Predictors of Mortality in Patients with Heart Failure

Racial Differences in Mortality among Elderly Patients Admitted for Heart Failure

Several studies have examined predictors of mortality among elderly patients hospitalized with heart failure. In some, elderly African American patients hospitalized for heart failure were reported to have lower risk-adjusted in-hospital mortality compared with Whites. Whether this difference is sustained in the long term and what factors account for this difference remain poorly understood. The objective of this study was to compare risk-adjusted short-term and long-term mortality of a cohort of elderly African American and White patients hospitalized for heart failure to all 30 hospitals in northeast Ohio. The database used for this analysis includes information on demographics and detailed clinical information abstracted from patients’ hospital records. Crude and adjusted 30-day and 18-month survival were compared using Kaplan-Meier method and logistic regression models for multivariate analysis. African American patients had significantly lower 30-day mortality compared with Whites. However, this difference diminished over time and when adjusted for important explanatory covariates, including “do not resuscitate” orders.

The early diastolic myocardial velocity: a marker of increased risk in patients with coronary heart disease

OBJECTIVE

Tissue Doppler imaging (TDI) is a promising echocardiographic modality allowing quantification of myocardial performance. However, the prognostic potential of TDI in patients with acute myocardial infarction (AMI) is not yet investigated. We sought to explore the ability of TDI in identifying patients at risk for new cardiovascular events after AMI.

METHODS

One hundred and nineteen patients with AMI were recruited prospectively (mean age 61 years; range 32-81 years of age). Patients with diabetes mellitus (DM) were excluded. Echocardiography was performed 3-12 months after AMI. Two-dimensional (2-D) and TDI variables were recorded. The patients were followed during a mean period of 4·6 years (range 1-8 years). The primary end-point was defined as any of the following: death from any cause, non-fatal reinfarction or stroke, unstable angina pectoris, congestive heart failure requiring hospitalization and coronary revascularization procedure.

RESULTS

Thirty patients had some form of cardiovascular events during follow-up. Seven patients had cardiovascular death, 13 patients had reinfarction and four patients had a stroke. New angina or unstable angina was recorded in 21 patients. Of these patients, 13 underwent percutaneous coronary angioplasty (PCI) or coronary artery bypass grafting (CABG). The early diastolic myocardial velocity (E(m)) emerged as the only echocardiographic variable that offered a clear differentiation between patients that presented with new cardiovascular (CV) events as compared to the corresponding group without any CV events at follow-up (P<0·05). In multivariate statistical analysis and after adjustment for age, sex, total cholesterol, body mass index (BMI) and other baseline characteristics, Em remained as independent predictors of CV events (HR, 1·18, 95% CI, 1·02-1·36; P<0·05). However, none of the investigated variables evolved as an independent predictor of cardiovascular morbidity and mortality.

CONCLUSION

E(m) appears to be a sensitive echocardiographic index in identifying non-diabetic patients with AMI at risk of new cardiovascular events.

Vital exhaustion and cardiovascular prognosis in myocardial infarction and heart failure: predictive power of different trajectories

BACKGROUND

We examined the different trajectories of vital exhaustion (VE) over a 12-month period and their impact on prognosis in a sample of myocardial infarction (MI) and chronic heart failure (CHF) patients.

METHOD

Consecutive MI (n=407) and CHF patients (n=297) were assessed at baseline, and at 3- and 12-month follow-up for symptoms of VE. Latent growth mixture modelling was used to examine the course of VE over time. The combined clinical endpoint was defined as cardiac hospital readmission or death.

RESULTS

Four distinct trajectories for VE were found: low VE, decreasing VE, increasing VE, and severe VE. Sex, marital status, left ventricular ejection fraction, psychotropic medication, sample group (CHF v. MI) and depressive symptoms were associated with VE, varying according to classes. The mean follow-up period was 25.3 months in which 34.7% of the patients experienced an event. Multivariate Cox regression showed that, compared with patients in the low VE class, patients in the increasing VE class [hazard ratio (HR)=1.16, 95% confidence interval (CI) 1.58-3.61, p=0.01], and the severe VE class (HR=1.69, 95% CI 1.31-2.64, p=0.02) had an increased risk for adverse cardiovascular events (i.e. cardiovascular hospital readmission or cardiovascular death). Decreasing VE was not related to adverse cardiovascular events (HR=0.97, 95% CI 0.66-1.69, p=0.81).

CONCLUSIONS

VE trajectories varied across cardiac patients, and had a differential effect on cardiovascular outcome. Increasing VE and severe VE classes were predictors of poor cardiovascular prognosis. These results suggest that identification of cardiac patients with an increased risk of adverse health outcomes should be based on multiple assessments of VE.

Hypothermia is a bedside predictor of imminent death in patients with congestive heart failure

BACKGROUND

Most studies on predictors of mortality for patients with congestive heart failure (CHF) have described predictors that are either difficult to measure in routine practice or are only modestly sensitive and specific. Having observed 3 patients whose body temperature decreased shortly before death, we hypothesized that hypothermia may predict inhospital mortality.

METHODS

The medical records of 291 patients with a primary discharge diagnosis of CHF were selected from 423 admissions to Memorial Hermann Hospital, Houston, Tex, 1998, after excluding patients with comorbidities that confound body temperature, deaths for causes other than progressive pump failure, and readmissions except the last. Three groups were defined on the basis of admission body temperature (T adm): hypothermia groups T adm (95.5 degrees F-96.5 degrees F) and T adm < 95.5 degrees F, and reference group T adm > or = 96.6 degrees F. Several other known CHF risk factors were studied for confounding, and adjusted hazard ratios were calculated using Cox regression.

