Clinical predictors of heart failure in patients with first acute myocardial infarction

The spectrum of post-myocardial infarction care: From acute ischemia to heart failure

Heart failure (HF) is the leading cause of mortality in patients with acute myocardial infarction (AMI), with incidence ranging from 14% to 36% in patients admitted due to AMI. HF post-MI develops due to complex inter-play between macrovascular obstruction, microvascular dysfunction, myocardial stunning and remodeling, inflammation, and neuro-hormonal activation. Cardiogenic shock is an extreme presentation of HF post-MI and is associated with a high mortality. Early revascularization is the only therapy shown to improve survival in patients with cardiogenic shock. Treatment of HF post-MI requires prompt recognition and timely introduction of guideline-directed therapies to improve mortality and morbidity. This article aims to provide an up-to-date review on the incidence and pathogenesis of HF post-MI, current strategies to prevent and treat onset of HF post-MI, promising therapeutic strategies, and knowledge gaps in the field.

Sacubitril/Valsartan in the Treatment of Heart Failure With Reduced Ejection Fraction Focusing on the Impact on the Quality of Life: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

There exists a paucity of research data reported by analyses performed on randomized clinical trials (RCTs) that encompass quality of life (QOL) and the aftermath for patients suffering from heart failure with reduced ejection fraction (HFrEF). This systematic review and meta-analysis of randomized clinical trials (RCTs) have been done to evaluate the drug sacubitril/valsartan in the treatment of heart failure (HF) with reduced ejection fraction (HFrEF) with a clear focus on the effect it bestows on measures of physical exercise tolerance and quality of life. A thorough systematic search was done in databases including Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, Embase, and PubMed from 1 January 2010 to 1 January 2023. The search only included published RCTs on adult patients aged 18 and above, with heart failure with reduced ejection fraction (HFrEF). Data analysis was performed by using the software RevMan 5.4 (Cochrane Collaboration, London, United Kingdom). The included studies' bias risk was assessed using the Cochrane Collaboration's Risk of Bias tool. The quality of evidence for the primary outcome was done using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. This systematic review and meta-analysis of RCTs yielded 458 studies, of which eight randomized clinical trials were included and analyzed. The meta-analysis of the included trials shows that the I2 value is 61% (i.e., I2 > 50%), demonstrating a substantial heterogeneity within the studies. The left ventricular ejection fraction (LVEF) expressed in percentage was reported in the five studies, and thereby, a subgroup analysis that yielded a confidence interval (CI) of 95% had the standard mean difference of 0.02 (-0.02, 0.07). The trials had disparity between the reporting of effect on peak oxygen consumption (VO2), measured through cardiopulmonary exercise testing (CPET) methods, six-minute walking test (6MWT), overall physical activity, and exercise capacity. Sacubitril/valsartan did not exponentially improve peak VO2 or 6MWT in these trials; however, the patient-reported data suggested that the quality of life was modestly influenced by the drug. A subgroup analysis was performed using the pooled effect value by the random effects model. The findings showed that the sacubitril/valsartan group significantly was better than the control group in improving HFrEF-associated health-related quality of life (HRQoL). This study is a systematic review and meta-analysis of randomized clinical trials that evaluated the drug sacubitril/valsartan in treating heart failure with reduced ejection fraction (HFrEF) and focused on its tangible effect on the measures of physical exercise tolerance and quality of life. It depicts that the statistical scrutiny due to the lack of significant data and parity across studies did not impart significant improvement of either LVEF, peak VO2, or 6MWT with the use of sacubitril/valsartan; however, the reported exercise tolerance, including daytime physical activity, had a modest impact with the said drug. The pooled values demonstrated that the sacubitril/valsartan group significantly outperformed the control group in improving HFrEF HRQoL.

Myeloid-specific knockout of SHP2 regulates PI3K/PLCγ signaling pathway to protect against early myocardial infarction injury

OBJECTIVES

To study the effects of myeloid-specific knockout of SHP2 on early myocardial infarction and explore its molecular mechanism.

METHODS

The model of myocardial infarction was established by using SHP2 in myeloid-specific knockout mice, and the effect of SHP2MAC-KO on myocardial function was detected by echocardiography. The effects of SHP2 on myocardial infarct size in myeloid-specific knockout mice was examined by TTC assay and Masson staining. Then, the detection of apoptosis was performed using TUNEL staining and inflammatory cell infiltration was observed using immunohistochemical staining. Moreover, macrophages in mouse hearts were selected by Flow Cytometry and treated with PI3K inhibitors respectively. Western blotting was then used to detect protein expression of p-SHP2 and PI3K/PLCγ signaling pathway. The phagocytic ability of cells was detected by endocytosis test, and the expression of inflammatory cytokines was detected by ELISA.

RESULTS

Specific knockout of SHP2 in mice with myocardial infarction can improve the cardiac function, decrease infarct size, and reduce apoptosis as well as inflammatory cell infiltration. It also can mediate the PI3K/PLCγ signaling pathway in macrophages, which in turn enhances the endocytosis of macrophages and reduces the expression of inflammatory cytokines in macrophages.

CONCLUSIONS

Myeloid-specific knockout of SHP2 regulates PI3K/PLCγ signaling pathway to protect against early myocardial infarction injury.

Heart failure as a complication of myocardial infarction: rational therapy. Case report

Heart failure (HF) is still a frequent complication of myocardial infarction. Timely identification of subjects at risk for HF development and early initiation of guideline-directed HF therapy in these patients, can decrease the HF burden. This article aims at summarizing clinical data on established pharmacological therapies in treating post-MI patients with left ventricular systolic dysfunction and signs and symptoms of HF.

The influence of heart failure on clinical and economic outcomes among older adults ≥75 years of age with acute myocardial infarction

BACKGROUND

We aimed to evaluate the influence of heart failure (HF) on clinical and economic outcomes among older adults ≥75 years of age during their acute myocardial infarction (AMI) admission in large population-based study from the United States. We also evaluated the clinical characteristics associated with the presence of HF and the predictors of mortality, healthcare utilization, and cost among older adults with AMI.

METHODS

From January 1, 2000, to December 31, 2016, AMI admission was identified using the primary diagnosis and concomitant HF was identified using any non-primary diagnoses in the Premier Healthcare Database.

RESULTS

Of the 468,654 patients examined, 42,946 (9%) had concomitant HF during their AMI admission. These patients were older, more often female, and were more likely to be White. Patients with concomitant HF were more likely to be frail than non-HF patients (59% vs 15%, P < .001). The mean (SD) Elixhauser comorbidity index was 2.6 (2.5) vs 0.4 (1.1), P < .001 in the AMI with HF vs AMI only group. The use of percutaneous coronary intervention in those with AMI and HF was lower than those with AMI only (15% vs 31%, P < .001). The overall mortality rate for those with HF was 12%, the median [IQR] hospital length of stay was 5 [3,9] days, and only 25% of patients were discharged home. A higher proportion of patients were discharged to rehabilitation or hospice if they had AMI and HF (Rehabilitation: 33% vs 20%, P < .001; Hospice: 5% vs 3%, P < .001). The mean unadjusted cost of an AMI hospitalization in patients with concomitant HF was lower ($12,411 ± $14,860) than in those without HF ($15,828 ± $19,330). After adjusting for age, gender, race, hypertension, frailty, revascularization strategy, and death, the average cost of hospitalization attributed to concomitant HF was +$1,075 (95% CI +876 to $1,274) when compared to AMI patients without HF.

