Heart failure in patients with preserved and deteriorated left ventricular ejection fraction

Characterisation of the patients with suspected heart failure: experience from the SHEAF registry

OBJECTIVES

To characterise and risk-stratify patients presenting to a heart failure (HF) clinic according to the National Institute for health and Care Excellence (NICE) algorithm.

METHODS

This is an observational study of prospectively collected data in the Sheffield HEArt Failure registry of consecutive patients with suspected HF between April 2012 and January 2020. Outcome was defined as all-cause mortality.

RESULTS

6144 patients were enrolled: 71% had HF and 29% had no HF. Patients with N-terminal pro-brain-type natriuretic peptide (NT-proBNP) >2000 pg/mL were more likely to have HF than those with NT-proBNP of 400-2000 pg/mL (92% vs 64%, respectively). Frequency of HF phenotypes include: HF with preserved ejection fraction (HFpEF) (33%), HF with reduced ejection fraction (HFrEF) (29%), HF due to valvular heart disease (4%), HF due to pulmonary hypertension (5%) and HF due to right ventricular systolic dysfunction (1%). There were 1485 (24%) deaths over a maximum follow-up of 6 years. The death rate was higher in HF versus no HF (11.49 vs 7.29 per 100 patient-years follow-up, p<0.0001). Patients with HF and an NT-proBNP >2000 pg/mL had lower survival than those with NT-proBNP 400-2000 pg/mL (3.8 years vs 5 years, p<0.0001). Propensity matched survival curves were comparable between HFpEF and HFrEF (p=0.88).

CONCLUSION

Our findings support the use by NICE's HF diagnostic algorithm of tiered triage of patients with suspected HF based on their NT-proBNP levels. The two pathways yielded distinctive groups of patients with varied diagnoses and prognosis. HFpEF is the most frequent diagnosis, with its challenges of poor prognosis and paucity of therapeutic options.

Medications that reduce emergency hospital admissions: an overview of systematic reviews and prioritisation of treatments

BACKGROUND

Rates of emergency hospitalisations are increasing in many countries, leading to disruption in the quality of care and increases in cost. Therefore, identifying strategies to reduce emergency admission rates is a key priority. There have been large-scale evidence reviews to address this issue; however, there have been no reviews of medication therapies, which have the potential to reduce the use of emergency health-care services. The objectives of this study were to review systematically the evidence to identify medications that affect emergency hospital admissions and prioritise therapies for quality measurement and improvement.

METHODS

This was a systematic review of systematic reviews. We searched MEDLINE, PubMed, the Cochrane Database of Systematic Reviews & Database of Abstracts of Reviews of Effects, Google Scholar and the websites of ten major funding agencies and health charities, using broad search criteria. We included systematic reviews of randomised controlled trials that examined the effect of any medication on emergency hospital admissions among adults. We assessed the quality of reviews using AMSTAR. To prioritise therapies, we assessed the quality of trial evidence underpinning meta-analysed effect estimates and cross-referenced the evidence with clinical guidelines.

RESULTS

We identified 140 systematic reviews, which included 1968 unique randomised controlled trials and 925,364 patients. Reviews contained 100 medications tested in 47 populations. We identified high-to moderate-quality evidence for 28 medications that reduced admissions. Of these medications, 11 were supported by clinical guidelines in the United States, the United Kingdom and Europe. These 11 therapies were for patients with heart failure (angiotensin-converting-enzyme inhibitors, angiotensin II receptor blockers, aldosterone receptor antagonists and digoxin), stable coronary artery disease (intensive statin therapy), asthma exacerbations (early inhaled corticosteroids in the emergency department and anticholinergics), chronic obstructive pulmonary disease (long-acting muscarinic antagonists and long-acting beta-2 adrenoceptor agonists) and schizophrenia (second-generation antipsychotics and depot/maintenance antipsychotics).

CONCLUSIONS

We identified 11 medications supported by strong evidence and clinical guidelines that could be considered in quality monitoring and improvement strategies to help reduce emergency hospital admission rates. The findings are relevant to health systems with a large burden of chronic disease and those managing increasing pressures on acute health-care services.

A Simplified Ultrasound Comet Tail Grading Scoring to Assess Pulmonary Congestion in Patients with Heart Failure

Ultrasound lung comets (ULCs) are a nonionizing bedside approach to assess extravascular lung water. We evaluated a protocol for grading ULC score to estimate pulmonary congestion in heart failure patients and investigated clinical and echocardiographic correlates of the ULC score. Ninety-three patients with congestive heart failure, admitted to the emergency department, underwent pulmonary ultrasound and echocardiography. A ULC score was obtained by summing the ULC scores of 7 zones of anterolateral chest scans. The results of ULC score were compared with echocardiographic results, the New York Heart Association (NYHA) functional classification, radiologic score, and N-terminal pro-b-type natriuretic peptide (NT-proBNP). Positive linear correlations were found between the 7-zone ULC score and the following: E/e′, systolic pulmonary artery pressure, severity of mitral regurgitation, left ventricular global longitudinal strain, NYHA functional classification, radiologic score, and NT-proBNP. However, there was no significant correlation between ULC score and left ventricular ejection fraction, left ventricle diameter, left ventricular volume, or left atrial volume. A multivariate analysis identified the E/e′, systolic pulmonary artery pressure, and radiologic score as the only independent variables associated with ULC score increase. The simplified 7-zone ULC score is a rapid and noninvasive method to assess lung congestion. Diastolic rather than systolic performance may be the most important determinant of the degree of lung congestion in patients with heart failure.