RESULTS

Of the 291 patients (mean age 73 years, 47% men), 17 (6%) had hypothermia on admission. Mean hospital stay was 5 days. Of the 17 (6%) patients who died of pump failure, 5 had been hypothermic on admission. Hypothermia was significantly associated with survival, and after adjusting for New York Heart Association functional class, hazard ratio for T adm < 95.5 degrees F was 4.46 (95% confidence interval 1.38-14.3) (P trend = .0283).

CONCLUSIONS

Hypothermia predicted inhospital death in these patients with CHF. If confirmed by future studies, this finding could prove useful, because temperature can be measured continuously, rapidly, and inexpensively, in or out of the hospital.

Renal insufficiency and anemia are independent risk factors for death among patients with acute myocardial infarction

BACKGROUND

Chronic kidney disease (CKD) increases risk of death among patients with coronary artery disease. Mortality risks associated with CKD among patients with cardiovascular disease (CVD) are not well defined. Anemia is associated with increased mortality in end-stage renal disease (ESRD) patients and may also increase risk among patients with CVD.

METHODS

A random sample of patients admitted to the hospital in a single southern state with a principal diagnosis of acute myocardial infarction (ICD-9 codes 410.xx) were followed up after hospital discharge.

RESULTS

CKD was found in 60% of the cohort. Hematocrit of >or=40 was found in 46% of the patients; 26.0% had a hematocrit between 36% and 39%, 21.8% between 30% and 35%, and 5.9% had a hematocrit of less than 30%. The 1-year death rates among individuals with and without CKD were 31.7% and 10.4% respectively [odds ratio (OR) = 4.00 (2.34, 6.91)]. The mortality at one year was 18.6% for individuals with a hematocrit greater than or equal to 40%; 23.5% (OR = 1.35; 95% CI = 0.78, 2.32) for hematocrit 36% to 39%; 30.7% (OR = 1.94; 95% CI = 1.12, 3.34) for hematocrit between 30% and 35%; and 35.8% (OR = 3.16; 95% CI = 1.35, 7.40) for those with a hematocrit less than 30% (chi2 for trend was 12.2, P = 0.007). Both hematocrit and serum creatinine were independently associated with increased risk of death during follow-up after controlling for other patient risk factors.

CONCLUSION

CKD and decreasing hematocrit were frequent among older patients hospitalized for acute myocardial infarction and are independent predictors of subsequent risk of death.

Is specialty care associated with improved survival of patients with congestive heart failure?

BACKGROUND

Implementation of the complex treatment strategies that have been shown to improve survival of patients with congestive heart failure (CHF) may require certain expertise. We wanted to examine the association between pattern of outpatient care and survival of patients with CHF.

METHODS

In a retrospective cohort study conducted with national Veterans Health Administration (VHA) databases, we examined the association between the pattern of outpatient care and survival in 11,661 patients discharged from VA hospitals between October 1, 1991, and September 30, 1992, with the primary diagnosis of CHF (cohort 1). Patients were divided into 4 groups, on the basis of their pattern of outpatient care over a 12-month period after discharge: 1) general medicine clinic visits only (GM-only); 2) cardiology clinic visits only (CARD-only); 3) general medicine and cardiology (MIXED) clinic visits; and 4) neither general medicine nor cardiology clinic visits (no-GM/CARD). We used the Cox proportional hazards model to evaluate 1-year survival, controlling for clinical and demographic factors. Consistency of our results was examined by performing identical analysis on a cohort of patients discharged from VHA hospitals between October 1, 1994, and September 30, 1995 (cohort 2, n = 10,141).

RESULTS

The overall 1-year mortality rate was 23% in the primary cohort. The unadjusted mortality rate was highest for patients in the no-GM/CARD follow up (29%) and lowest for patients in the MIXED group (19%). By use of the MIXED group as reference and adjusting for important clinical and demographic factors, the risk of death (risk ratio [95% CI]) was 1.12 (0.94-1.34) in the CARD-only group, 1.26 (1.15-1.38) in the GM-only group, and 1.48 (1.28-1.72) in the no-GM/CARD group. Cohort-2 results were consistent with cohort 1 for most covariates, and significant survival differences were again found between GM-only and the MIXED group (1.25 [1.14-1.37]).

CONCLUSIONS

We found an improved survival associated with cardiologist care and a mixture of general practitioner and cardiologist care compared with general practitioner care. The pattern of outpatient care may therefore be important for the survival of patients with CHF.

Anemia and renal insufficiency are independent risk factors for death among patients with congestive heart failure admitted to community hospitals: a population-based study