CONCLUSION

In patients ≥75 years of age, AMI with concomitant HF carries higher risk of death, but at ages ≥85 years, the risk difference diminishes due to other competing risks. HF was also associated with longer hospital length of stay and higher likelihood of referral to hospice and rehabilitation facilities when compared to older patients without HF. Care for these older adults is associated with increased hospitalization costs. Measures to identify HF in older adults during their AMI admission are necessary to optimize health outcomes, care delivery, and costs.

Role of NLRP3 Inflammasome in Myocardial Ischemia-Reperfusion Injury and Ventricular Remodeling

Reperfusion therapy is the optimal therapy for acute myocardial infarction (AMI), but acute inflammatory injury and chronic heart failure (HF) after myocardial ischemia and reperfusion (MI/R) remain the leading cause of death after AMI. Pyroptosis, a newly discovered form of cell death, has been proven to play a significant role in the acute reperfusion process and the subsequent chronic process of ventricular remodeling. Current research shows that multiple stimuli activate the pyroptotic signaling pathway and contribute to cell death and nonbacterial inflammation after MI/R. These stimuli promote the assembly of the nucleotide-binding and oligomerization-like receptor pyrin domain-containing protein 3 (NLRP3) inflammasome by activating NLRP3. The mature NLRP3 inflammasome cleaves procaspase-1 to active caspase-1, which leads to mature processing of interleukin (IL)-18, IL-1β, and gasdermin D (GSDMD) protein. That eventually results in cell lysis and generation of nonbacterial inflammation. The present review summarizes the mechanism of NLRP3 inflammasome activation after MI/R and discusses the role that NLRP3-mediated pyroptosis plays in the pathophysiology of MI/R injury and ventricular remodeling. We also discuss potential mechanisms and targeted therapy for which there is evidence supporting treatment of ischemic heart disease.

Impact of age, gender and heart failure on mortality trends after acute myocardial infarction in Italy

BACKGROUND

The outcome of patients with acute myocardial infarction (AMI) may vary substantially based on baseline risk. We aimed at analyzing the impact of gender, age and heart failure (HF) on mortality trends, based on a nationwide, comprehensive and universal administrative database of AMI.

METHODS

This is a nationwide cohort study of patients admitted with AMI from 2009 to 2018 in all Italian hospitals. In-hospital mortality rate (I-MR) and 1-year post-discharge mortality rate (1-Y-MR) were assessed.

RESULTS

Among the 1,000,965 AMI events included in the analysis, 43.6% occurred in patients aged ≥75 years, 34.7% in females and 21.8% in AMI complicated by HF at the index hospitalization. Both I-MR and 1-Y-MR significantly decreased over time (from 8.87% to 6.72%; mean annual change -0.23%; confidence intervals (CI): - 0.26% to -0.20% and from 12.24% to 10.59%; mean annual change -0.18%; CI: - 0.24% to -0.13%, respectively). This trend was confirmed in younger and elderly AMI patients, in both sexes. In AMI patients complicated by HF, both I-MR and 1-Y-MR were markedly high, regardless of age and gender.

CONCLUSIONS

This contemporary, nationwide study suggests that I-MR and 1-Y-MR are still elevated, albeit decreasing over time. Elderly patients and those with HF at the time of index admission, present a particularly high risk of fatal events, regardless of gender.

Chronic Porphyromonas gingivalis lipopolysaccharide induces adverse myocardial infarction wound healing through activation of CD8+ T cells

Oral and gum health have long been associated with incidence and outcomes of cardiovascular disease. Periodontal disease increases myocardial infarction (MI) mortality by sevenfold through mechanisms that are not fully understood. The goal of this study was to evaluate whether lipopolysaccharide (LPS) from a periodontal pathogen accelerates inflammation after MI through memory T-cell activation. We compared four groups [no MI, chronic LPS, day 1 after MI, and day 1 after MI with chronic LPS (LPS + MI); n = 68 mice] using the mouse heart attack research tool 1.0 database and tissue bank coupled with new analyses and experiments. LPS + MI increased total CD8+ T cells in the left ventricle versus the other groups (P < 0.05 vs. all). Memory CD8+ T cells (CD44 + CD27+) were 10-fold greater in LPS + MI than in MI alone (P = 0.02). Interleukin (IL)-4 stimulated splenic CD8+ T cells away from an effector phenotype and toward a memory phenotype, inducing secretion of factors associated with the Wnt/β-catenin signaling that promoted monocyte migration and decreased viability. To dissect the effect of CD8+ T cells after MI, we administered a major histocompatibility complex-I-blocking antibody starting 7 days before MI, which prevented effector CD8+ T-cell activation without affecting the memory response. The reduction in effector cells diminished infarct wall thinning but had no effect on macrophage numbers or MertK expression. LPS + MI + IgG attenuated macrophages within the infarct without effecting CD8+ T cells, suggesting these two processes were independent. Overall, our data indicate that effector and memory CD8+ T cells at post-MI day 1 are amplified by chronic LPS to potentially promote infarct wall thinning.NEW & NOTEWORTHY Although there is a well-documented link between periodontal disease and heart health, the mechanisms are unclear. Our study indicates that in response to circulating periodontal endotoxins, memory CD8+ T cells are activated, resulting in an acceleration of macrophage-mediated inflammation after MI. Blocking activation of effector CD8+ T cells had no effect on the macrophage numbers or wall thinning at post-MI day 1, indicating that this response was likely due in part to memory CD8+ T cells.

Heart failure after myocardial infarction: incidence and predictors

Aims

The aim of the present paper was to provide an up‐to‐date view on epidemiology and risk factors of heart failure (HF) development after myocardial infarction.

Methods and results

Based on literature review, several clinical risk factors and biochemical, genetic, and imaging biomarkers were identified to predict the risk of HF development after myocardial infarction.

Conclusions

Heart failure is still a frequent complication of myocardial infarction. Timely identification of subjects at risk for HF development using a multimodality approach, and early initiation of guideline‐directed HF therapy in these patients, can decrease the HF burden.

Post-Myocardial Infarction Heart Failure

Heart failure (HF) complicating myocardial infarction (MI) is common and may be present at admission or develop during the hospitalization. Among patients with MI, there is a strong relationship between degree of HF and mortality. The optimal management of the patient with HF complicating MI varies according to time since the onset of infarction. Medical therapy for HF after MI includes early (within 24 h) initiation of angiotensin-converting enzyme inhibitors and early (within 7 days) use of aldosterone antagonists. Alternatively, in patients with MI and ongoing HF, early use (<24 h) of beta-blockers is associated with an increased risk of cardiogenic shock and death. Long-term beta-blocker use after MI is associated with a reduced risk of reinfarction and death. Thus, it is critical to frequently re-evaluate beta-blocker eligibility among patients after MI with HF. Cardiogenic shock is an extreme presentation of HF after MI and is a leading cause of death in the MI setting. The only therapy proven to reduce mortality for patients with cardiogenic shock is early revascularization. Several studies are examining new approaches to mitigate the occurrence and adverse impact of post-MI HF. These studies are testing drugs for HF and diabetes and are evaluating mechanical support devices to bridge patients to recovery or transplantation.

Pseudonormal or Restrictive Filling Pattern of Left Ventricle Predicts Poor Prognosis in Patients with Ischemic Heart Disease Presenting as Acute Heart Failure

BACKGROUND

In patients with acute heart failure (AHF), diastolic dysfunction, especially pseudonormal (PN) or restrictive filling pattern (RFP) of left ventricle (LV), is considered to be implicated in a poor prognosis. However, prognostic significance of diastolic dysfunction in patients with ischemic heart disease (IHD) has been rarely investigated in Korea.

