patients classified with HFpEF and 1.4 (95% CI 1.1 to 1.7) in those with HFrEF; p for interaction = 0.05. The mean increase in length of hospital stay associated with anemia was 3.5 days (95% CI 3.4 to 3.6) for patients with HFpEF, compared with 1.8 days (95% CI 1.7 to 1.9) for those with HFrEF; p for interaction <0.0001. In conclusion, the incremental risks of death and lengthened hospital stay associated with anemia are more pronounced in ADHF patients classified with HFpEF than HFrEF.

Association of renal biochemical parameters with left ventricular diastolic dysfunction in a community-based elderly population in China: a cross-sectional study

Background

Relationship of left ventricular diastolic dysfunction (LVDD) with parameters that could provide more information than hemodynamic renal indexes has not been clarified. We aimed to explore the association of comprehensive renal parameters with LVDD in a community-based elderly population.

Methods

1,166 community residents (aged ≥ 65 years, 694 females) participating in the Shanghai Heart Health Study with complete data of renal parameters were investigated. Echocardiography was used to evaluate diastolic function with conventional and tissue Doppler imaging techniques. Serum urea, creatinine, urea-to-creatinine ratio, estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (UACR) were analyzed on their associations with LVDD.

Results

The prevalence of LVDD increased in proportion to increasing serum urea, urea-to-creatinine ratio and UACR. These three renal parameters were found negatively correlated to peak early (E) to late (A) diastolic velocities ratio (E/A), and positively to left atrial volume index; UACR also positively correlated with E to peak early (E’) diastolic mitral annular velocity ratio (E/E’). Serum urea, urea-to-creatinine ratio and UACR correlated with LVDD in logistic univariate regression analysis, and urea-to-creatinine ratio remained independently correlated to LVDD [Odds ratio (OR) 2.82, 95% confidence interval (CI) 1.34–5.95] after adjustment. Serum urea (OR 1.18, 95%CI 1.03–1.34), creatinine (OR 6.53, 95%CI 1.70­–25.02), eGFR (OR 0.22, 95%CI 0.07–0.65) and UACR (OR 2.15, 95%CI 1.42–3.24) were revealed independent correlates of advanced (moderate and severe) LVDD.

Conclusions

Biochemical parameters of renal function were closely linked with LVDD. This finding described new cardio-renal relationship in the elderly population.

Prognostic value of resting pulmonary function in heart failure

BACKGROUND

The heart and lungs are intimately linked anatomically and physiologically, and, as a result, heart failure (HF) patients often develop changes in pulmonary function. This study examined the prognostic value of resting pulmonary function (PF) in HF.

METHODS AND RESULTS

In all, 134 HF patients (enrolled from January 1, 1999 Through December 31, 2005; ejection fraction (EF) = 29% ± 11%; mean age = 55 ± 12 years; 65% male) were followed for 67 ± 34 months with death/transplant confirmed via the Social Security Index and Mayo Clinic registry. PF included forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), diffusing capacity of the lungs for carbon monoxide (DLCO), and alveolar volume (VA). Patients were divided in tertiles according to PF with survival analysis via log-rank Mantel-Cox test with chi-square analysis. Groups for FVC included (1) >96%, (2) 96% to 81%, and (3) <81% predicted (chi-square = 18.9, P < 0.001). Bonferroni correction for multiple comparisons (BC) suggested differences between groups 1 and 3 (P < 0.001) and 2 and 3 (P = 0.008). Groups for FEV1 included (1) >94%, (2) 94% to 77%, and (3) <77% predicted (chi-square = 17.3, P <0.001). BC suggested differences between groups 1 and 3 (P <0.001). Groups for DLCO included (1) >90%, (2) 90% to 75%, and (3) <75% predicted (chi-square = 11.9, P = 0.003). BC suggested differences between groups 1 and 3 (P < 0.001). Groups for VA included (1) >97%, (2) 97% to 87%, and (3) <87% predicted (Chi-square = 8.5, P = 0.01). BC suggested differences between groups 1 and 2 (P = 0.014) and 1 and 3 (P = 0.003).

CONCLUSIONS

In a well-defined cohort of HF patients, resting measures of PF are predictive of all-cause mortality.

[Predictive variables for mortality in elderly patients hospitalized due to heart failure with preserved ejection fraction]

BACKGROUND AND OBJECTIVES

The prevalence of heart failure (HF) increases with age. Even though the mortality of patients ≥ 80 years of age with HF and preserved left ventricle ejection fraction (LVEF) is very high, the predictor variables are not well-known. The main goal of this study was to evaluate the mortality predictor factors in this subgroup of the elderly population.

PATIENTS AND METHODS

An observational and prospective study of patients hospitalized due to HF with preserved LVEF has been conducted. The demographic, clinical, functional and analytic factors were evaluated when the patients were admitted with special attention to the co-morbidities. The primary endpoint was the total mortality in the subgroup of patients ≥ 80 years of age after a year of follow-up. The predictor variables were studied by means of a multivariate Cox regression model.