The purpose of this retrospective cohort study was to examine the associations among chronic kidney disease, anemia, and risk of death among patients with heart failure. Retrospective cohort study. Patients with a principal diagnosis of heart failure (ICD9 codes 402.01, 402.11, 402.91, 404.01, 404.11, 404.91, and 428.xx) were included. Chronic kidney disease (CKD) was defined as a serum creatinine >1.4 mg/dl for women and >1.5 mg/dl for men. There were 665 eligible patients in the sample with a mean (SD) age of 75.7 (10.9) yr; 60% were women, 71% were white, and 38% had CKD. On admission, a hematocrit > or =40% was found for 30.3% of the patients; 22.9% had a hematocrit between 36% and 40%, 33.2% between 30% and 35%, and 13.6% had a hematocrit of <30%. The 1-yr death rates among individuals with and without CKD were 44.9% and 31.4%, respectively (relative risk [RR], 1.43; 95% confidence interval [CI], 1.17 to 1.75). The mortality at 1 yr was 31.2% for individuals with a hematocrit > or =40%; 33.8% (RR, 1.08; 95% CI. 0.79 to 1.47) for hematocrit 36 to 39%; 36.7% (RR, 1.17; 95% CI, 0.89 to 1.54) for hematocrit between 30 and 35%; and 50.0% (RR, 1.60; 95% CI, 1.19 to 2.16) for those with a hematocrit <30% (chi(2) for trend was 7.37; P = 0.007). Both hematocrit and serum creatinine were independently associated with increased risk of death during follow-up after controlling for other patient risk factors. In conclusion, CKD and anemia are frequent among older patients with heart failure and are independent predictors of subsequent risk of death.

Cardiac 123 I-MIBG imaging and clinical variables in risk stratification in patients with heart failure treated with beta blockers

Both myocardial m-[123I]iodobenzylguanidine (123I-MIBG) uptake and plasma norepinephrine are markers of sympathetic activation in heart failure and have been shown to portend a poorer prognosis. However, these observations were noted before treatment with beta blockers became part of standard clinical practice. Fifty-eight patients with chronic heart failure (New York Heart Association functional class II and III, ejection fraction <35%; 53% ischaemic cardiomyopathy) were prospectively studied with a mean follow-up of 36 months. During the observational period, 17 patients (29.3%) had a predefined event (death and heart transplantation). All prognostic parameters were obtained before beta blocker therapy was initiated. In both uni- and multivariate analysis, the heart-mediastinum ratio of 123I-MIBG uptake did not correlate with cardiovascular mortality. In the multivariate Cox regression analysis, plasma norepinephrine, peak oxygen consumption, end-diastolic volume as measured by echocardiography and exercise performance during bicycling and walking had prognostic significance in patients with heart failure treated with beta blockers in addition to angiotensin-converting enzyme inhibitors.

Risk stratification in middle-aged patients with congestive heart failure: prospective comparison of the Heart Failure Survival Score (HFSS) and a simplified two-variable model

AIMS

The performance of a US-American scoring system (Heart Failure Survival Score, HFSS) was prospectively evaluated in a sample of ambulatory patients with congestive heart failure (CHF). Additionally, it was investigated whether the HFSS might be simplified by assessment of the distance ambulated during a 6-min walk test (6'WT) instead of determination of peak oxygen uptake (peak VO(2)).

METHODS AND RESULTS

In 208 middle-aged CHF patients (age 54+/-10 years, 82% male, NYHA class 2.3+/-0.7; follow-up 28+/-14 months) the seven variables of the HFSS: CHF aetiology; heart rate; mean arterial pressure; serum sodium concentration; intraventricular conduction time; left ventricular ejection fraction (LVEF); and peak VO(2), were determined. Additionally, a 6'WT was performed. The HFSS allowed discrimination between patients at low, medium and high risk, with mortality rates of 16, 39 and 50%, respectively. However, the prognostic power of the HFSS was not superior to a two-variable model consisting only of LVEF and peak VO(2). The areas under the receiver operating curves (AUC) for prediction of 1-year survival were even higher for the two-variable model (0.84 vs. 0.74, P<0.05). Replacing peak VO(2) with 6'WT resulted in a similar AUC (0.83).

CONCLUSION

The HFSS continued to predict survival when applied to this patient sample. However, the HFSS was inferior to a two-variable model containing only LVEF and either peak VO(2) or 6'WT. As the 6'WT requires no sophisticated equipment, a simplified two-variable model containing only LVEF and 6'WT may be more widely applicable, and is therefore recommended.

The results of a randomized trial of a quality improvement intervention in the care of patients with heart failure. The MISCHF Study Investigators

PURPOSE

Quality improvement and disease management programs for heart failure have improved quality of care and patient outcomes at large tertiary care hospitals. The purpose of this study was to measure the effects of a regional, multihospital, collaborative quality improvement intervention on care and outcomes in heart failure in community hospitals.

PATIENTS AND METHODS

This randomized controlled study included 10 acute care community hospitals in upstate New York. After a baseline period, 5 hospitals were randomly assigned to receive a multifaceted quality improvement intervention (n = 762 patients during the baseline period; n = 840 patients postintervention), while 5 were assigned to a "usual care" control (n = 640 patients during the baseline period; n = 664 patients postintervention). Quality of care was determined using explicit criteria by reviewing the charts of consecutive patients hospitalized with the primary diagnosis of heart failure during the baseline period and again in the postintervention period. Clinical outcomes included hospital length of stay and charges, in-hospital and 6-month mortality, hospital readmission, and quality of life measured after discharge.

RESULTS

Patients had similar characteristics in the baseline and postintervention phases in the intervention and control groups. Using hospital-level analyses, the intervention had mixed effects on 5 quality-of-care markers that were not statistically significant. The mean of the average length of stay among hospitals decreased from 8.0 to 6.2 days in the intervention group, with a smaller decline in mean length of stay in the control group (7.7 to 7.0 days). The net effects of the intervention were nonsignificant changes in length of stay of -1.1 days (95% confidence interval [CI]: -2.9 to 0.7 days, P = 0.18) and in hospital charges of -$817 (95% CI: -$2560 to $926, P = 0.31). There were small and nonsignificant effects on mortality, hospital readmission, and quality of life.