Addressing the Heterogeneity of Heart Failure in Future Randomized Trials

PURPOSE OF THE REVIEW

The aim of review is to describe the essential role of study designs beyond RCTs in contemporary contest of HF patients giving perspectives on its evolving. The article concludes with concern about the support of observational studies for future randomized clinical trials.

RECENT FINDINGS

With the aging population and spectacular advance in cardiovascular therapy, the clinical syndrome comprising heart failure (HF) is increasingly in complexity of heterogeneity. It remains among the most challenging of clinical syndromes with a magnitude of proposed pathophysiological mechanisms involving the heart and the interplay with cardiac and non-cardiac comorbidities. In this epidemiological scenario, randomized clinical trials are suffering from growing failed treatment, so that a deeper understanding of heterogeneity represents a major unmet need. This field also is greatly in a more nuanced comprehension about the applicability in clinical practice of trials' results derived from well-selected HF population. Thus, we need to reflect on trials failures and the translation of previous trials in clinical practice in order to redirect the future trial intervention.

Clinical characteristics and prognosis of patients admitted for heart failure: A 5-year retrospective study of African patients

BACKGROUND

Mortality associated with heart failure (HF) remains high. There are limited clinical data on mortality among HF patients from African populations. We examined the clinical characteristics, long-term outcomes, and prognostic factors of African HF patients with preserved, mid-range or reduced left ventricular ejection fraction (LVEF).

METHODS AND RESULTS

We conducted a retrospective longitudinal cohort study of individuals aged ≥18years discharged from first HF admission between January 1, 2009 and December 31, 2013 from the Cardiac Clinic, Directorate of Medicine of the Komfo Anokye Teaching Hospital, Ghana. A total of 1488 patients diagnosed of HF were included in the analysis. Of these, 345 patients (23.2%) had reduced LVEF (LVEF<40%) [HFrEF], 265(17.8%) with mid-range LVEF (40%≥LVEF<50%) [HFmEF] and 878 (59.0%) had preserved LVEF (LVEF≥50%) [HFpEF]. Kaplan-Meier curves and log-rank test demonstrated better prognosis for HFpEF compared to HFrEF and HFmEF patients. An adjusted Cox analysis showed a significantly lower risk of mortality for HFpEF (hazard ratio (HR); 0.74; 95% confidence interval (CI) 0.57-0.94) p=0.015). Multivariate analyses showed that age, higher New York Heart Association (NYHA) functional class, lower LVEF, chronic kidney disease, atrial fibrillation, anemia, diabetes mellitus and absence of statin and aldosterone antagonist treatment were independent predictors of mortality in HF. Although, prognostic factors varied across the three groups, age was a common predictor of mortality in HFpEF and HFmEF.

CONCLUSIONS

This study identified the clinical characteristics, long-term mortality and prognostic factors of African HF patients with reduced, mid-range and preserved ejection fractions in a clinical setting.

Mid-range Ejection Fraction Does Not Permit Risk Stratification Among Patients Hospitalized for Heart Failure

INTRODUCTION AND OBJECTIVES

European Society of Cardiology heart failure guidelines include a new patient category with mid-range (40%-49%) left ventricular ejection fraction (HFmrEF). HFmrEF patient characteristics and prognosis are poorly defined. The aim of this study was to analyze the HFmrEF category in a cohort of hospitalized heart failure patients (REDINSCOR II Registry).

METHODS

A prospective observational study was conducted with 1420 patients classified according to ejection fraction as follows: HFrEF, < 40%; HFmrEF, 40%-49%; and HFpEF, ≥ 50%. Baseline patient characteristics were examined, and outcome measures were mortality and readmission for heart failure at 1-, 6-, and 12-month follow-up. Propensity score matching was used to compare the HFmrEF group with the other ejection fraction groups.

RESULTS

Among the study participants, 583 (41%) had HFrEF, 227 (16%) HFmrEF, and 610 (43%) HFpEF. HFmrEF patients had a clinical profile similar to that of HFpEF patients in terms of age, blood pressure, and atrial fibrillation prevalence, but shared with HFrEF patients a higher proportion of male participants and ischemic etiology, and use of class I drugs targeting HFrEF. All other features were intermediate, and comorbidities were similar among the 3 groups. There were no significant differences in all-cause mortality, cause of death, or heart failure readmission. The similar outcomes were confirmed in the propensity score matched cohorts.

CONCLUSIONS

The HFmrEF patient group has characteristics between the HFrEF and HFpEF groups, with more similarities to the HFpEF group. No between-group differences were observed in total mortality, cause of death, or heart failure readmission.

Spectrum of epidemiological and clinical findings in patients with heart failure with preserved ejection fraction stratified by study design: a systematic review

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) represents a major global and economic burden, but its epidemiological, clinical, and outcome data have varied according to study design.

METHODS AND RESULTS

We conducted a systematic review of published HFpEF clinical trials and observational studies (community-based studies and registries) from August 1998 to July 2013 using PubMed and EMBASE databases. Two independent investigators manually screened and extracted relevant data. We included 62 articles (19 describing clinical trials, 12 describing community-based observational studies, and 31 describing registries). The ejection fraction (EF) cut-off values ranged widely for HFpEF from >40% to >55%. However, differences in EF cut-offs were not clearly associated with incidence and prevalence data across studies. Of all patients with heart failure in community studies, 33-84% had HFpEF, which tended to be higher than reported in registries. The HFpEF patients in included studies were primarily older, white (>70%) patients with hypertension (∼50-90%) and coronary artery disease (up to 60%). All-cause mortality and all-cause hospitalizations ranged from 13% to 23% (26-50 months follow-up) and 55% to 67% (37-50 months follow-up), respectively, in clinical trials; cardiovascular causes accounted for 70% of both outcomes. All-cause mortality tended to be higher in registries than in clinical trials and community-based observational studies up to 5 years into follow-up.