METHODS

We enrolled 138 patients with IHD presenting as AHF and sinus rhythm during echocardiographic study. Diastolic dysfunction of LV was graded as ≥ 2 (group 1) or 1 (group 2) according to usual algorithm using E/A ratio and deceleration time of mitral inflow, E'/A' ratio of tissue Doppler echocardiography and left atrial size.

RESULTS

Patients in group 1 showed higher 2-year mortality rate (36.2% ± 6.7%) than those in group 2 (13.6% ± 4.5%; p = 0.008). Two-year mortality rate of patient with LV ejection fraction (LVEF) < 40% (26.8% ± 6.0%) was not different from those with LVEF 40%-49% (28.0% ± 8.0%) or ≥ 50% (13.7% ± 7.4%; p = 0.442). On univariate analysis, PN or RFP of LV, higher stage of chronic kidney disease (CKD) and higher New York Heart Association (NYHA) functional class were poor prognostic factors, but LVEF or older age ≥ 75 years did not predict 2-year mortality. On multivariate analysis, PN or RFP of LV (hazard ratio [HR], 2.52; 95% confidence interval [CI], 1.09-5.84; p = 0.031), higher stage of CKD (HR, 1.57; 95% CI, 1.14-2.17; p = 0.006) and higher NYHA functional class (HR, 1.81; 95% CI, 1.11-2.94; p = 0.017) were still significant prognostic factors for 2-year mortality.

CONCLUSIONS

PN or RFP of LV was a more useful prognostic factor for long-term mortality than LVEF in patients with IHD presenting as AHF.

Prevalence and risk factors of heart failure in the USA: NHANES 2013 - 2014 epidemiological follow-up study

Background: Heart Failure (HF) is a progressive epidemic associated with considerable morbidity and mortality. Self-reported data from the National Health and Nutrition Examination Survey (NHANES) provides a unique representation of individuals suffering from HF. The purpose of this study is to analyze updated NHANES 2013-2014 data to identify any changes in the prevalence and current risk factors of HF, especially given the novel lifestyles and increased medical awareness of current generations. Methods: NHANES uses a multistage probability sampling design under the Centers for Disease Control and Prevention (CDC). The Student's t-test and Chi-square test/ Fisher's exact test was used for analysis of variables. A multiple logistic regression model was used to identify statistically significant risk factors for HF. Analyses were performed with the use of SAS software, version 9.4. Results: Based on our analysis, the primary risk factor was coronary artery disease followed by hypertension, diabetes mellitus, age ≥ 65 years, and obesity. Conclusion: The findings revealed that despite improved population awareness and advancements in diagnostics and therapeutics, the same risk factors continue to persist. This provided an insight into the path towards which our resources need to be directed, so as to effectively tackle the aforementioned risk factors.

Heart Failure Complicating Acute Myocardial Infarction; Burden and Timing of Occurrence: A Nation-wide Analysis Including 86 771 Patients From the Cardiovascular Disease in Norway (CVDNOR) Project

BACKGROUND

Coronary heart disease (CHD) represents often the underlying conditions for the development of heart failure (HF). We aimed at exploring the burden and timing of HF complicating an acute myocardial infarction (AMI), using the total population of AMI patients hospitalized during 2001-2009 in Norway.

METHODS AND RESULTS

A total of 86 771 patients with a first AMI during 2001-2009 and without previous HF were identified in the "Cardiovascular Disease in Norway" project and followed until HF development, death, or December 31, 2009. In 16 219 patients (18.7%), HF was present on admission or developed during hospitalization for the incident AMI. HF occurrence varied according to age (8.9%, 15.2%, and 25.6% among men and 10.2%, 16.8%, and 27.1% among women ages 25-54, 55-74, and 75-85 years). Among 63 853 patients discharged alive without HF, 8058 (12.6%) were hospitalized with or died because of HF during a median follow-up time of 3.2 years. HF incidence rates (IRs) per 1000 person-years during follow-up were 31 (95% CI, 30-32) for men and 46 (95% CI, 44-47) for women (P<0.01). IRs of HF were highest during the first 6 months of follow-up, after which they leveled off and remained stable until the end of follow-up.

CONCLUSIONS

In this nation-wide cohort study, we observed that HF remains a frequent complication of the first AMI; both during the acute phase and shortly after the discharge from the hospital.

[Incidence, associated factors, and follow-up of hospital heart failure complicating acute anterior myocardial infarction successfully treated by primary angioplasty]

Heart failure (HF) complicating acute myocardial infarction (AMI) is of poor prognosis and is often associated with patient's characteristics and success of reperfusion strategies. However, few data is available regarding the high-risk subgroup of patients with anterior AMI treated successfully by primary angioplasty. The aim of the study was to assess the incidence, associated factors, and the future of HF occurring during hospitalisation, in the setting of anterior AMI treated successfully by primary angioplasty.

METHODS

Eighty-five consecutive patients with anterior AMI treated successfully by primary angioplasty (final angiographic TIMI flow grade=3, without residual stenosis) were included. Clinical, biochemical, angiographic, and echocardiographic data were prospectively collected and compared between patients with (Killip 2 and 3) and without HF during hospitalisation.

RESULTS

Fifteen patients had HF (18%) during hospitalisation and 70 did not. By comparison to patients without HF, patients with HF were more frequently diabetics, had troponin peak and CPK, leucocytes count, and fasting glucose higher, LVEF and wall motion score index in the left anterior descending territory (WMSi-lad) poorer, and a lower non-invasive coronary flow reserve (CFR) in the LAD 24hours after angioplasty (all, P<0.05). In multivariate analysis, fasting glucose, leucocytes count after angioplasty, CFR and WMSi-lad were independently associated with HF, even after adjusting with angiographic variables (all, P<0.05). At 6months, patients with HF had less recovery of LV function and higher frequency of adverse LV remodelling (58% versus 20%, P<0.01) by comparison to patients without HF.

CONCLUSION

In conclusion, HF is not uncommon even after successful primary angioplasty for anterior AMI (nearly one patient out of 5), is associated with hyperglycaemia and inflammation, a poor microvascular reperfusion, and left ventricular systolic function, and is more frequently complicated by adverse LV remodelling and lack of LV recovery.

Contemporary trends in heart failure with reduced and preserved ejection fraction after myocardial infarction: a community study

Major changes have recently occurred in the epidemiology of myocardial infarction (MI) that could possibly affect outcomes such as heart failure (HF). Data describing trends in HF after MI are scarce and conflicting and do not distinguish between preserved and reduced ejection fraction (EF). We evaluated temporal trends in HF after MI. All residents of Olmsted County, Minnesota (n = 2,596) who had a first-ever MI diagnosed in 1990-2010 and no prior HF were followed-up through 2012. Framingham Heart Study criteria were used to define HF, which was further classified according to EF. Both early-onset (0-7 days after MI) and late-onset (8 days to 5 years after MI) HF were examined. Changes in patient presentation were noted, including fewer ST-segment-elevation MIs, lower Killip class, and more comorbid conditions. Over the 5-year follow-up period, 715 patients developed HF, 475 of whom developed it during the first week. The age- and sex-adjusted risk declined from 1990-1996 to 2004-2010, with hazard ratios of 0.67 (95% confidence interval (CI): 0.54, 0.85) for early-onset HF and 0.63 (95% CI: 0.45, 0.86) for late-onset HF. Further adjustment for patient and MI characteristics yielded hazard ratios of 0.86 (95% CI: 0.66, 1.11) and 0.63 (95% CI: 0.45, 0.88) for early- and late-onset HF, respectively. Declines in early-onset and late-onset HF were observed for HF with reduced EF (<50%) but not for HF with preserved EF, indicating a change in the case mix of HF after MI that requires new prevention strategies.