RESULTS

From a total of 218 patients with an average age of 75.6 (±8.7) years of age, 75 patients (34.4%) were ≥ 80 years. The mortality rate of patients ≥ 80 years of age totaled 42.7%, in relation to 26.6% for the lower age group (log-rank<.001). After a multivariate analysis using the Cox regression model in patients ≥ 80, the serum urea levels above the average (hazard ratio [HR] 3.93; 95% confidence interval [95% CI] 1.58-9.75; P = .003), the age (HR 1.17; 95% CI 1.07-1.28; P<.001), the hyponatremia (HR 3.19; 95% CI 1.51-6.74; P = .002) and a lower score on the Barthel index (BI) (HR 1.016; 95% CI 1.002-1.031; P = .034) were independent mortality predictors after an one-year follow-up.

CONCLUSIONS

Serum urea levels, age, hyponatremia and a low BI score could be proposed as independent mortality predictors in patients ≥ 80 of age hospitalized for HF with preserved LVEF.

The diversity of heart failure in a hospitalized population: the role of age

BACKGROUND

The prevalence of heart failure (HF) among hospitalized elderly patients is high and steadily growing. However, because most studies have focused mostly on young patients, little is known about the clinical characteristics, echocardiographic measures, prognostic factors, and outcome of hospitalized elderly HF patients.

METHODS AND RESULTS

We identified all HF patients aged ≥50 years who had undergone ≥1 echocardiography study and had been hospitalized during January 2000 to December 2009. A comparative analysis was performed between 3,897 "young" patients (aged 50-75 years) and 5,438 "elderly" patients (aged >75 years), followed for a mean 2.8 ± 2.6 years. Elderly HF patients were more often female (50% vs 35%; P < .0001) and had a higher prevalence of HF with preserved ejection fraction (64.8% vs 53%; P < .0001), more significant valvular disease (35.7% vs 32.5%; P < .0001), and lower rates of ischemic heart disease (65.5% vs 70.9%; P < .0001) and diabetes (34.4% vs 53.9%; P < .0001). Thirty-day and 1-year mortality rates were significantly higher among the elderly population (12.2% vs 6.9% [P < .0001] and 34.3% vs 21.2% [P < .0001], respectively). Prognostic markers differed significantly between age groups. Young-specific predictors were chronic renal failure, diastolic dysfunction, malignancy, and tricuspid regurgitation, whereas elderly-specific predictors were HF with reduced ejection fraction, chronic obstructive pulmonary disease, pulmonary hypertension, and mitral regurgitation.

CONCLUSIONS

Hospitalized elderly, compared with young, HF patients differed in prevalence of cardiac and noncardiac comorbid conditions, echocardiographic parameters, and predictors of short- and intermediate-term mortality. Identifying unique features in the elderly population may render age-tailored therapeutics.

Emergence of blood urea nitrogen as a biomarker of neurohormonal activation in heart failure

The nonosmotic release of arginine vasopressin, concurrent with the activation of the sympathetic nervous system and renin-angiotensin-aldosterone system, is thought to represent the maladaptive response that is central to the pathophysiology of heart failure (HF). The degree of neurohormonal activation correlates with the severity of the disease and can predict the outcomes. However, quantification of components of neurohormonal axis (e.g., serum arginine vasopressin level) is mainly reserved for research purposes rather than routine practice. The results of several recent HF trials have shed light on the differential role of blood urea nitrogen (BUN) and creatinine in predicting the outcomes in this setting. These studies suggest that BUN could indeed represent a surrogate marker for "renal response" to neurohormonal activation in this setting, above and beyond its role in the estimation of renal function. In this report, the relevant physiologic mechanisms underlying urea and water transport in the kidney are first reviewed. Then, the activation of the neurohormonal axis and the impact of its components on renal urea transport, independent of changes in renal function, are explained. Finally, the unique role of BUN as a biomarker of neurohormonal activation in the setting of HF is discussed, and the potential clinical implication of this novel concept is emphasized. In conclusion, this review explains the pathophysiologic basis for the emerging role of BUN as a biomarker in HF.

Predictors of early mortality in patients age 80 and older receiving implantable defibrillators

BACKGROUND

There are no upper age restrictions for implantable defibrillators (ICDs) but their benefit may be limited in patients > or = 80 years with strong competing risks of early mortality. Risk factors for early (1-year) mortality in ICD recipients > or = 80 years of age have not been established.

METHODS

Two-center retrospective cohort study to assess predictors of one-year mortality in ICD recipients > or = 80 years of age.