CONCLUSIONS

Important differences in EF thresholds, epidemiological indices, clinical profiles, treatment patterns, and outcomes exist across contemporary HFpEF clinical trials, observational studies, and registries. Precision in definition and inclusion of more uniform populations may facilitate improved profiling of HFpEF patients.

Different characteristics of heart failure due to pump failure and bradyarrhythmia

Background

Heart failure (HF) can be caused by left ventricular (LV) pump failure as well as by bradyarrhythmias. Hemodynamic differences between HF by LV pump failure and that by bradyarrhythmia have not been fully investigated. We hypothesized that HF by LV pump failure could be associated with both reduced cardiac output (CO) and increased LV filling pressure due to associated LV diastolic dysfunction, whereas HF by bradyarrhythmia could be associated with reduced CO but only modestly increased LV filling pressure due to the absence of LV diastolic dysfunction.

Methods

In 39 patients with HF by LV pump failure (LV ejection fraction <35 %), 24 with HF by bradyarrhythmia, and 22 normal controls, LV volume, ejection fraction, stroke volume, left atrial volume, and early diastolic mitral valve flow to tissue annular velocity ratio (E/E′) were measured by echocardiography.

Results

Compared to patients with HF by LV pump failure, those with HF by bradyarrhythmia had significantly lower heart rates, less LV dilatation, preserved LV ejection fraction, preserved stroke volume, similarly reduced cardiac index (1.8 ± 0.4 vs. 1.6 ± 0.4 L/min/m², n.s.), preserved LV diastolic function (E′) (4.4 ± 2.1 vs. 7.1 ± 2.9 cm/s, p < 0.001), less dilated end-systolic LA volume, and preserved E/E′ (24 ± 10 vs. 13 ± 7, p < 0.001).

Conclusions

HF by LV pump failure is characterized by both significantly reduced CO and increased LV filling pressure, whereas HF by bradyarrhythmia is characterized by a similar reduction in CO but only modestly increased LV filling pressure.

Correlation of blood pressure and the ratio of S1 to S2 as measured by esophageal stethoscope and wireless bluetooth transmission

Objective : Esophageal stethoscope has the advantage of being non-invasive, easily placed and capability to monitor the heart sound. This study was designed to determine whether the ratio of S1 to S2 analyzed by esophageal stethoscope and wireless bluetooth transmission can be accurate indicator that express the correlation with blood pressure.

METHODS

Total 33 adult male and female without cardiac disorder and with normal heart rhythm were selected randomly as the subjects of this Study. Two microphones were used with one for acquisition of heart sound by connecting it to the esophageal stethoscope while the other was used to measure the background noise in the operating room. After having transmitted the heart sound measured with the esophageal stethoscope to the receiver by using bluetooth module, it was saved in PC and outputted, following removal of noise in the operating room and the respiratory sound. S1 and S2 were measured with computation of the ratio of S1 to S2. Correlations between the systolic blood pressure with each of the S1, S2 and ratio of S1 to S2 were examined by using correlation analysis.

RESULTS

The ratio of S1 to S2 displayed the highest correlation with the systolic blood pressure, with S1 and S2 also displaying positive correlation with the systolic blood pressure.

CONCLUSION

As the result of analysis of the heart sound and the systolic blood pressure measured by using the esophageal stethoscope, the radio of S1 to S2 displayed greater correlation with the systolic blood pressure in comparison to the S1.

Age-dependent effect of left ventricular ejection fraction on long-term mortality in patients with heart failure (from the Heart Failure Survey in ISrael)

Contemporary heart failure (HF) therapies have not resulted in improved outcomes among patients with HF and preserved left ventricular ejection fraction (LVEF). We sought to evaluate the differential effect of LVEF on long-term mortality after hospitalization for acute decompensated HF in a real-world setting. All-cause mortality at 4 years after hospitalization for HF was assessed by LVEF (categorized as preserved [≥50%], mildly [40% to 49%], moderately [30% to 39%], and severely [<30%] reduced) among 1,620 patients enrolled in the Heart Failure Survey in ISrael. Among the study patients, 30% had preserved LVEF and 20%, 25%, and 25%, had mild, moderate, and severe reductions in LVEF, respectively. Multivariate analysis showed that patients with preserved LVEF had a similar risk of long-term mortality as patients with mild or moderate reduction in LVEF (hazard ratio [HR] 0.92 [p = 0.40] and 1.01 [p = 0.90], respectively) while severely reduced LVEF conferred increased increase rate compared with preserved LVEF (HR 1.20, p = 0.04). Interaction term analysis showed that the risk associated with severely reduced LVEF was evident only among patients ≤75 years (HR 1.49, p = 0.003), whereas among older patients, there was no difference in the risk of long-term mortality between those with preserved versus severely reduced LVEF (HR 1.02 [p = 0.86]; p value for age-by-LVEF interaction = 0.03). In conclusion, patients hospitalized for HF who have preserved LVEF experience similar long-term mortality as patients with mild or moderate reductions in LVEF, whereas severely reduced LVEF remains an independent predictor of long-term mortality in this population. The differential effect of LVEF on long-term mortality is significantly attenuated in the older age group.

Gender differences in the etiology of heart failure: A systematic review

Background

Heart failure (HF) is an increasing problem for the aging population, specifically among women. The etiology of HF influences both the selection and outcome of the treatment. There are variations between genders in morbidity and mortality in different studies, possibly reflecting etiology. The objective of this study was to examine the strength of evidence available for gender differences in the etiology of chronic heart failure.