Scirica B. Risk of Heart Failure Complication During Hospitalization for Acute Myocardial Infarction in a Contemporary Population

Background—

Patients with acute myocardial infarction (MI) complicated by heart failure (HF) are subject to higher mortality during the index hospitalization. Early risk prediction and intervention may help prevent HF-related morbidity and mortality.

Methods and Results—

We examined 77 675 ST-elevation MI and 110 128 non-ST-elevation patients with MI without cardiogenic shock or HF at presentation treated at 609 hospitals in Acute Coronary Treatment and Intervention Outcomes Network Registry (ACTION) Registry-Get With The Guidelines between January 1, 2007, and March 31, 2011. Logistic regression identified patient characteristics associated with development of in-hospital HF. Overall, 3.8% of patients with MI developed in-hospital HF, which was associated with higher mortality in both ST-elevation MI and non-ST elevation MI. In multivariable logistic regression, left ventricular ejection fraction ≤30%, prior HF, diabetes mellitus, female sex, ST-elevation MI, and hypertension (all P <0.005) were independently associated with in-hospital HF. Patients who developed HF during non-ST-elevation MI were more likely to be medically managed without catheterization (30% versus 13% with HF, P <0.0001) or had longer delays to surgical or percutaneous revascularization. Patients with ST-elevation MI and HF were less likely to receive primary percutaneous coronary revascularization (84% versus 79% with HF, P <0.0001), and more likely to receive thrombolytic therapy (14% versus 11%; P =0.0001).

Conclusions—

Patients with MI who develop HF during hospitalization have a higher risk clinical profile and greater mortality, but may be less likely to receive revascularization in a timely fashion. Targeting these highest risk patients may improve outcome post-MI.

Characteristics and in-hospital outcomes of patients with acute coronary syndromes and heart failure in the United Arab Emirates

Background

Heart failure (HF) is a serious complication of acute coronary syndromes (ACS), and is associated with high in-hospital mortality and poor long-term survival. The aims of this study were to describe the clinical characteristics, management and in-hospital outcomes of coronary syndrome (ACS) patients with HF in the United Arab Emirates.

Findings

The study was selected from the Gulf Registry of Acute Coronary Events (Gulf RACE), a prospective multi-national, multicenter registry of patients hospitalized with ACS in six Middle East countries. The present analysis was focused on participants admitted to various hospitals in the UAE with a diagnosis of ACS in 2007 and were analyzed in terms of HF (Killip class II/III and IV) on admission. Of 1691 patients (mean age: 52.6 ± 11.7 years; 210 Females, 1481 Males) with ACS, 356 (21%) had an admission diagnosis of HF (Killip class II/III and IV). HF patients were less frequently males (19.2% vs. 34.3%; P < 0.001). HF was more frequently associated with hypertension (64.3% vs. 43.9%; P < 0.001), hyperlipidemia (49.4% vs. 31.8%; P < 0.001) and diabetes mellitus (DM) (51.1% vs. 36.2%; P < 0.001). HF was significantly associated with in-hospital mortality (OR = 11.821; 95% CI: 5.385-25.948; P < 0.001). In multivariate logistic regression, age, hyperlipidemia, heart rate and DM were associated with higher in-hospital HF.

Conclusions

HF is observed in about 1 in 5 patients with ACS in the UAE and is associated with a significant increase in in-hospital mortality and other adverse outcomes.

Pulse oximetry in the diagnosis of acute heart failure

INTRODUCTION AND OBJECTIVES

Oxygen saturation by pulse oximetry is commonly used for monitoring critical patients, but its utility as a diagnostic marker of acute heart failure has not been assessed. This study analyzed the diagnostic role of oxygen saturation by pulse oximetry in a series of patients with acute myocardial infarction.

METHODS

In a prospective observational cohort study of 220 consecutive patients with acute myocardial infarction, data collection included baseline oxygen saturation by pulse oximetry (without oxygen), physiologic measurements, Killip class and data from portable chest radiography, recorded at the same hour on each of the first three days after admission. Patients were followed up for one year.

RESULTS

There were 612 assessments. Baseline oxygen saturation by pulse oximetry decreased progressively in relation to the presence and the severity of acute heart failure assessed by Killip classes 1 to 3 (mean: 95, 92 and 85, respectively; P<.001) or by Radiology Score 0 to 4 (95, 94, 92, 89 and 83, respectively; P<.001), with a correlation coefficient of 0.66 and 0.63, respectively. Receiver operating characteristic curves disclosed the cut-off of oxygen saturation by pulse oximetry<93 to have the greatest area, with a sensitivity of 65%, specificity 90%, and overall test accuracy 83%. Patients grouped according to lowest oxygen saturation by pulse oximetry showed significantly different rates of one-year mortality or rehospitalization for heart failure.

CONCLUSIONS

Baseline oxygen saturation by pulse oximetry is useful in establishing the diagnosis and severity of heart failure in acute settings such as myocardial infarction and may have prognostic implications.The diagnosis may be suspected when baseline oxygen saturation by pulse oximetry is <93. Full English text available from:www.revespcardiol.org.

Galectin-3 and the development of heart failure after acute coronary syndrome: pilot experience from PROVE IT-TIMI 22

BACKGROUND

Galectin-3 is a β-galactoside-binding lectin that has been implicated in cardiac fibrosis and remodeling, is increased in models of failure-prone hearts, and has prognostic value in patients with heart failure (HF). The relationship between galectin-3 and the development of HF after acute coronary syndrome (ACS) is unknown.

METHODS

In a nested case-control study among patients with ACS in PROVE IT-TIMI 22, we identified 100 cases with a hospitalization for new or worsening HF. Controls were matched (1:1) for age, sex, ACS type, and randomized treatment. Serum galectin-3 was measured at baseline (within 7 days post-ACS).

RESULTS

Patients who developed HF had higher baseline galectin-3 [median 16.7 μg/L (25th, 75th percentile 14.0, 20.6) vs 14.6 μg/L (12.0, 17.6), P=0.004]. Patients with baseline galectin-3 above the median had an odds ratio of 2.1 (95% CI 1.2-3.6) for developing HF, P=0.010. Galectin-3 showed a graded relationship with risk of HF. Cases were more likely to have hypertension, diabetes, prior MI, and prior HF; after adjustment for these factors, this graded relationship with galectin-3 quartile and HF remained significant [adjusted OR 1.4 (95% CI 1.1-1.9), P=0.020]. When BNP was added to the model, the relationship between galectin-3 and HF was attenuated [adjusted OR 1.3 (95% CI: 0.96-1.9), P=0.08].

CONCLUSIONS

The finding that galectin-3 is associated with the risk of developing HF following ACS adds to emerging evidence supporting galectin-3 as a biomarker of adverse remodeling contributing to HF as well as a potential therapeutic target.

Experienced clinicians improve detection of third and fourth heart sounds by viewing acoustic cardiography

BACKGROUND

Clinical assessment of diastolic heart sounds is challenging.