CONCLUSIONS

The incremental effect of regional collaboration among peer community hospitals toward the goal of quality improvement was small and limited to a slightly, but not significantly, shorter length of stay.

Race-related differences among patients with left ventricular dysfunction: observations from a biracial angiographic cohort. Harlem-Bassett LP(A) Investigators

BACKGROUND

This study was designed to describe race-related differences in left ventricular function among a consecutive series of patients undergoing cardiac catheterization and to identify racial differences in coexistent medical and social conditions that are associated with the development of heart failure (HF).

METHODS AND RESULTS

This was a prospective cohort study conducted at 2 university-affiliated teaching hospitals. We used the database of the Harlem-Bassett Lp(a) Study. We included all black (N = 143) or white (N = 313) patients from the main study database for whom complete survey, laboratory, coronary angiographic, and ventriculographic data were available. "Left ventricular dysfunction" was arbitrarily defined as an ejection fraction < or =0.40 or prior pharmacologic treatment for HF. We found that blacks were younger, had a higher proportion of women, and had fewer years of formal education than their white counterparts. Coronary artery disease was less common among blacks, although this group had a higher prevalence of hypertension, diabetes, cigarette smoking, illicit drug use, and alcohol consumption. Black patients had a higher prevalence of previous treatment for HF, larger left ventricular volumes, and lower ejection fractions than white patients. Blacks with left ventricular dysfunction were more likely to have had a previous myocardial infarction or a history of hypertension compared with those without left ventricular dysfunction.

CONCLUSIONS

Regarding left ventricular dysfunction and HF, we conclude that blacks seem to have a much higher burden of disease than whites. Our observations support prior evidence that hypertension is linked to race-related differences in the epidemiology of HF. The interaction between race and access to quality care for HF remains an important area for future investigation.

Differential clinical prognostic classifications in dilated and ischemic advanced heart failure: the EPICAL study

BACKGROUND

The clinical management of severe congestive heart failure (CHF) should be graded according to the prognosis of each individual patient. Our objective was to elaborate a prognostic rating system for severe CHF.

METHODS

The EPICAL program (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) identified patients with severe CHF defined by hospitalization accompanied by class III/IV dyspnea, edema, or hypertension; an ejection fraction </=30% or a cardiothoracic index >/=60%. Baseline variables were tested in Cox multivariate models.

RESULTS

Patients with ischemic heart disease (n = 219) had a lower 1-year survival rate (57.6%) than patients with dilated cardiomyopathy (n = 182) (69. 1%). Multivariate analysis identified 5 prognostic factors for ischemic CHF and 7 for CHF caused by dilated cardiomyopathy. These variables were used to classify patients within prognostic subgroups of good (>75%), intermediate, or poor (</=25%) 1-year survival.

CONCLUSION

A score for prognostic prediction was further derived from readily available data to help physicians improve decision making and to assist in clinical trials as a stratification tool.

Clinical outcomes in heart failure: report from a community hospital-based registry

PURPOSE

Most of the recent information on the prognosis of patients with heart failure has come from large clinical trials or tertiary care centers. This study reports current information from a community hospital-based heart failure registry.

SUBJECTS AND METHODS

We compiled data from 2,906 unselected consecutive patients with heart failure who were admitted to 10 acute care community hospitals in New York State between 1995 and 1997. Patients were followed prospectively for 6 months after hospital discharge or until their death.

RESULTS

The mean (+/- SI)) age of the sample was 76 +/- 11 years. The majority of the patients were women (56%) and most were white (95%). Hospital length of stay averaged 7.4 +/- 7.6 days; hospital charges averaged $7,460 +/- $6,114. Mortality during the index admission was 5%. Among the 2,508 patients for whom mortality or follow-up data were available, an additional 411 died during follow-up, for a cumulative 6-month mortality of 23%. Progressive pump failure was the predominant cause of death in the hospital and after discharge. Although mean functional class (on a 1 to 4 scale) improved from 3.4 +/- 0.7 at hospital admission to 2.3 +/- 0.9 at 1 month after discharge, 43% of patients had at least one hospital readmission during follow-up and 25% had at least one recurrent admission for heart failure. The mean time from index discharge to first rehospitalization was 60 +/- 56 days. In all, 55% of patients (1,370 of 2,508) were rehospitalized or died during the study period.

CONCLUSIONS

Despite advances in the management of heart failure, patients recently hospitalized for this disorder remain at high risk of death, hospital readmission, and poor clinical outcome. Discovery or implementation of new or existing methods of prevention and treatment remain a high priority.

Cardiology or primary care for heart failure in the community setting: process of care and clinical outcomes

STUDY OBJECTIVES

Severity of illness, treatment choices, and clinical outcomes may vary with physician training. This study was performed to determine whether such differences exist among patients with congestive heart failure (CHF) treated by cardiologists and by noncardiologists in the community hospital setting.

DESIGN

Prospective cohort study.

SETTING

Ten acute-care community hospitals. PATIENTS, MEASUREMENTS, AND RESULTS: Two thousand four hundred fifty-four patients with CHF were identified and followed up for 6 months after hospital discharge. Patients who were not treated by a cardiologist (group I; n = 977) were compared with patients whose attending physician was a cardiologist (group II; n = 419) and patients who received consultative care from a cardiologist (group III; n = 1,058). When compared with group I patients, group II patients were more likely to receive the recommended diagnostic tests and treatment strategies, although some of these differences could be explained by variations in the case mix. Group II patients had higher hospital charges, but lower CHF readmission rates and better postdischarge quality-of-life measures. No differences in adjusted mortality rates were observed.