Methods

Computer-assisted searches from 1980–2009 for gender differences in the etiology of heart failure were performed (Medline, EMBASE and PubMed). From 2347 abstracts reviewed based on inclusion criteria, 35 original articles were chosen for review. Data extraction was based on observational studies (prospective/retrospective cohort or cross sectional) with a mean follow up of 3 months. There was no interrater variability between the 2 reviewers on data-extraction.

Results

Ventricular systolic dysfunction being more associated with male sex, but female sex was more reported to be associated with preserved left ventricular function. Ischemic etiology and associated coronary heart disease were strongly correlated with male sex. The risk for HF was dramatically more elevated for women with systolic hypertension but the association for diabetes mellitus as the etiology of HF was somewhat equal between males and females.

Conclusions

One of the limitations in reaching conclusions about gender differences in cardiovascular disease is that many major clinical trials do not include a gender analysis nor they are powered to do so as women are under-represented in most of the HF studies. The need remains for a well designed prospective study of sufficient numbers of male and female patients with and without heart failure and analyzing etiology and risk factors based on the sex differences.

The kinetics of highly sensitive cardiac troponin T release after prolonged treadmill exercise in adolescent and adult athletes

The nature and kinetics of postexercise cardiac troponin (cTn) appearance is poorly described and understood in most athlete populations. We compared the kinetics of high-sensitivity cTn T (hs-cTnT) after endurance running in training-matched adolescents and adults. Thirteen male adolescent (mean age: 14.1 ± 1.1 yr) and 13 male adult (24.0 ± 3.6 yr) runners performed a 90-min constant-load treadmill run at 95% of ventilatory threshold. Serum hs-cTnT levels were assessed preexercise, immediately postexercise, and at 1, 2, 3, 4, 5, 6, and 24 h postexercise. Serum NH2-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels were recorded preexercise and 3, 6, and 24 h postexercise. Left ventricular function was assessed preexercise, immediately postexercise, and 6 h postexercise. Peak hs-cTnT occurred at 3–4 h postexercise in all subjects, but was substantially higher ( P < 0.05) in adolescents [median (range): 211.0 (11.2–794.5) ng/l] compared with adults [median (range): 19.1 (9.7–305.6) ng/l]. Peak hs-cTnT was followed by a rapid decrease in both groups, although adolescent data had not returned to baseline at 24 h. Substantial interindividual variability was noted in peak hs-cTnT, especially in the adolescents. NT-pro-BNP was significantly elevated postexercise in both adults and adolescents and remained above baseline at 24 h in both groups. In both groups, left ventricular ejection fraction and the ratio of early-to-atrial peak Doppler flow velocities were significantly decreased immediately postexercise. Peak hs-cTnT was not related to changes in ejection fraction, ratio of early-to-atrial peak Doppler flow velocities, or NT-pro-BNP. The present data suggest that postexercise hs-cTnT elevation 1) occurred in all runners, 2) peaked 3–4 h postexercise, and 3) the peak hs-cTnT concentration after prolonged exercise was higher in adolescents than adults.

Heart failure and preserved left ventricular function: long term clinical outcome

Background

Patients with heart failure (HF) have a poor prognosis. The proportion of patients with HF and preserved left ventricular function (LVF) is increasing. Long term prognosis of HF with preserved LVF may not be so benign.

Objectives

To evaluate the long term clinical outcome of patients with HF and preserved LVF and predictors of outcome.

Methods

We prospectively evaluated 309 patients hospitalized with a definite clinical diagnosis of HF. Patients were followed for a mean of 6.5 years for clinical outcome.

Results

More than a third (36%) of the patients had preserved systolic LVF based on echocardiography. The long term survival rate in this group was poor and not significantly different from patients with reduced LVF (28% vs 23% respectively, P = 0.2). The adjusted survival rate by Cox regression analysis was also not significantly different (hazard ratio 1.16, 95% confidence interval 0.87–1.55, P = 0.31). The event free survival from death or heart failure re-hospitalization was also low in both groups and not significantly different between patients with preserved vs. reduced LVF (12% vs. 10% respectively, P = 0.2). Predictors of mortality in patients with preserved LVF were age, functional capacity and serum urea levels.

Conclusions

The long term clinical outcome of patients with heart failure and preserved LVF is poor and not significantly different from patients with reduced LVF.

Key role of congestion in natural history of heart failure

The natural course of heart failure with decreased and preserved systolic function is almost identical. The current concept of heart failure where decreased cardiac output plays the major role does not explain this similarity. We suggest a revised concept of heart failure where congestion plays the leading role. While congestion is almost invariably present in heart failure with normal and with reduced systolic function, the low output syndrome is only present in heart failure with reduced systolic function. The small difference in morbidity and mortality in favor of heart failure with preserved systolic function reflects the contribution of low output syndrome to the natural course of the disease. Congestion can result from low output or from multiple other conditions, but severity of congestion is the major determinant of progression of heart failure.

Outcome of heart failure with preserved ejection fraction: a multicentre spanish registry

Background:

Studies on clinical features, treatment and prognosis of patients with congestive heart failure (CHF) and preserved left ventricular ejection fraction (LVEF) are few and their results frequently conflicting.

Aims:

To investigate the characteristics and long term prognosis of patients with CHF and preserved (≥ 45%) LVEF.