HYPOTHESIS

We sought to examine whether visual inspection of acoustic cardiographic tracings augments the accuracy of medical students' and physicians' detection of third and fourth heart sounds (S(3), S(4)) compared to auscultation alone.

METHODS

A total of 90 adults referred for left heart catheterization underwent digital precordial heart sound recordings by computerized acoustic cardiography. Two blinded, experienced readers using a consensus method determined the presence of the S(3)/S(4) on each file. There were 35 subjects from the following 5 groups participating in this study from 1 teaching institution: first-year medical students (n = 5), fourth-year medical students (n = 5), interns (n = 5), medicine residents (n = 5), cardiology fellows (n = 5), and attendings (n = 10). Using a computer module, each subject listened to the heart sounds alone and documented whether an S(3)/S(4) was present. Next, subjects listened to each recording in random order while viewing phonocardiographic tracings, and recorded S(3)/S(4) presence.

RESULTS

An S(3) was present in 21 patients (23%) and an S(4) in 31 patients (34%) by consensus overread in 90 recordings. Baseline accuracy for auscultation of S(3)/S(4) did not change with level of experience. While viewing the acoustic cardiogram, first-year medical students had minimal improvement in S(3) (2%) and S(4) (11%) accuracy. More experienced subjects improved S(3) accuracy by 8% to 18% and S(4) by 15% to 32% (P < .05). Accuracy was superior for S(3) compared to S(4) in all ausculatory groups.

CONCLUSIONS

While listening to heart sound recordings, viewing acoustic cardiography increased subjects' accuracy in detecting diastolic heart sounds, particularly among more experienced subjects. There was greater improvement for S(4) compared to S(3) detection.

The Effect of Age upon Care and Outcomes in Patients Hospitalized for Congestive Heart Failure in Alberta, Canada

We describe the age-specific outcomes for patients hospitalized with newly diagnosed congestive heart failure using administrative hospital abstracts from Alberta, Canada, from April 1, 1994, to March 31, 2000. Seniors (aged 65 years and older) constituted about 85 per cent of the 16,162 patients. Both co-morbidity and severity of illness tended to increase with age. The use of special care unit admissions, coronary artery diagnostic services (cardiac catheterization), and revascularization procedures (percutanenous transluminal coronary angioplasty/stenting, coronary artery bypass surgery) peaked in the 50-to 64-year age group and decreased with increasing age. Specialist/sub-specialist care, prescriptions of beta blockers and angiotensin-converting enzyme inhibitors / angiotensin receptor blockers decreased with age in seniors. Adjusted in-hospital, 1-year mortality and crude, age-specific 5-year mortality were significantly greater in those 75 years and older. Outcomes and process of care in patients with newly diagnosed congestive heart failure were not uniformly distributed with age. The elderly had greater mortality but received less therapy.

Risk factors for heart failure: a population-based case-control study

BACKGROUND

The relative contribution of risk factors to the development of heart failure remains controversial. Further, whether these contributions have changed over time or differ by sex is unclear. Few population-based studies have been performed. We aimed to estimate the population attributable risk (PAR) associated with key risk factors for heart failure in the community.

METHODS

Between 1979 and 2002, 962 incident heart failure cases in Olmsted County were age and sex-matched to population-based controls using Rochester Epidemiology Project resources. We determined the frequency of risk factors (coronary heart disease, hypertension, diabetes mellitus, obesity, and smoking), odds ratios, and PAR of each risk factor for heart failure.

RESULTS

The mean number of risk factors for heart failure per case was 1.9 + or - 1.1 and increased over time (P<.001). Hypertension was the most common (66%), followed by smoking (51%). The prevalence of hypertension, obesity, and smoking increased over time. The risk of heart failure was particularly high for coronary disease and diabetes with odds ratios (95% confidence intervals) of 3.05 (2.36-3.95) and 2.65 (1.98-3.54), respectively. However, the PAR was highest for coronary disease and hypertension; each accounted for 20% of heart failure cases in the population, although coronary disease accounted for the greatest proportion of cases in men (PAR 23%) and hypertension was of greatest importance in women (PAR 28%).

CONCLUSION

Preventing coronary disease and hypertension will have the greatest population impact in preventing heart failure. Sex-targeted prevention strategies might confer additional benefit. However, these relationships can change, underscoring the importance of continued surveillance of heart failure.

The incidence of heart failure among nondiabetic patients with and without impaired fasting glucose

OBJECTIVE

The purpose of this study was to elucidate the relationship between fasting plasma glucose (FPG), development of diabetes, and incident heart failure (HF) in a large, community sample of nondiabetic subjects.

RESEARCH DESIGN AND METHODS

From Kaiser Permanente Northwest medical records, we identified 10,113 subjects with an FPG level of 100-125 mg/dl in 1997 or 1998 who were free of diabetes and HF and matched them to an equal number of subjects with an FPG level of <100 mg/dl on sex and 5-year age groups. Subjects were followed until a new diagnosis of HF was entered into the medical record, death, termination of health plan membership, or December 31, 2005, whichever came first.

RESULTS

After controlling for known HF risk factors, each 10 mg/dl increase in FPG was independently associated with an 8% increase in the risk of HF over a mean follow-up of 79 months [hazard ratio (HR)=1.08, 95% confidence interval (CI) 1.03-1.13, P=.003]. However, in a subsequent analysis that included only those HF cases that occurred prior to diabetes onset and censored follow-up at the time of diabetes development, FPG was not a significant predictor of HF risk (HR=1.01, 95% CI 0.96-1.07, P=.621). Age, male sex, body mass index, smoking, and cardiovascular disease were highly predictive of HF incidence.

CONCLUSIONS

Although the risk of HF is increased among subjects with higher FPG, the increased risk is explained by greater likelihood of developing diabetes. Risk factors other than FPG are much stronger independent predictors of incident HF.

Identifying the best treatment among common nonsurgical neck pain treatments: a decision analysis

STUDY DESIGN

Decision analysis.

OBJECTIVE

To identify the best treatment for nonspecific neck pain.

SUMMARY OF BACKGROUND DATA

In Canada and the United States, the most commonly prescribed neck pain treatments are nonsteroidal anti-inflammatory drugs (NSAIDs), exercise, and manual therapy. Deciding which treatment is best is difficult because of the trade-offs between beneficial and harmful effects, and because of the uncertainty of these effects.

METHODS

(Quality-adjusted) life expectancy associated with standard NSAIDs, Cox-2 NSAIDs, exercise, mobilization, and manipulation were compared in a decisionanalytic model. Estimates of the course of neck pain, background risk of adverse events in the general population, treatment effectiveness and risk, and patient-preferences were input into the model. Assuming equal effectiveness, we conducted a baseline analysis using risk of harm only. We assessed the stability of the baseline results by conducting a second analysis that incorporated effectiveness data from a high-quality randomized trial.

RESULTS

There were no important differences across treatments. The difference between the highest and lowest ranked treatments predicted by the baseline model was 4.5 days of life expectancy and 3.4 quality-adjusted life-days. The difference between the highest and lowest ranked treatments predicted by the second model was 7.3 quality-adjusted life-days.

CONCLUSION

When the objective is to maximize life expectancy and quality-adjusted life expectancy, none of the treatments in our analysis were clearly superior.