CONCLUSIONS

In the community-hospital setting, the clinical practices of cardiologists are more compatible with published treatment guidelines than the clinical practices of other physicians. The benefits of cardiology specialty care include lower CHF readmission rates and better postdischarge quality-of-life measures, rather than lower mortality rates, fewer hospital charges, or shorter length of stay.

Intraventricular conduction delay: a prognostic marker in chronic heart failure

Chronic heart failure (CHF) is associated with high mortality, and there are several established clinical and laboratory parameters that predict mortality in CHF. The purpose of this study was (a) to identify the best ECG parameter that predicts mortality, (b) to evaluate the prognostic marker of ECG against well-established indicators of prognosis. Relevant data from 241 CHF patients were analysed retrospectively. Cardiopulmonary exercise testing and radionuclide ventriculogram were also performed where possible. The mean follow-up period was 31 months. On univariate analysis by the Cox proportional Hazard method, intraventricular conduction delay (IVCD) [P<0.0001, hazard ratio 1.017 (1.011-1.024)] and QTc [P<0.0001, hazard ratio 1.012 (1.006-1.017)] were identified as predictors of mortality. On bivariate analysis, IVCD and MVO2 were better predictors when combined together. A model based on multivariate analysis showed that IVCD, MVO2 and left ventricular ejection fraction (LVEF) were the best predictors of mortality. The addition of plasma sodium, age and NYHA class had no added benefit on the predictive power of the model. Further analysis of IVCD and QTc showed that, for different cut-off values, IVCD is better than QTc, and that there is a graded increase in mortality with increasing value of IVCD. We have found that IVCD is an important ECG predictor of prognosis in patients with CHF.

Insights into the contemporary epidemiology and outpatient management of congestive heart failure

OBJECTIVES

To evaluate the epidemiology, prognosis, and patterns of practice in patients with chronic congestive heart failure (CHF) treated and followed at a specialized clinic.

METHODS

Prospective cohort study of consecutive patients referred to and followed up in a specialized heart failure clinic between September 1989 and March 1996.

RESULTS

Of the 628 patients referred, 566 were confirmed to have CHF. Mean duration of follow-up was 518 +/- 490 days (range 1 to 2192 days). Vital status was available for 99.3% of patients. Mean age at enrollment was 66 years, 68% were men, 67% had an ischemic cause of heart disease, and 78% had systolic dysfunction. Patients with preserved systolic function were older, more often female, had higher mean systolic blood pressures, and a lower prevalence of ischemic heart disease, ventricular arrhythmias, or impaired renal function when compared with those with systolic dysfunction (all P </=.001). Although there was a significant negative trend in survival with decreasing ejection fraction (P =. 03), the survival experience of those with CHF and preserved systolic function did not significantly differ from those with systolic failure (P =.25). Multiple logistic regression analysis showed increased mortality risk was associated with increasing age, New York Heart Association class IV, ischemic cause of disease, elevated serum creatinine level, use of diuretics, and systolic dysfunction, whereas use of beta-blockers was associated with reduced risk.

CONCLUSIONS

Our data suggest that a specialized outpatient clinic can improve practice patterns in patients with CHF. The high mortality risk in CHF with preserved systolic function suggests the need to find efficacious (and effective) therapies for this condition.

Prognostic indices in heart transplant candidates after the first hospitalization triggered by the need for intravenous pharmacologic circulatory support

BACKGROUND

Patients with heart failure refractory to optimal oral pharmacologic therapy have a dismal short term prognosis. Heart transplantation is the only therapy shown to improve survival in these patients. Unfortunately, due to the critical shortage of donor organs, approximately 30% of listed patients with end-stage heart failure die before a suitable donor heart becomes available. The principal aim of this study was to determine whether intravenous pharmacologic circulatory support favorably influences the clinical course of heart transplant candidates or whether mechanical circulatory support should be instituted in this high risk patient population.

METHODS

Data from 154 consecutive hospitalizations in 125 patients 49+/-12 years were retrospectively reviewed. The product limit method was used to estimate survival. Multiple logistic regression analysis was used to identify the clinical and hemodynamic variables that independently predict outcome after each admission in which heart transplantation did not occur.

RESULTS

One year survival for the study population was 65%. This survival is significantly lower than the 91% 1 year survival in similarly ill patients undergoing heart transplantation. The Cox proportional hazard method identified serum bilirubin, blood urea nitrogen (BUN), serum sodium levels and right atrial pressure as independent prognostic indices. Serum bilirubin, BUN levels and duration of intravenous pharmacologic circulatory support were associated with a poor outcome. A composite index including serum bilirubin and BUN levels predicted outcome with a sensitivity and specificity of 79% and 77%, respectively. The addition of pharmacologic support duration increased the model's sensitivity to 95%, but did not significantly alter specificity that was 74%. Of the 125 patients hospitalized due to the need to initiate intravenous pharmacologic support for the first time (index hospitalization), 69 (55%) were discharged after optimization of medical therapy. Of 21 patients who did not undergo transplantation during the follow-up period, 18 (86%) died within 2 years of the index hospitalization. The duration of intravenous pharmacologic support beyond which prognosis dramatically worsens without heart transplantation is 21 days.

CONCLUSION

Heart transplant candidates who require intravenous pharmacologic circulatory support for more than 21 days and do not receive a suitable donor heart within this period of time have a high mortality. Alternative therapies, such as implantation of a mechanical circulatory assist device should be considered in this high risk population.