Methods and Results:

We conducted a prospective multicentre study with 4720 patients attended in 62 heart failure clinics from 1999 to 2003 in Spain (BADAPIC registry). LVEF was preserved in 30% patients. Age, female gender, prevalence of atrial fibrillation, hypertension and non-ischaemic cardiopathy were all significantly greater in patients with preserved LVEF. Mean follow-up was 40±12 months. Mortality and other cardiovascular complication rates during follow up were similar in both groups. On multivariate analysis ejection fraction was not an independent predictor for mortality. Survival at one and five years was similar in both groups (79% and 59% for patients with preserved LVEF and 78% and 57% for those with reduced LVEF, respectively).

Conclusions:

In the BADAPIC registry, a high percentage of heart failure patients had preserved LVEF. Although clinical differences were seen between groups, morbidity and mortality were similar in both groups.

[Prognostic factors and long-term survival after initial diagnosis of heart failure]

BACKGROUND AND OBJECTIVE

To assess long-term mortality and prognostic factors after initial diagnosis of heart failure (HF), to analyze the differences in function of the left ventricular ejection fraction (preserved [HFPEF] vs. systolic dysfunction [HFSD]) and to compare the results with the main series of incident cases of HF published.

PATIENTS AND METHODS

Retrospective cohort study including patients first diagnosed of heart failure (Framingham criteria), between 1-01-1997 and 31-12-2001, classified according to a left ventricle ejection fraction (LVEF) above or equal to 50% (HFPEF) or below 50% (HFSD). Follow-up of patients was conducted during ten years.

RESULTS

Out of 400 incident cases of heart failure, 231 patients (57,7%) presented with HFPEF. At 10 years, mortality rates were higher in the HFSD group (64,5 vs. 55,4%, p=0,04). Following a multi-variant analysis, HFPEF mortality was related with age, diabetes mellitus, ischemic heart disease, and chronic renal failure. Treatment with statins and beta-blockers was associated with improved prognosis. Among patients with HFSD, mortality predictors were similar, although patients treated with statins did not show higher survival rates. For other series of incident cases, there were differences in variables related to prognosis and mortality of patients.

CONCLUSIONS

After an initial diagnosis of HF, more than half of patients die within 10 years of monitoring. Age, diabetes mellitus, ischemic heart disease and chronic renal failure are all associated with worse prognosis in these patients, whereas the use of beta-blockers and statins is associated with a better prognosis.

Diuretics as pathogenetic treatment for heart failure

Increased intracardiac filling pressure or congestion causes symptoms and leads to hospital admissions in patients with heart failure, regardless of their systolic function. A history of hospital admission, in turn, predicts further hospitalizations and morbidity, and a higher number of hospitalizations determine higher mortality. Congestion is therefore the driving force of the natural history of heart failure. Congestion is the syndrome shared by heart failure with preserved and reduced systolic function. These two conditions have almost identical morbidity, mortality, and survival because the outcomes are driven by congestion. A small difference in favor of heart failure with preserved systolic function comes from decreased ejection fraction and left ventricular remodeling which is only present in heart failure with decreased systolic function. The magnitude of this difference reflects the contribution of decreased systolic function and ventricular remodeling to the progression of heart failure. The only treatment available for congestion is fluid removal via diuretics, ultrafiltration, or dialysis. It is the only treatment that works equally well for heart failure with reduced and preserved systolic function because it affects congestion, the main pathogenetic feature of the disease. Diuretics are pathogenetic therapy for heart failure.

Prediction clinical profile to distinguish between systolic and diastolic heart failure in hospitalized patients

BACKGROUND

In recent decades, the growing incidence of patients with heart failure who have preserved systolic function, underlines the need to differentiate between heart failure due to diastolic dysfunction and that due to systolic dysfunction.

OBJECTIVE

To develop a prediction profile of clinical parameters that enables clinicians to differentiate between patients with systolic and diastolic heart failure.

METHODS

164 patients admitted for congestive heart failure to the cardiology department of an academic tertiary care hospital, whose left ventricular systolic and diastolic function had been evaluated echocardiographically and who satisfied the Framingham criteria for heart failure, were prospectively recruited. All patients answered a questionnaire which included, in addition to other clinical variables, the Framingham criteria.

RESULTS

Patients with diastolic heart failure (61.6%) were more likely to be older, female, and to present left ventricular hypertrophy (LVH), with a lower proportion of smokers, alcohol drinkers, coronary disease, q wave and left bundle branch block (all p<0.005). The predicting model obtained on the logistic regression analysis was very significant, with three variables and 72.3% of correct predictions (x(2) value=40,457, p<0.001). These three variables, predictors of diastolic as opposed to systolic heart failure, were female sex (OR=3.546), left ventricle hypertrophy (OR=4.011) and absence of coronary disease (OR=3.547).

CONCLUSION

Three variables which can be easily evaluated, female sex, left ventricular hypertrophy and presence or absence of coronary disease, may enable clinicians to differentiate between patients with systolic or diastolic heart failure.

Mortality Factor Survey of Severe Acute Respiratory Syndrome in Taiwan

Background

Severe acute respiratory syndrome (SARS) is a new respiratory tract infectious disease caused by the highly contagious coronavirus (SARS-CoV). Its propagation and symptom progress are very rapid. This study evaluated the clinical characteristics, laboratory results and mortality factors of probable SARS cases.

Methods

This study was adopted with a retrospective research design to study probable SARS cases from the Chang Gung Memorial Hospital in Linkou and Kaoshiung from August 2003 to February 2004, with a total of 78 cases (average age, 44 years; standard deviation, 18 years; age range, 13–84 years) including 24 males (30.8%) and 54 females (69.2%).