RESULTS

Of 2,967 ICDs implanted in the two centers from 1990-2006, 225 (7.6%) patients were > or =80 years of age and followed-up at one of the two centers. Mean age was 83.3 +/- 3.1 years and follow-up time 3.3 +/- 2.6 years. Median survival was 3.6 years (95% confidence interval 2.3-4.9). Multivariate predictors of 1-year mortality included ejection fraction (EF) < or = 20% and the absence of beta-blocker use. Actuarial 1-year mortality of ICD recipients > or = 80 with an EF < or = 20% was 38.2% versus 13.1% in patients 80+ years with an EF > 20% and 10.6% for patients < 80 years with an EF < or = 20% (P < 0.001 for both). There was no significant difference in the risk of appropriate ICD therapy between those patients 80+ years with EF above and below 20%.

CONCLUSION

In general, patients > or = 80 years of age who meet current indications for ICD implantation live sufficiently long to warrant device implantation based on anticipated survival alone. However, those with an EF < or = 20% have a markedly elevated 1-year mortality with no observed increase in appropriate ICD therapy, thus reducing the benefit of device implantation in this population.

Geriatric conditions and subsequent mortality in older patients with heart failure

OBJECTIVES

This study was designed to develop models for short- (30-day) and long- (5-year) term mortality after heart failure (HF) hospitalization that include geriatric conditions, specifically mobility disability and dementia, to determine whether these conditions emerge as strong and independent risk factors.

BACKGROUND

Although 80% of patients with HF are 65 years of age or older, no large studies have focused on the prognostic importance of geriatric conditions.

METHODS

We analyzed medical record data from a national sample of Medicare beneficiaries hospitalized for HF. To identify independent predictors of mortality, we performed stepwise selection in multivariable logistic regression models. We used net reclassification improvement to assess the incremental benefit of adding geriatric conditions to a model containing traditional risk factors for mortality.

RESULTS

The mean age of patients included in the analysis was 80 years; 59% were women, 13% were nonwhite, 10% had dementia, and 39% had mobility disability. Mortality rates were 9.8% at 30 days and 74.7% at 5 years. Twenty-one variables were considered for inclusion in the final multivariable model. Dementia and mobility disability were among the top predictors of short- and long-term mortality, with among the top 6 largest absolute standardized estimates in the final model for 30-day mortality, and among the top 7 largest standardized estimates for 5-year mortality. The net reclassification improvement when geriatric conditions were added to traditional factors was 5.1% at 30 days and 4.2% at 5 years.

CONCLUSIONS

Geriatric conditions are strongly and independently associated with short- and long-term mortality among older patients with HF.

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.

Patient sex does not modify ejection fraction as a predictor of death in heart failure: insights from the APPROACH cohort

BACKGROUND

Normal and low ejection fraction (EF) heart failure patients appear to have similar outcomes.

OBJECTIVE

The object of this study was to determine whether sex modifies the effects of left ventricular EF on prevalent heart failure mortality.

DESIGN

Prospective cohort study.

PATIENTS

Patients (n = 6, 095) with a diagnosis of heart failure and a measure of EF undergoing cardiac catheterization in Alberta, Canada between April 1999 and December 2004; follow-up continued through October 2005.

MEASUREMENTS

All-cause mortality was assessed in analyses stratified by patient sex and EF (<or=50% vs. >50%).

MAIN RESULTS

Overall, female heart failure patients were older, had more hypertension, valvular disease, less systolic impairment and coronary artery disease. Baseline medication use was similar in the four sex-EF groups. Low EF heart failure mortality over 6.5 years was slightly higher but was not significantly modified by patient sex. This relationship remained unchanged after adjustment for differences in baseline characteristics and process of care (women normal EF, reference group; men normal EF adjusted HR 1.1, 95% CI 0.9-1.3; women low EF adjusted HR 1.5, 95% CI 1.1-2.0; men low EF adjusted HR 1.6, 95% CI 1.2-2.1).

CONCLUSIONS

Patient sex did not appear to modify the negative effects of low EF on long-term survival in this prospective study of prevalent heart failure. The small absolute difference in survival between low and normal EF heart failure highlights the need for further research into optimal therapy for the latter, a less well-understood condition.

The partial pressure of resting end-tidal carbon dioxide predicts major cardiac events in patients with systolic heart failure

BACKGROUND

The resting partial pressure of end-tidal carbon dioxide (Petco2) has been shown to reflect cardiac performance in acute care settings in patients with heart failure (HF). The purpose of the present study was to compare the prognostic ability of the partial pressure of Petco2 at rest to other commonly collected resting variables in patients with systolic HF.

METHODS

A total of 353 patients (mean age 58.6+/-13.7, 72% male) with systolic HF were included in this study. All patients underwent cardiopulmonary exercise testing where New York Heart Association (NYHA) class, resting Petco2, peak oxygen consumption, and the minute ventilation/carbon dioxide production slope were determined. Subjects were then followed for major cardiac events (mortality, left ventricular assist device implantation implantation, urgent heart transplantation).