Angiotensin-converting enzyme inhibitor use in older patients with heart failure and renal dysfunction

OBJECTIVE

To examine the relationship between angiotensin-converting enzyme (ACE) inhibitor use and clinical outcomes among recently hospitalized patients with congestive heart failure (CHF) and coexisting renal insufficiency.

DESIGN

A prospective cohort study.

SETTING

Ten community hospitals in upstate New York.

PARTICIPANTS

A total of 1076 hospital survivors identified from a consecutive series of CHF inpatients.

MEASUREMENTS

Patients were followed prospectively for 6 months after hospital discharge to track mortality, hospital readmission, and quality of life. Clinical outcomes were stratified by ACE inhibitor use among those with renal dysfunction, defined as serum creatinine > or = 2.0 mg/dL, and among the remaining patients, whose serum creatinine was < or = 1.9.

RESULTS

ACE inhibitor use was lower among 187 patients with renal dysfunction than among 889 patients with preserved function (41 vs 69%, P < .001). Age and sex were among the significant determinants of drug use in both groups. After adjustment for covariables, ACE inhibitor use among those with abnormal renal function was not associated with a lower risk for death or readmission, or better quality of life. By comparison, ACE inhibition conferred meaningful clinical benefit among those whose creatinine was < or = 1.9 mg/dL.

CONCLUSION

Convincing evidence of clinical benefit from ACE inhibitor use is not readily detectable among a sample of 187 unselected older patients with CHF and moderate or severe renal insufficiency. Further studies to identify subsets of this group who might benefit are warranted.

Managed care for congestive heart failure: influence of payer status on process of care, resource utilization, and short-term outcomes

BACKGROUND

Although health maintenance organizations (HMO) are insuring an increasing number of Americans, there are concerns that cost-reduction strategies may limit access to medical care or jeopardize its quality. This study was conducted to examine the influence of insurance payer status on the process of care and resource utilization among patients hospitalized for congestive heart failure (CHF).

METHODS AND RESULTS

Administrative information on all 1995 New York State hospital discharges assigned ICD-9-CM codes indicative of CHF in the principal diagnosis position were obtained from the Statewide Planning and Research Cooperative System database. The following were compared among patients with HMO, indemnity, Medicaid fee-for-service, and Medicare fee-for-service insurance coverage: demographics, comorbid illness, process of care, length of stay, hospital charges, mortality rate, and CHF readmission rate. A total of 43,157 patients were identified (HMO, 1322; indemnity, 4350; Medicaid, 3878; Medicare, 33 607). Noninvasive procedures were used with similar frequency, whereas greater use of invasive techniques was observed among HMO and indemnity patients. After adjustment for patient characteristics and hospital type and location, HMO care was associated with shorter length of stay and lower hospital charges, the latter partially explained by fewer hospital days. Medicaid patients had the longest length of stay, greatest hospital charges, and highest CHF readmission rate. The adjusted risk of death during the index hospitalization did not vary among insurance groups.

CONCLUSIONS

Though insuring only a small proportion of New Yorkers hospitalized for CHF, managed care plans provide similar access to clinical services while generating fewer charges. Whether these observed differences in short-term outcomes derive from patient mix or quality of care is uncertain and deserves wider prospective study.

Influence of race and gender on care process, resource use, and hospital-based outcomes in congestive heart failure

Race and gender are important determinants of certain clinical outcomes in cardiovascular disease. To examine the influence of race and gender on care process, resource use, and hospital-based case outcomes for patients with congestive heart failure (CHF), we obtained administrative records on all 1995 New York State hospital discharges assigned ICD-9-CM codes indicative of this diagnosis. The following were compared among black and white women and men: demographics, comorbid illness, care processes, length of stay (LOS), hospital charges, mortality rate, and CHF readmission rate. We identified 45,894 patients (black women, 4,750; black men, 3,370; white women, 21,165; white men, 16,609). Blacks underwent noninvasive cardiac procedures more often than whites; procedure and specialty use rates were lower among women than among men. After adjusting for other patient characteristics and hospital type and location, we found race to be an important determinant of LOS (black, 10.4 days; white, 9.3 days; p = 0.0001), hospital charges (black, $13,711; white, $11,074; p = 0.0001), mortality (black-to-white odds ratio = 0.832; p = 0.003), and readmission (black-to-white odds ratio = 1.301; p = 0.0001). Gender was an important determinant of LOS (women, 9.8 days; men, 9.2 days; p = 0.0001), hospital charges (women, $11,690; men, $11,348; p = 0.02), and mortality (women-to-men odds ratio = 0.878; p = 0.0008). We conclude that race and gender influence care process and hospital-based case outcomes for patients with CHF.

Factors determining angiotensin-converting enzyme inhibitor underutilization in heart failure in a community setting

BACKGROUND

Angiotensin-converting enzyme (ACE) inhibitors were underprescribed for patients with congestive heart failure (CHF) treated in the community setting in the early 1990s despite convincing evidence of benefit.

HYPOTHESIS

We postulated that (1) the prevalence of ACE inhibitor use has increased, and (2) prescribing biases have narrowed, as community physicians have gained additional clinical experience with these drugs for treatment of CHF.

METHODS

We examined rates of ACE inhibitor use among 1,150 patients with CHF hospitalized at 10 community hospitals in 1995, evaluated determinants of ACE inhibitor prescription, and compared the results with survey data gathered among similar patients during 1992.