Results

Most of the 78 cases involved nosocomial infection (56.4%). A total of 24 patients died, and the mortality rate was as high as 30.8%. Logistic regression analysis found that intubation (odds ratio, 115; p < 0.001) was the mortality forecast factor.

Conclusion

The mortality rate of intubation patients was 115 times higher than that of those who did not require intubation. Therefore, special care must be taken with SARS disease with severe infiltration chest X-ray images and respiratory distress. Positive medical treatment should be performed to lower the mortality rate.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Prospective cohort study.

PATIENTS

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

MEASUREMENTS

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

MAIN RESULTS

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

CONCLUSIONS

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

Why and when do patients with heart failure and normal left ventricular ejection fraction die? Analysis of >600 deaths in a community long-term study

BACKGROUND

The aim of the study was to examine the causes of the death of patients with heart failure (HF) and evaluate the differences in this respect between patients with and without depression of left ventricular ejection fraction (LVEF).

METHOD

All patients hospitalized with HF between 1995 and 2002 in the cardiology service of a tertiary hospital were assessed. LVEF was evaluated by echocardiography during hospitalization and was considered normal when it was > or =50%. After a mean follow-up time of 3.7 +/- 2.8 years, 615 cases had terminated in death.

RESULTS

The most common cause was refractory HF, both in the whole group (39%) and in both the subgroups defined with respect to LVEF (normal and depressed). There was no statistically significant difference between the normal and depressed subgroups as regard the distribution of deaths, although the depressed group showed a somewhat greater incidence of sudden death (21% as against 16% in the normal group) and a somewhat smaller incidence of death due to refractory HF (37% as against 47%). However, in the depressed LVEF group, the cumulative risk of death due to acute myocardial infarction in the first 1.5 years first increased rapidly and then more slowly, whereas the reverse pattern was held in the normal left ventricular systolic function group, in which it was the cumulative risks of death from noncardiovascular or vascular noncardiac causes that initially increased more rapidly than later.

CONCLUSIONS

The spectrum of causes of death among patients with HF who have been hospitalized is independent of LVEF in the long term. In the short term, there are differences between patients with normal LVEF and depressed LVEF as regard the dynamics of the risks of death from acute myocardial infarction, noncardiac vascular causes, and noncardiovascular causes. These results may help orient the short-term and long-term management of HF, especially for patients with normal LVEF, for whom there is still no well-established consensus strategy.

Preserved systolic ventricular function heart failure patients referred to a division of internal medicine

BACKGROUND

At least 70% of patients with heart failure (HF) are referred to departments of internal medicine. Some 40-50% have preserved systolic ventricular function (PSVF; LVEF > 0.45). The aim of this study was to evaluate survival and prognostic value of several functional parameters in PSVF-HF patients admitted to a department of internal medicine.

METHODS

Eighty-two consecutive patients hospitalized between January 1 and December 31, 2001 (44 men and 38 women, mean age 63.7 years) were followed up for a mean period of 37 months. The severity of symptoms at admission was assessed by NYHA classification. Twenty-five patients were in NYHA class I, 43 in II, and 14 in III-IV. All patients underwent chest X-ray, echocardiogram, and a 6-minute walking test.

RESULTS

Seventeen patients (20.7%) died, 16 of cardiovascular causes and 1 of cancer. Survival was not affected by etiology, sex, age, left ventricular ejection fraction (LVEF), LV filling pattern, or pulmonary artery pressure. With univariate analysis, NYHA class at admission was the strongest predictor of death. Distance covered after the 6-minute walking test was also related to survival. The Cox stepwise regression model showed that only NYHA class at admission (p < 0.05) was significantly related to survival.

CONCLUSIONS

During a 3-year follow-up, mortality in PSVF-HF patients referred to a department of internal medicine is close to 7% per year. A high NYHA class at admission and decreased functional capacity (i.e., distance walked at 6 min < 350 m) are related to a worse prognosis.

Consultation between specialists in Internal Medicine and Family Medicine improves management and prognosis of heart failure

BACKGROUND AND OBJECTIVE

To evaluate if consultation between specialists in Internal Medicine and family doctors (CIMFD) improves the clinical management and prognosis of patients with heart failure (HF).

DESIGN

prospective case-control study (5 years of follow-up).

SETTING

community-based sample within the area of a university teaching hospital.

SUBJECTS

1857 patients (> or = 14 years) diagnosed for the first time with HF (1stDxHF), in the CIMFD.

CONTROL GROUP

1981 patients (from health centres not covered by the CIMFD), 1stDxHF, in the external consultations of the hospital.

MAIN OUTCOME MEASURES

mortality rate (MR). Admissions (HA). Emergency services visits (ESV). Delays in receiving specialist attention (DRSA), and the resolution of the process (DRP). Number (NTP) and delays in reporting (DTP) tests performed. Proportion (PRC) and delay (DRC) in resolving cases.

RESULTS

We observed a reduction of: MR (by 10.8%, CI 95%, 8.6-13.0, p < 0.005); HA, per patient per year (ppy) (by 1.8, 1.3-2.3, p < 0.01); ESV, ppy (by 1.9, 1.2-2.6, p < 0.01); DRSA (by 26.5 days, 21.8-31.2, p < 0.001); DRP (by 21.0 days, 18.3-23.7, p < 0.001), and DRC (by 25.8 days, 20.3-31.4, p < 0.01). The PRC (17.2%, CI 95%, 15.5-18.9, p < 0.01) was higher for the CIMFD.

CONCLUSION

The CIMFD approach improves prognosis and efficacy in the clinical management of patients with HF because it reduces mortality and morbidity (HA and ESV), shortens the delays in receiving care and in resolving the diagnostic and therapeutic process (DRSA, DRP, DRC), and increases the proportion of diagnosed and treated patients.