RESULTS

There were 104 major cardiac events during the 23.6+/-17.0-month tracking period. Multivariate Cox regression analysis revealed NYHA class (chi2 28.7, P<.001), left ventricular ejection fraction (residual chi2 21.7, P<.001), and resting Petco2 (residual chi2 14.1, P<.001) were all prognostically significant and retained in the regression. In a separate Cox regression analysis, left ventricular ejection fraction (residual chi2 8.8, P=.003), NYHA class (residual chi2 7.7, P=.005), and resting Petco2 (residual chi2 5.7, P=.02) added prognostic value to the minute ventilation/carbon dioxide production slope (chi2 26.0, P<.001).

CONCLUSION

Resting Petco2 can be noninvasively collected from subjects in a short period, at a low cost, and with no risk or discomfort to the patient. Given the prognostic value demonstrated in the present study, the clinical assessment of resting Petco2 in the HF population may be warranted.

Hospitalized patients with acute decompensated heart failure: recognition, risk stratification, and treatment review

Acute decompensated heart failure (ADHF) has emerged as a major healthcare problem. It causes approximately 3% of all hospitalizations in the United States, with the direct medical cost of these hospitalizations estimated at $18.8 billion per year. Early recognition, risk stratification, and evidence-based treatment are crucial in reducing the morbidity, mortality, and costs associated with this disorder. Classic signs and symptoms of ADHF, such as rales, dyspnea, and peripheral edema, may be absent at hospital presentation and, even when present, are not specific to this disorder. As a result, serum B-type natriuretic peptide level is now used to rapidly and accurately detect ADHF. Multivariate analyses have identified renal dysfunction, hypotension, advanced age, hyponatremia, and comorbidities as significant and independent mortality risk factors. Based on these factors, mortality risk can be stratified from very low to very high using published algorithms that have been validated in independent populations. Evidence-based guidelines for the treatment of ADHF are available from both the European Society of Cardiology and the Heart Failure Society of America. In general, an intravenous loop diuretic, either alone or in combination with a vasodilator, is recommended as initial therapy in patients with volume overload, depending on the patient's clinical status. Use of inotropic agents should be limited to the small subset of patients with low-output syndrome and significant hypotension. In any event, frequent monitoring of clinical response is essential, with subsequent therapy determined by this response. Finally, focused patient education during hospitalization may help reduce readmissions for ADHF.

Decreased renal function as an independent predictor of re-hospitalization for congestive heart failure

BACKGROUND

Patients with congestive heart failure (CHF) are often re-hospitalized, worsening both their quality of life and prognosis. Although renal dysfunction reportedly increases the risk of CHF, the association between renal dysfunction and re-hospitalization for CHF remains unclear.

METHODS AND RESULTS

Patients with CHF and decreased renal function were reviewed. The estimated glomerular filtration rate (GFR) was calculated with the Modification of Diet in Renal Disease equation. Patients with decreased renal function (estimated GFR on admission <45 ml .min(-1) . 1.73 m(-2)) were re-hospitalized more frequently than were patients with preserved renal function (estimated GFR on admission >or=45). Patients with decreased renal function were older and had higher rates of anemia, worsening renal function during hospitalization, and previous hospitalization for CHF. Independent predictors of re-hospitalization for CHF identified with multivariate analysis were age, previous hospitalization for CHF, decreased renal function, and non-use of an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker.

CONCLUSIONS

Renal dysfunction is an independent predictor of re-hospitalization for CHF, so careful follow-up is needed, even after discharge.

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.

Serum urea and total cholesterol independently predict re-hospitalisation with a cardiac-related event following an acute ST-elevation myocardial infarction

BACKGROUND

Although elevated serum urea and low serum sodium have been shown to be associated with increased short-term (30-day) mortality following an ST-elevation myocardial infarction (STEMI), little is known about the role of these biochemical markers as predictors of intermediate-term (1-year) re-hospitalisation.

METHODS

Case notes of 90 consecutively admitted patients discharged with a primary diagnosis of an STEMI were retrospectively investigated. Baseline parameters were recorded and patients' clinical course following hospital discharge was carefully reviewed up to 1-year post-STEMI. Multivariate logistic regression analysis was performed to determine the independent association between baseline parameters and 1-year re-hospitalisation.

RESULTS

The mean age of the patients was 62.8+/-1.38 years. Thirty patients (33.3%) were re-hospitalised for cardiac-related events and three patients (3.3%) died within 1 year of index STEMI. Using stepwise regression analysis, after adjusting for all independent variables, admission total cholesterol (p=0.013) and urea (p=0.04) were found to be the only significant independent predictors of re-hospitalisation or death. Admission serum sodium was non-significant (p=0.065), but only just. For each mmol/L increase in total cholesterol, a patient was 2.18 times more likely to be re-hospitalised, while for each mmol/L increase in serum urea, a patient was 1.32 times more likely to be re-hospitalised or die. When data were categorised based on high urea (> 7 mmol/L), high total cholesterol (> 5.0 mmol/L) and low sodium (< 135 mmol/L) at admission, none of these variables showed any significant increased risk of re-hospitalisation or death. This suggests that these biochemical parameters were continuously associated with risk of re-hospitalisation through the whole range of serum concentrations.