Risk stratification and prognostic factors in the post-myocardial infarction patient

Among the 5 million patients presenting to emergency departments with chest pain each year in the United States, approximately 1 million are diagnosed with myocardial infarction (MI). Physicians have the difficult task of making decisions regarding admission and treatment and identifying patients at high risk for adverse outcomes, such as early mortality, left ventricular dysfunction (LVD), and heart failure. Several measures can be implemented in the process of risk assessment, including clinical judgment, electrocardiographic and echocardiographic findings, and the presence of biomarkers. Biomarkers--which can be classified as antecedent, screening, diagnostic, staging, or prognostic--may help identify the subset of patients who need early intervention and/or intensive therapy. Using a multimarker strategy that combines a marker of hemodynamic stress (brain natriuretic peptide) or of inflammation (C-reactive protein) with a marker of necrosis (cardiac troponin) may help to risk-stratify patients, guide treatment, and optimize admission and discharge decisions. This article discusses the potential benefits of risk assessment tools in the management of post-MI patients with LVD.

Effect of invasive coronary revascularization in acute myocardial infarction on subsequent death rate and frequency of chronic heart failure

There is debate about whether therapies that reduce mortality in acute myocardial infarction (AMI) will increase the risk for heart failure. In this study, an inception cohort of patients hospitalized with AMIs from April 1, 1994, to March 31, 1999 (without previous diagnoses of heart failure or myocardial infarction), were followed for a mean of 32 months to explore whether invasive coronary revascularization during the index AMI hospitalization was associated with a trade-off between reduced mortality in the short term and increased heart failure in the intermediate term. Of 13,472 patients (mean age 65 +/- 13 years, 70% men), 3,278 (24%) underwent invasive coronary revascularization during their index AMI hospitalizations. Patients who underwent invasive revascularization during their index AMI hospitalizations were less likely to die (171 of 3,278 [5%] vs 1,688 of 10,194 [17%], p <0.0001) and were less likely to develop heart failure, either during the AMI hospitalization (571 of 3,278 [17%] vs 2,422 of 10,194 [24%], p <0.0001) or after discharge (144 of 3,278 [4%] vs 754 of 10,194 [7%], p <0.0001). These associations persisted after covariate adjustment (for heart failure, hazard ratio 0.68, 95% confidence interval 0.56 to 0.81; for death or heart failure, hazard ratio 0.60, 95% confidence interval 0.51 to 0.70). In conclusion, invasive coronary revascularization during AMI hospitalization is associated with lower rates of death and subsequent heart failure; there is no trade-off of 1 outcome for the other.

Identifying the best treatment among common nonsurgical neck pain treatments: a decision analysis

STUDY DESIGN

Decision analysis.

OBJECTIVE

To identify the best treatment for nonspecific neck pain.

SUMMARY OF BACKGROUND DATA

In Canada and the United States, the most commonly prescribed neck pain treatments are nonsteroidal anti-inflammatory drugs (NSAIDs), exercise, and manual therapy. Deciding which treatment is best is difficult because of the trade-offs between beneficial and harmful effects, and because of the uncertainty of these effects.

METHODS

(Quality-adjusted) life expectancy associated with standard NSAIDs, Cox-2 NSAIDs, exercise, mobilization, and manipulation were compared in a decision-analytic model. Estimates of the course of neck pain, background risk of adverse events in the general population, treatment effectiveness and risk, and patient-preferences were input into the model. Assuming equal effectiveness, we conducted a baseline analysis using risk of harm only. We assessed the stability of the baseline results by conducting a second analysis that incorporated effectiveness data from a high-quality randomized trial.

RESULTS

There were no important differences across treatments. The difference between the highest and lowest ranked treatments predicted by the baseline model was 4.5 days of life expectancy and 3.4 quality-adjusted life-days. The difference between the highest and lowest ranked treatments predicted by the second model was 7.3 quality-adjusted life-days.

CONCLUSION

When the objective is to maximize life expectancy and quality-adjusted life expectancy, none of the treatments in our analysis were clearly superior.

Does absolute neutrophilia predict early congestive heart failure after acute myocardial infarction? A cross-sectional study

BACKGROUND

Acute myocardial infarction (AMI) is usually associated with increased neutrophil count. However, it has not clearly been defined whether neutrophilia can cause myocardial injury. In this study, we hypothesized that absolute neutrophilia can predict the occurrence of congestive heart failure (CHF) after AMI.

METHODS

A cross-sectional study was carried out on 312 patients with a diagnosis of AMI. Patients with a history of chest pain for more than 12 hours before admission, heart failure with Killip class III and IV, history of recent gastrointestinal bleeding, major trauma, infection, malignancy, renal failure and corticosteroid consumption were excluded. A blood sample was drawn for leukocyte count and an echocardiogram was obtained 4 days after admission. Congestive heart failure was defined as an ejection fraction less than 40% on echocardiogram or clinical heart failure according to the Framingham's criteria for diagnosis of heart failure.

RESULTS

After excluding 19 patients, data for 293 patients were analyzed. Among them, 152 (51.9%) patients developed new onset CHF. Two hundred and two patients (68.9%) had neutrophilia (neutrophil count >7500/mic/lit). The risk of developing heart failure was higher in patients with neutrophilia (OR = 2.32; 95% CI = 1.33-4.03, P = 0.000). There was a negative correlation between ejection fraction and neutrophil count (r = -0.191, P = 0.000). After adjustment for age, sex, serum creatinine level, peak enzyme CK-MB level and MI location, the relationship between the absolute neutrophil count and the presence of congestive heart failure remained significant (OR = 2.14; 95% CI = 1.19-3.84, P = 0.011).

CONCLUSIONS

The study shows that the presence of absolute neutrophilia during the first 12 hours after AMI can predict the occurrence of CHF. This association may help identify high-risk individuals, who might benefit from more aggressive interventions.

Serum cardiac markers in patients with acute myocardial infarction: oxidative stress, C-reactive protein and N-terminal probrain natriuretic Peptide

The aim of this study was to investigate the predictive value of an oxidative stress, C-reactive protein (CRP) and N-terminal probrain natriuretic peptide (NT-proBNP) biomarkers in acute myocardial infarction (AMI). The study population contained 100 patients with AMI and 40 healthy subjects. Malondialdehyde (MDA) was measured as thiobarbituric acid reactive substances. Total antioxidant status (TAC) was assayed with colorimetric method. CRP and NT-proBNP was quantitated by immunoassay. MDA, CRP and NT-proBNP levels were found significantly high in patients with AMI as compared to healthy controls (p<0.01). Patients were divided into six groups based on the presence of disease history before AMI. In patients with non-disease before AMI. MDA, CRP and NT-proBNP levels were lowest among the patient groups. MDA levels in patients with hyperlipidemia/ diabetes/renal disease were higher than the other groups. TAC levels in patients with hypertension were lower than as compared to healthy controls (p<0.05). CRP levels in hypertension + hyperlipidemia patients and NT-proBNP levels in cardiovascular + hypertension patients were found high as compared to other patient groups. It is concluded that serum levels of MDA, CRP and NT-proBNP were significantly increased in patients with AMI and these markers were strongly predictive in AMI.

Gender differences in mortality after acute myocardial infarction with mild to moderate heart failure

BACKGROUND

Heart failure (HF) is associated with poor outcome after acute myocardial infarction (AMI). Women have higher mortality rate than men after AMI, however, it is unknown whether women with HF after AMI have different prognosis than men.

AIM

To compare the prognosis of men and women with AMI and mild-moderate HF.

METHODS

We analyzed data of 3456 consecutive patients with AMI hospitalized in all cardiac care units in Israel during two nationwide surveys.