RESULTS

Compared with 1992, ACE inhibitor use prior to hospital admission was increased among all patients (42 vs. 33%, p < 0.001) and the subset with a history of CHF (53 vs. 39%, p < 0.0005). Angiotensin-converting enzyme inhibitor prescription at hospital discharge also increased among all survivors (64 vs. 51%, p < 0.00005) and the subset eligible for ACE inhibitor treatment based on clinical trial criteria (77 vs. 66%, p = 0.04). Multivariate analysis suggested no change in the prescribing biases previously observed; ACE inhibitor use was related to lower ejection fraction, lower serum creatinine, documentation of left ventricular systolic function, younger patient age, prescription of any diuretic drug, and nonprescription of alternate vasodilators and calcium blockers. In multivariate analyses, physician specialty did not predict ACE inhibitor use.

CONCLUSIONS

Angiotensin-converting enzyme inhibitor use among patients with CHF is increasing but remains below the 80-90% rates of drug tolerance documented in randomized clinical trials. This discrepancy is partially explained by the prevalence of renal impairment and "diastolic" heart failure in the community setting. However, age bias, use of alternative vasodilators, and substandard quality of care may also play a role.

Recipient selection and management before cardiac transplantation

Cardiac transplantation is a proven, effective therapy for selected patients with end-stage congestive heart failure. Recipient selection is performed by a multidisciplinary team consisting of transplant physicians and surgeons. Clinicians responsible for patient assessment must establish the severity of cardiac dysfunction, formulate a prognosis, and stratify patients according to risk for mortality. Patients whose survival and quality of life are most limited without cardiac transplantation are candidates for therapy. The scarcity of organ donors makes careful screening of potential recipients necessary to identify those individuals most likely to obtain a long-term benefit. Recipient selection criteria and management strategies are evolving because of extended waiting times and high mortality caused by the lack of sufficient numbers of donors. Alternative therapies should be applied wherever possible.

Association between diuretic use, clinical response, and death in acute heart failure

Because the impact of diuretic use on mortality in acute congestive heart failure (CHF) is not known, we examined the association between drug use, fluid balance, and death among 1,150 patients hospitalized for evaluation and treatment of CHF. After adjusting for other relevant intergroup differences, we observed that less net weight loss and a greater number of intravenous drug doses retained significant predictive value for death, suggesting that more frequent diuretic dosing or diuretic resistance may be related to mortality in acute CHF.

Use of angiotensin-converting enzyme inhibitors in heart failure with preserved left ventricular systolic function

This study was conducted to provide evidence of an association between angiotensin-converting enzyme (ACE) inhibitor use and clinical outcomes among patients with congestive heart failure (CHF) and preserved left ventricular (LV) systolic function who are treated in the community setting, and to compare the magnitude and direction of these associations among the subset with preserved function to the subset with LV contractile dysfunction. Seven hundred sixty-three hospital survivors who had measurement of systolic function were identified from among a series of consecutive patients with CHF admitted to 10 community hospitals. They were prospectively followed-up for 6 months after discharge to track death, hospital readmission, and quality of life. Outcomes were stratified by ACE inhibitor use among those with preserved systolic function, defined as an LV ejection fraction (EF) > or = 40% or qualitatively normal contractility, and among those with systolic dysfunction, defined as an EF < or = 39% or qualitatively abnormal contractility. ACE inhibitor prescription rates were higher among the 413 patients with LV contractile dysfunction than among the 350 with preserved function (77% vs 54%, p < 0.0001). Drug-treated and untreated patients were similar in many ways, although lower serum creatinine levels, lower EF, and a higher prevelance of high blood pressure characterized those receiving ACE inhibitors. After adjusting for these and other covariables, ACE inhibitor use among the group with normal function was associated with a trend for a lower risk of death and delayed time to hospital readmission but not absolute rates of rehospitalization. By comparison, ACE inhibition among those with impaired systolic function was associated with trends for lower risk of death and rehospitalization. These data suggest that ACE inhibition may be of benefit when CHF occurs in the context of preserved or normal LV systolic function. Large, multicenter, prospective randomized trials to better test this hypothesis are warranted.

Causes of congestive heart failure. Prompt diagnosis may affect prognosis

Congestive heart failure (CHF) is a progressive disease with multiple possible causes. Systolic heart failure, defined as contractile failure of the myocardium leading to a reduced ejection fraction, is the most common type. Systolic heart failure may result from coronary artery disease, hypertension, a metabolic disorder, infection, or an infiltrative or other disease, or it may be idiopathic. Recognition of CHF can be difficult, especially in elderly patients with several medical conditions. An early clinical sign may be dyspnea on exertion. The extent of workup needed is often indicated by findings on history taking and physical examination. In all patients suspected of having new-onset CHF, a chest film, an electrocardiogram, and left ventricular ejection fraction should be obtained and a search for complicating and causative factors undertaken. Early treatment may halt the otherwise inevitable decline in cardiac function and improve prognosis.