CONCLUSION

In this retrospective study, independent predictors of 1-year re-hospitalisation following an STEMI include high serum urea, raised cholesterol levels and, possibly, reduced sodium levels. These simple biomarkers can be included in patients' risk stratification when following post-STEMI patients in out-patient clinics.

Heart failure mortality in Southeast Asian patients with left ventricular systolic dysfunction

BACKGROUND

Prognostic indicators and mortality in multiethnic Southeast Asian patients with heart failure (HF) may be different.

METHODS AND RESULTS

The study population comprised 225 inpatients with HF with a left ventricular ejection fraction of 40% or less who were discharged alive. Five years later, survival and causes of death were determined. Proportionally, more Malay and Indian patients were admitted compared with Chinese patients (P < .001). There were 55.6% in New York Heart Association (NYHA) class III or IV. Ischemic heart disease was the most common cause (85.8%). At 5 years, 152 patients (67.5%) had died. Angiotensin-converting enzyme inhibitors were prescribed to 79.1% of patients on discharge. Cardiovascular causes accounted for 69.7% of deaths. Predictors of mortality include female gender (P = .046), age 70 years or more (P = .017), renal impairment (P = .008), NYHA class III or IV (P = .03), and non-use of angiotensin-converting enzyme inhibitors (P = .005). On multivariate analysis, increasing age (P = .001) and renal impairment (P = .019) were independent predictors of all-cause mortality. Cardiovascular death was more likely with NYHA class III or IV (P = .004) and renal impairment (P = .012).

CONCLUSION

Mortality is unusually high in this group of patients despite treatment. Greater use of evidence-based therapies in HF-management programs may arrest this trend.

The contribution of observational studies to the knowledge of drug effectiveness in heart failure

AIMS

Randomized controlled trials (RCTs) are the golden standard for the assessment of drug efficacy. Little is known about the add-on value of observational studies in heart failure (HF). We aimed to assess the contribution of observational studies to actual knowledge regarding the effectiveness of angiotensin-converting enzyme inhibitors (ACEI), and beta-blockers (BB) in HF.

METHODS

Observational studies that assessed the effectiveness of ACEI and BB in HF were identified by searching Medline, Embase, Cochrane Database (1990-2005) and the bibliographies of published articles. Cohort, case-control and time-series analysis studies were considered for inclusion. Studies with <100 patients and those who did not perform a multivariate analysis were excluded.

RESULTS

A total of 23 cohort studies met the inclusion criteria. Studies of ACEI and BB showed a decrease in mortality with drug use in elderly patients with a broad range of ejection fraction (EF), and in those with depressed EF. Additionally, they showed a decrease in mortality in patients with renal insufficiency. The effect of ACEI and BB in HF with preserved EF was not clear, although last evidence suggests a potential benefit. Low-dose ACEI and BB may have beneficial effects. Target doses of ACEI seemed superior to low doses, but there was no clear dose-response relationship.

CONCLUSIONS

Observational studies in HF validate the effectiveness of ACEI and BB in populations underrepresented or excluded from RCTs. Observational studies of drug effectiveness provide relevant additional information for clinical practice.

Anemia Does Not Predict Mortality in Elderly Patients With Heart Failure

Recent studies suggest that anemia is an independent predictor of adverse outcomes in patients with heart failure (HF), but the importance of anemia in elderly HF patients is unclear. To investigate this relationship, the authors quantified the prognostic importance of anemia in elderly vs younger patients with HF was performed. A chart review of 359 patients hospitalized in 1999 with HF was performed. Patients were categorized based on their hemoglobin (Hgb) level (<11.5, 11.5-13.4, >13.4 g/dL), and the authors used time-to-event analyses to test the hypothesis that Hgb predicted mortality over a mean follow-up of 25 months. Lower Hgb predicted worse survival in patients younger than 75 years (n=204; P=.03), but there was no correlation between Hgb level and mortality in patients 75 or older (n=155; P not significant). The authors conclude that anemia is not an important predictor of long-term survival in very elderly patients hospitalized with HF.