RESULTS

Among patients with AMI and HF on admission: women were older, had more risk factors, and were less likely to undergo percutaneous coronary angiography/intervention. Women with HF had higher (7-days, 30-days, and 1-year) crude mortality rates than men. However, adjusted mortality rates were not significantly different between genders.

CONCLUSIONS

Women with AMI complicated by HF had higher crude mortality rate than men that was eliminated after multivariate analysis, suggesting that the higher mortality rate may be attributed to increased prevalence of risk factors and lower rate of revascularization and medical therapies among women. Women with AMI and HF should be considered as a high-risk subgroup with adverse outcome. It remains to be determined whether more intensive management will improve their prognosis.

Restrictive Filling Pattern is a Powerful Predictor of Heart Failure Events Postacute Myocardial Infarction and in Established Heart Failure: A Literature-Based Meta-Analysis

BACKGROUND

Two recent literature-based meta-analyses revealed that restrictive filling pattern (RFP) was associated with a 4-fold increase in the risk of death in patients with heart failure (HF) and postacute myocardial infarction (AMI). This similar but unique analysis evaluated the link between RFP and morbidity.

METHODS AND RESULTS

Prospective echocardiographic studies of patients post-AMI and with HF that reported HF morbidity were identified. Events (post-AMI: development of HF; HF: HF readmission) were compared between patients with and without RFP in both patient groups. Review Manager version 4.2.7 software was used for the analysis. Twelve post-AMI studies (1286 patients, 271 events) and 5 HF studies (647 patients, 176 events) were identified. RFP was associated with HF readmission in the HF patients (OR 2.96 [2.02-4.33] and development of HF post-AMI (OR 10.10 [7.02-14.51]). The event rate in the RFP group was the same regardless of disease category (49% post-AMI, 42% HF); however, RFP was less prevalent in the post-AMI group (22% versus 39%).

CONCLUSIONS

This literature-based meta-analysis confirms that RFP is a powerful predictor of HF hospitalization in patients with HF and especially the development of HF post-AMI. This is an important prognostic sign and should be incorporated into routine clinical practice.

Epidemiology of heart failure and left ventricular systolic dysfunction after acute myocardial infarction: prevalence, clinical characteristics, and prognostic importance

The development of heart failure and/or left ventricular systolic dysfunction (LVSD) in the setting of acute myocardial infarction (AMI) results in significant risk far above that of AMI independently. In patients admitted to the hospital for AMI, concomitant heart failure and/or LVSD on hospital admission or development of either or both of these conditions during admission are among the strongest predictors of inhospital death and are associated with significant increases in inhospital, 30-day, and long-term mortality and rehospitalization rates. Given the high risks in this population, aggressive treatment, comprising early initiation and sustained use of evidence-based treatments, is essential for improving prognosis.

Therapies to prevent heart failure post-myocardial infarction

Heart failure (HF) is a common complication of myocardial infarction (MI) that carries a poor prognosis when present. HF and/or left ventricular systolic dysfunction (LVSD) occur in approximately 40% of patients who suffer acute MI. The estimated mortality of patients developing HF or LVSD post-MI is 20% to 30%, with that risk varying based on the presence of HF upon initial assessment versus occurring later during the MI hospitalization. Clinical factors and comorbidities associated with post-MI HF include age, diabetes, hypertension, female gender, infarct size, and tachycardia. Factors associated with decreased survival in patients with post-MI HF include Killip class, age, low blood pressure, tachycardia, male gender, and anterior location of MI. Despite extensive data identifying this patient population as high risk, patients with post-MI HF or LVSD are significantly less likely to receive evidence-based medications or revascularization procedures than those without HF. Despite the high prevalence of HF after MI, few studies have examined therapies to prevent it. This review summarizes studies that reported the incidence, risk factors, and outcomes of patients with post-MI HF or LVSD. Additionally, we discuss therapies to prevent post-MI HF and treatment of patients with post-MI HF and/or LVSD.

Clinical modifiers for heart failure following myocardial infarction

Heart failure (HF) is a clinical syndrome that occurs when the ability of the heart to meet the requirements of the body fails. Myocardial infarction (MI) is a common antecedent event that predisposes a patient to HF. Loss of cardiac function following MI occurs in the context of myocyte death and ventricular remodeling. The clinical significance of HF following MI is underscored by the fact that among MI survivors, the risk of death is markedly elevated in those who develop HF compared with those who do not. Various modifying factors associated with the development of HF following MI have been identified. Use of multimodality therapy with improved clinical outcomes for HF has increased the need to specifically identify the failing heart at an earlier stage. The ability to identify heart failure early in its pathogenesis will enable finer risk stratification following MI. This article reviews various risk predictors for the development of HF following MI.

Depression predicts mortality and hospitalization in patients with myocardial infarction complicated by heart failure

BACKGROUND

To evaluate whether depressive symptoms are independently predictive of mortality and hospitalization among patients with acute myocardial infarction (AMI) complicated by heart failure.

METHODS

The EPHESUS trial enrolled patients with AMI complicated by heart failure. Patients from Canada, the UK, and the United States completed a Medical Outcomes Study-Depression questionnaire at baseline in addition to a comprehensive clinical examination. Cox proportional hazards regression was used to determine the relationship between depressive symptoms and outcomes, including 2-year all-cause mortality and cardiovascular death or hospitalization, adjusting for baseline clinical variables.

RESULTS

Overall, 143 of 634 patients (22.6%) had significant depressive symptoms at baseline (Medical Outcomes Study-Depression score > or = 0.06). Depressed patients had higher 2-year mortality (29% vs 18%; P = .004) and cardiovascular death or hospitalization (42% vs 33%; P = .016). After risk adjustment, depressive symptoms remained significantly associated with mortality (hazard ratio 1.75, 95% CI 1.15-2.68, P = .01) and cardiovascular death or hospitalization (hazard ratio 1.41, 95% CI 1.03-1.93, P = .03). Results were consistent across demographic and clinical subgroups.

CONCLUSIONS

Depression is an independent predictor of all-cause mortality and cardiovascular death or hospitalization after AMI complicated by heart failure. Although many factors may mediate outcomes in patients with AMI, studies are warranted to evaluate whether a depression intervention can improve survival and/or reduce hospitalizations.

Congestive heart failure complicating non-ST segment elevation acute coronary syndrome: incidence, predictors, and clinical outcomes

There are limited data regarding the incidence and clinical significance of congestive heart failure (CHF) in patients with non-ST segment elevation acute coronary syndromes (ACS). The objectives of this study were to examine the incidence, predictors, and clinical outcomes in patients with ACS without ST elevation who develop CHF. We studied patients with unstable angina or non-ST segment elevation myocardial infarction (NSTEMI) randomized to hirudin or unfractionated heparin in the Organisation to Assess Strategies for Ischemic Syndromes (OASIS-2) trial. The diagnosis of CHF was based on a combination of clinical and radiographic features. Patients were followed for 6 months. Of 10 141 randomized patients, 501 (4.9%) developed CHF within the first week and 643 (6.3%) during 6 months of followup. Independent predictors for the development of CHF were older age, female sex, diabetes, prior MI, prior CHF, and NSTEMI at presentation. Compared with patients who did not develop CHF, patients who developed CHF were at increased risk of death (odds ratio (OR) 3.4, 95% CI 2.7-4.3), new MI (OR 2.8, 95% CI 2.2-3.6), and the need for intra-aortic balloon pump insertion (OR 5.4, 95% CI 3.5-8.4) at 7 days and 6 months. There was no increase in use of cardiac catheterization (OR 0.8, 95% CI 0.7-1.0) or revascularization (OR 0.9, 95% CI 0.7-1.1) in patients who developed CHF. CHF is a common complication in patients presenting with non-ST segment elevation ACS and is strongly associated with adverse clinical outcomes including new MI and death. Despite this worse prognosis, patients with ACS developing CHF are less likely to be referred for invasive management.