Refractory Heart Failure: A Therapeutic Approach

Optimal “triple therapy” for patients with chronic congestive heart failure (CHF) includes diuretics, digoxin, and either angiotensin-converting enzyme inhibitors or hydralazine plus nitrates. Refractory CHF is defined as symptoms of CHF at rest or repeated exacerbations of CHF despite “optimal” triple-drug therapy. Most patients with refractory CHF require hemodynamic monitoring and treatment in the intensive care unit. If easily reversible causes of refractory CHF cannot be identified, then more aggressive medical and surgical interventions are necessary. The primary goal of intervention is to improve hemodynamics to palliate CHF symptoms and signs (i.e., dyspnea, fatigue, edema). Secondary goals include improved vital organ and tissue perfusion, discharge from the intensive care unit, and, in appropriate patients, bridge to cardiac transplantation. Medical interventions include inotropic resuscitation (e.g., adrenergic agents, phosphodiesterase inhibitors, allied nonglycoside inodilators), load resuscitation (e.g., afterload and preload reduction with nitroprusside or nitroglycerin; preload reduction with diuretics and diuretic facilitators, such as dopaminergic agents or ultrafiltration), and electrical resuscitation (e.g., prevention of sudden death, correction of new or rapid atrial fibrillation, or dual chamber pacing in the setting of relative prolongation of the PR interval and diastolic mitral/tricuspid regurgitation). Surgical interventions are temporizing (e.g., intra-aortic balloon pump and other mechanical assist devices) or definitive (e.g., coronary artery revascularization, valvular surgery, and cardiac transplantation). Although these interventions may improve immediate survival in the short term, only coronary artery revascularization and cardiac transplantation have been shown to improve long-term survival.

Patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure in two community hospitals

Because they provide relief of symptoms and reduce mortality, angiotensin-converting enzyme (ACE) inhibitors have become a highly recommended part of the pharmacologic treatment of patients with congestive heart failure (CHF). Although clinical trials suggest that 80% to 90% of patients with CHF tolerate ACE inhibitors, recent surveys reveal that for fewer than this number of patients are actually receiving these drugs. The reasons for this discrepancy are not known. To better understand physician-prescribing behavior, the current study examined the demographic, clinical, laboratory, and medical care characteristics of patients treated and not treated with ACE inhibitors during hospitalization for decompensated CHF. The charts of a consecutive series of patients admitted to 2 acute care hospitals during 1992 (n = 424) were reviewed and comparisons made between those receiving and not receiving ACE inhibitors at the time of hospital admission and hospital discharge. In addition, measures of in-hospital and postdischarge outcome were compared between the groups. The results revealed significant differences in certain demographic variables (e.g., patient age), clinical measures (e.g., left ventricular ejection fraction and serum creatinine), management issues (e.g., documentation of left ventricular function and documentation of etiology of CHF), and treatment strategies (e.g., ancillary drug use). Few differences were noted in measures of severity of CHF (e.g., New York Heart Association functional class and serum sodium level). Death rates were significantly higher for those not receiving ACE inhibitors. Patterns that emerged that could explain under-prescription ACE inhibitors included older age, worse renal function, left ventricular diastolic dysfunction, use of alternate vasodilators, and overall less intense medical management. Programs to educate care providers regarding the proper use of ACE inhibitors in CHF are recommended.

Selection and treatment of candidates for heart transplantation. A statement for health professionals from the Committee on Heart Failure and Cardiac Transplantation of the Council on Clinical Cardiology, American Heart Association

Improved outcome of heart failure in response to medical therapy, coupled with a critical shortage of donor organs, makes it imperative to restrict heart transplantation to patients who are most disabled by heart failure and who are likely to derive the maximum benefit from transplantation. Hemodynamic and functional indexes of prognosis are helpful in identifying these patients. Stratification of ambulatory heart failure patients by objective criteria, such as peak exercise oxygen consumption, has improved ability to select appropriate adult patients for heart transplantation. Such patients will have a poor prognosis despite optimal medical therapy. When determining the impact of individual comorbid conditions on a patient's candidacy for heart transplantation, the detrimental effects of each condition on posttransplantation outcome should be weighed. Evaluation of patients with severe heart failure should be done by a multidisciplinary team that is expert in management of heart failure, performance of cardiac surgery in patients with low left ventricular ejection fraction, and transplantation. Potential heart transplant candidates should be reevaluated on a regular basis to assess continued need for transplantation. Long-term management of heart failure should include continuity of care by an experienced physician, optimal dosing in conventional therapy, and periodic reevaluation of left ventricular function and exercise capacity. The outcome of high-risk conventional cardiovascular surgery should be weighed against that of transplantation in patients with ischemic and valvular heart disease. Establishment of regional specialized heart failure centers may improve access to optimal medical therapy and new promising medical and surgical treatments for these patients as well as stimulate investigative efforts to accelerate progress in this critical area.

Exercise intolerance in patients with chronic heart failure

Patients with chronic heart failure (CHF) experience significant morbidity because of dyspnea and fatigue with activities of daily living. Although central hemodynamic abnormalities are the hallmark of this disorder, investigators have not shown a relationship between left ventricular ejection fraction or exercise pulmonary capillary wedge pressure and exercise intolerance in this disorder. Recent studies have focused on the contributions of pulmonary abnormalities and alterations in peripheral vasomotor control and skeletal muscle in exercise intolerance in this disorder. Early anaerobic metabolism occurs in patients with CHF and appears to be caused by a combination of reduced skeletal muscle blood flow and decreased aerobic enzyme content in skeletal muscle. Atrophy in skeletal muscle and alterations in skeletal muscle fiber typing are accompanied by alterations in contractile function in skeletal muscle. These results suggest that exercise intolerance in patients with CHF is multifactorial, and that research efforts must consider central hemodynamic abnormalities, pulmonary abnormalities, and alterations in peripheral blood flow and skeletal muscle biochemistry and histology. The present review will explore current research in this area and develop a model for understanding exercise intolerance in CHF.