Chronic kidney disease associated mortality in diastolic versus systolic heart failure: a propensity matched study

Chronic kidney disease (CKD) is common and is associated with increased mortality in heart failure (HF). However, it is unknown whether the effect of CKD on mortality varies by left ventricular ejection fraction (LVEF). We evaluated the effect of CKD on mortality in patients with systolic (LVEF <or=45%) and diastolic (LVEF >45%) HF. Of the 7,788 patients in the Digitalis Investigation Group trial, 3,527 (45%) had CKD (estimated glomerular filtration rate <60 ml/min/1.73 m2). We calculated the propensity score for CKD for each patient, using a multivariate logistic regression model (c statistic 0.76, postmatch absolute standardized differences <5% for all 32 co-variates). We matched 2,399 pairs of patients with and without CKD with similar propensity scores. There were 757 (rate 1,049/10,000 person-years) and 882 (rate 1,282/10,000 person-years) deaths, respectively, in patients without and with CKD (hazard ratio 1.22, 95% confidence interval 1.09 to 1.36, p <0.0001). CKD-associated mortality was higher in those with diastolic HF (371 extra deaths/10,000 person-years, hazard ratio 1.71, 95% confidence interval 1.21 to 2.41, p = 0.002) than in systolic HF (214 extra deaths/10,000 person-years, hazard ratio 1.19, 95% confidence interval 1.07 to 1.32, p = 0.001), which was significant (adjusted p for interaction = 0.034). A graded association was found between CKD-related deaths and LVEF. The hazard ratios for CKD-associated mortality for the LVEF subgroups of <35%, 35% to 55%, and >55% were 1.15 (95% confidence interval 1.02 to 1.29), 1.35 (95% confidence interval 1.11 to 1.64), and 2.33 (95% confidence interval 1.34 to 4.06). In conclusion, CKD-associated mortality was higher in those with diastolic than systolic HF. Patients with diastolic HF should be evaluated for CKD, and the role of inhibitors of the renin-angiotensin system in these patients needs to be investigated.

Effectiveness of beta-blocker therapy in daily practice patients with advanced chronic heart failure; is there an effect-modification by age?

AIMS

The effects of beta-blockers in daily practice patients with advanced chronic heart failure (CHF) and a broad range of ejection fraction (EF) are not well established. We aimed to assess, first, the association between beta-blocker prescription at discharge and mortality in a cohort of patients with advanced CHF, and second, whether this association is modified by the age of the patient.

METHODS

Patients diagnosed with advanced CHF (n = 625) were prospectively followed after discharge from the Cardiology Department. The mean age was 76 years, 53% male, mean EF 42 +/- 16%. Overall, 308 (49%) patients had a beta-blocker prescribed at discharge, 140 (22%) low-dose and 168 (27%) high-dose therapy. We used multivariate Cox analysis to assess the association between beta-blocker use at discharge and mortality.

RESULTS

After a mean follow-up of 22 months, 117 (27%) patients died. Prescription of a beta-blocker was associated with a 45% relative risk reduction (hazard ratio 0.55, 95% confidence interval 0.39, 0.78). The relative risk reduction was similar with low and high doses of beta-blockers (42% and 49%). However, the relative risk reduction was higher in younger than in older patients (P = 0.006). In patients < or = 75 years old prescription of a beta-blocker was associated with 71% risk reduction, whereas in patients >75 years old it was associated with 21% risk reduction.

CONCLUSIONS

In this daily practice cohort of patients with advanced CHF, prescription of a beta-blocker was associated with significant mortality reduction. However, the beneficial effects of beta-blockers appear to be greater in younger patients.

Predictors of Mortality and Hospitalization in Women with Heart Failure in the Digitalis Investigation Group Trial

We performed a retrospective follow-up study of 1926 women with heart failure who participated in the Digitalis Investigation Group trial. Adjusted hazard ratios and 95% confidence intervals for covariates that were significant independent predictors of all-cause mortality were age in years (1.02; 1.01-1.03; P<0.001), NYHA class IH-IV (1.56; 1.31-1.87), diabetes (1.63; 1.36-1.95), glomerular filtration rate in mL/min/1.73 m(2) (0.99; 0.98-4).996; P=0.001), pulmonary congestion by chest x-ray (1.57; 1.22-2.02), left ventricular ejection fraction (LVEF) (0.99; 0.98-0.993; P<0.001), and use of digoxin (1.20; 1.02-1.42). Covariates that were significant independent predictors of hospitalization due to worsening heart failure were: nonwhite race (1.28; 1.03-1.58), NYHA class III-IV (1.55; 1.30-1.84), diabetes (1.75; 1.47-2.09), glomerular filtration rate as mL/min/1.73 m(2) (0.99; 0.986-0.996; P<0.001), pulmonary congestion by chest x-ray (1.42; 1.12-1.81), and use of ACE inhibitors (0.67; 0.49-0.91). Longer duration of heart failure, higher NYHA classes, diabetes, chronic kidney disease, pulmonary congestion, and lower LVEF were significant independent predictors of all-cause mortality, all-cause hospitalization, and hospitalization for heart failure in women with heart failure.