The incidence of congestive heart failure associated with antidiabetic therapies

BACKGROUND

Increased risk for CHF in persons with type 2 diabetes is well established. Our objectives were to estimate the CHF risk associated with specific therapies for diabetes and to determine the differences in incidence rates of CHF associated with adding various antidiabetic agents.

METHODS

Subjects were members of the Kaiser Permanente Northwest (KPNW) diabetes registry as of 1 January 1998, with no prior history of CHF (n = 8063). We identified their therapy as of that date and then defined the start of the subject study period as the date when their drug regimen changed, either by switching to or by adding another antidiabetic drug. We defined the new therapy as the index therapy and the date of initiating the new therapy as the index date. Follow-up on the patients was done until the index therapy was discontinued or changed, or until 31 December 2002, whichever came earlier. We calculated the incidence rate of CHF in patients on various therapeutic regimens adjusting for age, gender, diabetes duration, existing ischemic heart disease, hypertension, renal insufficiency and glycemic control (HbA(1c)).

RESULTS

CHF incidence rates were highest in index therapy categories that included insulin and lowest in regimens that included metformin. When insulin was added to an initial therapy, CHF incidence was increased 2.33 times (p < 0.0001) and 2.66 times (p < 0.0001) compared to the addition of sulphonylurea or metformin respectively.

CONCLUSIONS

Our findings support the theory that elevated serum insulin levels promote the development of cardiac disease. Consistent with the UKPDS, metformin may offer some protection from incident CHF relative to sulphonylurea or insulin.

Association between physician specialty and volumes of treated patients and mortality among patients hospitalized for newly diagnosed heart failure

PURPOSE

To assess the effects of hospital care by a specialist or nonspecialist physician, and by volume of treated patients, on mortality among hospitalized patients with newly diagnosed heart failure.

METHODS

Data describing heart failure patients in Alberta, Canada, from April 1, 1994, to March 31, 2000, were extracted from hospital abstracts and analyzed using hierarchical regression, with adjustment for patient demographic characteristics, comorbid conditions, physician volume, physician specialty, and hospital volume.

RESULTS

There were 16,162 hospital discharges for heart failure. Nonspecialist physicians were predominantly in the two lowest-volume quartiles (93%) and specialists were predominantly in the two highest-volume quartiles (68%). Considering the effects of volume alone and after adjustment for comorbidity, for each 10 additional hospital patients treated by a physician, the odds ratio for in-hospital mortality was 0.97 (95% confidence interval [CI]: 0.95 to 0.98), and the odds ratio for 1-year mortality was 0.99 (95% CI: 0.98 to 0.999). In analyses that considered both volume and specialty, the odds of in-hospital mortality decreased by 4% for each 10 additional in-hospital patients treated by a physician (odds ratio [OR] = 0.96; 95% CI: 0.95 to 0.98). In these same analyses, the odds ratio for in-hospital mortality was 1.32 (95% CI: 1.13 to 1.53) for general practitioners with specialist consultation and 1.32 (95% CI: 1.08 to 1.61) for specialists compared with general practitioners without specialist consultations. At 1 year, mortality was not associated significantly with the volume of in-hospital patients treated, or with the specialty of the treating physician.

CONCLUSION

Treatment by high-volume physicians during hospitalization for newly diagnosed heart failure was associated with a decrease in mortality, but these benefits did not persist at 1 year. The increased mortality noted in patients treated by specialists may be due to residual confounding or unmeasured comorbidity.

Incidence and predictors of heart failure during long-term follow-up after stress Tc-99m sestamibi tomography in patients with suspected coronary artery disease

BACKGROUND

Heart failure is a major cause of morbidity and death in patients with coronary artery disease (CAD). The aim of this study was to define the incidence and predictors of heart failure during long-term follow-up in patients with suspected CAD referred for stress myocardial perfusion imaging.

METHODS AND RESULTS

We studied 787 patients (mean age, 57 +/- 12 years; 470 men) with suspected CAD who had no history of previous myocardial infarction or heart failure with exercise (n = 508) or dobutamine (n = 279) stress technetium 99m sestamibi single photon emission computed tomography. Patients were followed up for the occurrence of heart failure, nonfatal myocardial infarction, and death. An abnormal perfusion scan (reversible or fixed perfusion defect) was detected in 341 patients (43%). During a mean follow-up of 6.7 +/- 2.3 years, heart failure occurred in 46 patients (6%), 170 patients (22%) died, and 52 patients (7%) had nonfatal myocardial infarction. Patients in whom heart failure developed were older (mean age, 60 +/- 12 years vs 56 +/- 12 years; P = .01) and were more likely to be men (34 [74%] vs 436 [59%], P = .01) and to have an abnormal scan (32 [70%] vs 309 [42%], P = .0002) compared with patients without heart failure. Nonfatal myocardial infarction occurred before the onset of heart failure in only 3 patients (7%). By multivariate analysis, predictors of heart failure were age (risk ratio [RR], 1.04 [95% CI, 1.01-1.08]), male gender (RR, 2 [95% CI, 1.3-4.5]), resting heart rate (RR, 1.1 [95% CI, 1.05-1.2]), and abnormal scan (RR, 2.3 [95% CI, 1.4-3.9]). The annual mortality rate was 15% after the diagnosis of heart failure.

CONCLUSION

In patients with suspected CAD and no history of myocardial infarction, late heart failure is predicted by age, gender, resting heart rate, and abnormal perfusion, and it is associated with a substantial mortality rate. The majority of heart failure events are heralded by perfusion abnormalities on sestamibi single photon emission computed tomography but not by an earlier myocardial infarction.

The incidence of congestive heart failure in type 2 diabetes: an update

OBJECTIVE

The aims of this study were to update previous estimates of the congestive heart failure (CHF) incidence rate in patients with type 2 diabetes, compare it with an age- and sex-matched nondiabetic group, and describe risk factors for developing CHF in diabetic patients over 6 years of follow-up.

RESEARCH DESIGN AND METHODS

We performed a retrospective cohort study of 8,231 patients with type 2 diabetes and 8,845 nondiabetic patients of similar age and sex who did not have CHF as of 1 January 1997, following them for up to 72 months to estimate the CHF incidence rate. In the diabetic cohort, we constructed a Cox regression model to identify risk factors for CHF development.

RESULTS

Patients with diabetes were much more likely to develop CHF than patients without diabetes (incidence rate 30.9 vs. 12.4 cases per 1,000 person-years, rate ratio 2.5, 95% CI 2.3-2.7). The difference in CHF development rates between persons with and without diabetes was much greater in younger age-groups. In addition to age and ischemic heart disease, poorer glycemic control (hazard ratio 1.32 per percentage point of HbA(1c)) and greater BMI (1.12 per 2.5 units of BMI) were important predictors of CHF development.

CONCLUSIONS

The CHF incidence rate in type 2 diabetes may be much greater than previously believed. Our multivariate results emphasize the importance of controlling modifiable risk factors for CHF, namely hyperglycemia, elevated blood pressure, and obesity. Younger patients may benefit most from risk factor modification.