Clinical outcome of patients with heart failure and preserved left ventricular function

BACKGROUND

Patients with heart failure have a poor prognosis. However, it has been presumed that patients with heart failure and preserved left ventricular function (LVF) may have a more benign prognosis.

OBJECTIVES

We evaluated the clinical outcome of patients with heart failure and preserved LVF compared with patients with reduced function and the factors affecting prognosis.

METHODS

We prospectively evaluated 289 consecutive patients hospitalized with a definite clinical diagnosis of heart failure based on typical symptoms and signs. They were divided into 2 subsets based on echocardiographic LVF. Patients were followed clinically for a period of 1 year.

RESULTS

Echocardiography showed that more than one third (36%) of the patients had preserved systolic LVF. These patients were more likely to be older and female and have less ischemic heart disease. The survival at 1 year in this group was poor and not significantly different from patients with reduced LVF (75% vs 71%, respectively). The adjusted survival by Cox regression analysis was not significantly different (P=.25). However, patients with preserved LVF had fewer rehospitalizations for heart failure (25% vs 35%, P<.05). Predictors of mortality in the whole group by multivariate analysis were age, diabetes, chronic renal failure, atrial fibrillation, residence in a nursing home, and serum sodium < or = 135 mEq/L.

CONCLUSION

The prognosis of patients with clinical heart failure with or without preserved LVF is poor. Better treatment modalities are needed in both subsets.

[Heart failure in outpatients: comorbidities and management by different specialists. The EPISERVE Study]

INTRODUCTION AND OBJECTIVES

The aim of the EPISERVE study was to investigate the clinical characteristics of heart failure in outpatients and its diagnostic and therapeutic management by cardiology, internal medicine and primary care specialists.

METHODS

The study involved 507 physicians working in primary care (n=181, 36%), cardiology (n=172, 34%) or internal medicine (n=154, 30%) who treated 2249 consecutive outpatients with heart failure between June and November 2005.

RESULTS

The prevalence of heart failure was 2% in primary care, 17% in cardiology and 12% in internal medicine. Hypertension or coronary disease was the cause in more than 80% of cases. The prevalence of comorbidities was high: atrial fibrillation, 46%; diabetes, 38%; obesity, 64%; dyslipidemia, 60%; anemia, 27%; and renal failure, 7%. In 40% of cases, systolic function was preserved (i.e., left ventricular ejection fraction > or =45%). Echocardiographic and coronary angiographic studies were performed more frequently in patients seen in cardiology and in male patients. There were significant differences between men and women in pharmacologic treatment involving beta-blockers (55% vs. 44%, respectively; P< .001), diuretics (88% vs. 92%, respectively; P< .01) and statins (57% vs. 47%, respectively; P< .001). Only 20% of patients received the treatment recommended by clinical practice guidelines. The factors independently associated with appropriate treatment were being treated in cardiology, hypercholesterolemia, age and etiology.

CONCLUSIONS

The varied approaches of different specialists, the smaller effort put into diagnosis and therapy in women, and the low percentage of patients treated according to guidelines make it essential that an educational and multidisciplinary strategy should be developed for managing outpatients with heart failure.

Morbidity and mortality among heart failure patients in Galicia, N.W. Spain: the GALICAP Study

OBJECTIVE

Characterization of current morbidity and mortality among heart failure (HF) outpatients in Galicia (N.W. Spain), together with their main determinants.

DESIGN

Prospective multicentre study involving 149 primary care physicians.

SETTING

Primary care physicians selected randomly from among all (1959) primary care physicians in Galicia.

PATIENTS

Clinical and epidemiological information for 1195 outpatients with HF were collected in 2006, with a mean follow-up of 6.5+/-1.5 months.

MAIN OUTCOME MEASURES

Survival rates were calculated by Cox's proportional hazard model.

RESULTS

Mean patient age was 76 years, 48% were male, 82% had a history of arterial hypertension, and 32% ischaemic cardiopathy. Echocardiography had been performed in 67%, showing preserved systolic function in 61%. Ninety-two (8%) died during follow-up [74 (80%) of them from cardiac causes], and 313 (29%) were re-admitted to hospital [230 (73%) of them for cardiac reasons]. Multivariate analysis identified the following independent predictors of cardiovascular death and/or readmission: ischaemic cardiopathy [hazard ratio (HR) 1.76, 95% confidence interval (CI) 1.29-4.40], stroke (HR 1.79, CI 1.18-2.73), oedema (HR 1.49, CI 1.10-2.03), anaemia (HR 1.66, CI 1.21-2.27), deteriorated systolic function (HR 1.62, CI 1.19-2.20), and previous cardiovascular admissions (HR 2.33, CI 1.67-3.24). Residence in the Barbanza district was identified as an independent predictor of survival free from cardiovascular admission (HR 0.56, CI 0.37-0.86).

CONCLUSION

Morbidity and mortality are currently high among Galician HF patients, and their best single predictor is previous hospitalization for cardiovascular reasons.