Life expectancy of elderly and very elderly patients with chronic heart failure

INTRODUCTION

The survival of patients with chronic heart failure is typically reported as a comparison of different groups of patients using the hazard ratio from a Cox proportional hazards analysis. The absolute survival is generally neglected. Furthermore, attention is often focused on relatively young patients although chronic heart failure largely affects older patients. The present study was undertaken to determine the life expectancy (a measure of absolute survival) of older patients with chronic heart failure.

METHODS

Patients >75 years with chronic heart failure caused by impaired left ventricular systolic function who attended an outpatient clinic were included in the study. Follow-up commenced on August 1, 1993, and continued until September 30, 2005, when vital status was ascertained. Mean survival time was calculated as a measure of life expectancy.

RESULTS

There were 210 patients included in the study. Male patients of mean age 80 years had a life expectancy of 3.9 years (95% CI 3.2-4.5), compared with that of 7 years for men in the general population of the same age. For female patients of mean age 80 years, the life expectancy was 4.5 years (95% CI 3.6-5.7), compared with 8.5 years for the general population of women of the same age.

CONCLUSION

The presence of chronic heart failure in older patients results in an approximately 50% reduction in life expectancy.

A history of arterial hypertension does not affect mortality in patients hospitalised with congestive heart failure

OBJECTIVES

To evaluate the importance of a history of hypertension on long-term mortality in a large cohort of patients hospitalised with congestive heart failure (CHF).

DESIGN

Retrospective analysis of 5491 consecutive patients, of whom 24% had a history of hypertension. 60% of the patients had non-systolic CHF, and 57% had ischaemic heart disease.

SETTING

38 primary, secondary and tertiary hospitals in Denmark.

MAIN OUTCOME MEASURES

Total mortality 5-8 years after inclusion in the registry.

RESULTS

Female sex and preserved left ventricular systolic function was more common among patients with a history of hypertension. 72% of the patients died during follow up. A hypertension history did not affect mortality risk (hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.92 to 1.07). Correction for differences between the normotensive and hypertensive groups at baseline in a multivariate model did not alter this result (HR 1.08, 95% CI 1.00 to 1.17, p = 0.06). The hazard ratio was similar in patients with and without a history of ischaemic heart disease. Hence, a specific effect of hypertension in the group of patients with CHF with ischaemic heart disease, as suggested in earlier studies, could not be confirmed.

CONCLUSION

A history of arterial hypertension did not affect mortality in patients hospitalised with CHF.

Serum digoxin concentration and outcomes in women with heart failure: A bi-directional effect and a possible effect modification by ejection fraction

BACKGROUND

The association between serum digoxin concentration (SDC) and outcomes in women with heart failure (HF) has not been well studied.

AIMS

To test the hypothesis that the effect of digoxin on outcomes in women with HF is bi-directional and dependent on SDC, as in men, and is modified by ejection fraction (EF).

METHODS

We studied 1366 female participants of the Digitalis Investigation Group trial in whom data on SDC (ng/ml) were available. We calculated adjusted odds ratios (AOR) and Bonferroni-adjusted 97.5% confidence intervals (CI) for various outcomes at a median follow up of 41 months, in all women and stratified by EF 35%.

RESULTS

Compared with placebo (26.9%), 40.3% with SDC> or =1.2 (AOR=1.80; CI=1.14-2.86; p=0.004) and 26.6% with SDC 0.5-1.1 (AOR=1.05; CI=0.73-1.51; p=0.762) died. Respective rates for HF-hospitalizations were: placebo (32.8%), SDC> or =1.2 (38.0%) and SDC 0.5-1.1 (25.5%). For women with EF<35% (N=677), SDC 0.5-1.1 lowered odds for HF-hospitalizations (AOR=0.63; CI=0.39-1.00; p=0.026) without increasing odds for death (AOR=0.77; CI=0.47-1.26; p=0.233). In women with EF> or =35% (N=689), SDC 0.5-1.1 had a borderline association with death (AOR=1.58; CI=0.92-2.72; p=0.058) but not with HF-hospitalization (AOR=0.95; CI=0.54-1.66; p=0.826).

CONCLUSIONS

As in men, in women with HF, digoxin has a bi-directional effect based on SDC, and the beneficial effects were significant only among women with EF<35%.

Pathophysiologic targets in the early phase of acute heart failure syndromes

An episode of acute heart failure syndromes (AHFS) can be defined as a rapid or gradual onset of signs and symptoms of heart failure (HF) in hospital admission and can arise from a variety of pathophysiologic mechanisms. This article reviews our current understanding of the pathophysiology of AHFS in order to identify potential therapeutic targets. Most patients with AHFS present with either normal systolic blood pressure or elevated blood pressure. Patients who present with elevated systolic blood pressure usually have pulmonary congestion and a relatively preserved left ventricular ejection fraction (LVEF), and have symptoms that typically develop abruptly, these patients often are elderly women. Patients with normal systolic blood pressure presenting with systemic congestion and reduced LVEF are usually younger, with a history of chronic HF, and have symptoms that develop gradually over days or weeks. Accordingly, most episodes of AHFS can be classified as either "vascular" failure or "cardiac" failure. In addition to the abnormal hemodynamics (increase in pulmonary capillary wedge pressure and/or decrease in cardiac output) that characterize patients with AHFS, myocardial injury--which may be related to a decrease in coronary perfusion and/or further activation of neurohormones and renal dysfunction (ie, the cardiorenal syndrome)--probably contributes to short-term and post-discharge cardiac events. Patients with AHFS also have significant cardiac and non-cardiac underlying conditions that contribute to the pathogenesis of AHFS, including coronary artery disease (ischemia, hibernating myocardium, and endothelial dysfunction), hypertension, atrial fibrillation, and type 2 diabetes mellitus. The goals of therapy for AHFS should be not only to improve symptoms and hemodynamics, but also to preserve or improve renal function and prevent myocardial damage.

Prognostic value of resting end-tidal carbon dioxide in patients with heart failure

BACKGROUND

Cardiopulmonary exercise testing (CPET) variables provide valuable prognostic information in the heart failure (HF) population. The purpose of the present study is to assess the ability of resting end-tidal carbon dioxide partial pressure (PETCO2) to predict cardiac-related events in patients with HF.

METHODS

121 subjects diagnosed with compensated HF underwent CPET on an outpatient basis. Mean age and ejection fraction were 49.3 years (+/-14.7) and 28.4% (+/-13.4), respectively. Resting P(ET)CO2 was determined immediately prior to the exercise test in the seated position. Peak oxygen consumption (VO2) and the minute ventilation-carbon dioxide production (VE/VCO2) slope were also acquired during CPET.

RESULTS

There were 41 cardiac-related hospitalizations and 9 cardiac-related deaths in the year following CPET. Mean resting P(ET)CO2, peak VO2 and VE/VCO2 slope were 34.1 mmHg (+/-4.6), 14.5 ml*kg(-1)*min(-1) (+/-5.1) and 35.9 (+/-8.7) respectively. Univariate Cox regression analysis revealed that resting P(ET)CO2 (Chi-square=28.4, p<0.001), peak VO2 (Chi-square=21.6, p<0.001) and VE/VCO2 slope (Chi-square=54.9, p<0.001) were all significant predictors of cardiac related events. Multivariate Cox regression analysis revealed resting P(ET)CO2 added to the prognostic value of VE/VCO2 slope in predicting cardiac related events (residual Chi-square=4.4, p=0.04). Peak VO2 did not add additional value and was removed (residual Chi-square=3.2, p=0.08).

CONCLUSIONS

These results indicate a resting ventilatory expired gas variable possesses prognostic value independently and in combination with an established prognostic marker from the CPET. Resting P(ET)CO2 may therefore be a valuable objective measure to obtain during both non-exercise and exercise evaluations in patients with HF.

The Role of Hospitalists in the Management of Acute Decompensated Heart Failure

Heart failure and episodes of acute decompensated heart failure have an important effect on the US health care system, especially the elderly Medicare population. Efforts to improve the quality of care for patients hospitalized with acute decompensated heart failure have focused on creating standardized treatment guidelines based on substantial clinical evidence, but inadequate implementation of these guidelines continues to result in excess morbidity and mortality from heart failure. Hospitalists specializing in inpatient treatment strategies may play an important role in implementing clinical guidelines because their main commitment is to overall clinical treatment of inpatients. This review focuses on current recommended guidelines for diagnosis, treatment, and long-term management of patients with acute decompensated heart failure and the hospitalist's role in providing the oversight needed to adhere to these guidelines and manage this complex disease state.

The diagnosis and management of chronic heart failure in the older patient

Chronic heart failure is a common problem in old age. Dyspnoea and fatigue are the most common symptoms and should alert the clinician to the likely diagnosis. When there is a clinical suspicion of heart failure, further assessment is required to confirm the aetiology. In older patients, heart failure with normal systolic function is frequently encountered. However, patients with left ventricular systolic dysfunction usually have a poorer prognosis, and most treatments have been evaluated in these patients. Useful investigations include the 12-lead electrocardiogram, chest radiology and echocardiography. A blood test for B-type natriuretic peptide is being increasingly used as a 'rule out' test for heart failure. There are several treatment options. Initially, patients should be treated with a diuretic and ACE inhibitor, provided there are no contraindications. beta-Blocker therapy is also first-line therapy once a patients' haemodynamic status has been stabilized. Additional treatments include spironolactone, angiotensin antagonists and digoxin. Patient factors and tolerability may limit the number of treatment options. Treatment regimes are most effective when delivered using a multidisciplinary approach.