PPARdelta activation normalizes cardiac substrate metabolism and reduces right ventricular hypertrophy in congestive heart failure

Previously, it was shown that selective deletion of peroxisome proliferator activated receptor delta (PPARdelta) in the heart resulted in a cardiac lipotoxicity, hypertrophy, and heart failure. The aim of the present study was to determine the effects of chronic and selective pharmacological activation of PPARdelta in a model of congestive heart failure. PPARdelta-specific agonist treatment (GW610742X at 30 and 100 mg/kg/day for 6-9 weeks) was initiated immediately postmyocardial infarction (MI) in Sprague-Dawley rats. Magnetic resonance imaging/spectroscopy was used to assess cardiac function and energetics. A 1-(13)C glucose clamp was performed to assess relative cardiac carbohydrate versus fat oxidation. Additionally, cardiac hemodynamics and reverse-transcription polymerase chain reaction gene expression analysis was performed. MI rats had significantly reduced left ventricle (LV) ejection fractions and whole heart phosphocreatine/adenosine triphosphate ratio compared with Sham animals (reduction of 43% and 14%, respectively). However, GW610742X treatment had no effect on either parameter. In contrast, the decrease in relative fat oxidation rate observed in both LV and right ventricle (RV) following MI (decrease of 58% and 54%, respectively) was normalized in a dose-dependent manner following treatment with GW610742X. These metabolic changes were associated with an increase in lipid transport/metabolism target gene expression (eg, CD36, CPT1, UCP3). Although there was no difference between groups in LV weight or infarct size measured upon necropsy, there was a dramatic reduction in RV hypertrophy and lung congestion (decrease of 22-48%, P<0.01) with treatment which was associated with a >7-fold decrease (P<0.05) in aterial natriuretic peptide gene expression in RV. Diuretic effects were not observed with GW610742X. In conclusion, chronic treatment with a selective PPARdelta agonist normalizes cardiac substrate metabolism and reduces RV hypertrophy and pulmonary congestion consistent with improvement in congestive heart failure.

Detection of myocardial dysfunction in the presence of normal ejection fraction

Detection of subclinical myocardial involvement is of utmost importance in risk stratification and prognosis; the role of ejection fraction in the detection of subclinical disease may be unhelpful. Our aim was to evaluate the methodology and importance of early detection of myocardial involvement in the presence of normal ejection fraction. Most of the pertinent English and non-English articles published from 1980 to 2006 in Medline, Scopus, and EBSCO Host research databases have been reviewed. Serial assessment of systolic function with different techniques should be avoided, since imaging modalities and ejection fraction measurements are not interchangeable. Additional non-invasive tools still are needed for the identification of subclinical left ventricular dysfunction in certain diseases. The recognition of subclinical involvement will prompt initiation of specific therapy to prevent the development of overt left ventricular dysfunction. This also is needed for determining the best timing for intervention in asymptomatic patients with metabolic and valvular disorders.

Characteristics, treatments, and outcomes of patients with preserved systolic function hospitalized for heart failure: a report from the OPTIMIZE-HF Registry

OBJECTIVES

We sought to evaluate the characteristics, treatments, and outcomes of patients with preserved and reduced systolic function heart failure (HF).

BACKGROUND

Heart failure with preserved systolic function (PSF) is common but not well understood.

METHODS

This analysis of the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure) registry compared 20,118 patients with left ventricular systolic dysfunction (LVSD) and 21,149 patients with PSF (left ventricular ejection fraction [EF] > or =40%). Sixty- to 90-day follow-up was obtained in a pre-specified 10% sample of patients. Analyses of patients with PSF defined as EF >50% were also performed for comparison.

RESULTS

Patients with PSF (EF > or =40%) were more likely to be older, female, and Caucasian and to have a nonischemic etiology. Although length of hospital stay was the same in both groups, risk of in-hospital mortality was lower in patients with PSF (EF > or =40%) (2.9% vs. 3.9%; p < 0.0001). During 60- to 90-day post-discharge follow-up, patients with PSF (EF > or =40%) had a similar mortality risk (9.5% vs. 9.8%; p = 0.459) and rehospitalization rates (29.2% vs. 29.9%; p = 0.591) compared with patients with LVSD. Findings were comparable with those with PSF defined as EF >50%. In a risk- and propensity-adjusted model, there were no significant relationships between discharge use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker or beta-blocker and 60- to 90-day mortality and rehospitalization rates in patients with PSF.

CONCLUSIONS

Data from the OPTIMIZE-HF registry reveal a high prevalence of HF with PSF, and these patients have a similar post-discharge mortality risk and equally high rates of rehospitalization as patients with HF and LVSD. Despite the burden to patients and health care systems, data are lacking on effective management strategies for patients with HF and PSF. (Organized Program To Initiate Lifesaving Treatment In Hospitalized Patients With Heart Failure [OPTIMIZE-HF]); http://www.clinicaltrials.gov/ct/show/NCT00344513?order=1; NCT00344513).

Impact of Repeated Prolonged Exercise Bouts on Cardiac Function and Biomarkers

PURPOSE

The present study examined the impact of repeated bouts of prolonged (< 60 min) exercise on left ventricular function and cardiac biomarkers.

METHODS

Ten athletes completed a 15.3-mile hill run on three consecutive days and were assessed before, immediately after, 1 h after, and 20 h after each bout. Six of the athletes completed a fourth bout. Left ventricular (LV) function was examined echocardiographically using two-dimensional M-mode, Doppler, and flow propagation velocity (Vp). Venous blood samples were analyzed for cardiac biomarkers including cardiac troponin T (cTnT).

RESULTS

Ejection fraction (EF) significantly decreased (P = 0.027) after the third exercise bout compared with baseline (mean +/- SD: 56.3 +/- 4.4 vs 51.3 +/- 5.9%), accompanied by a nonsignificant decrease in systolic blood pressure/end systolic volume (SBP/ESV) ratio. A sustained depression in systolic function 20 h after bout 3 also persisted in the subset who completed a fourth bout, yet this did not reach clinical levels. Significant (P < 0.01) reductions in early to late diastolic filling (E:A) ratio pre-to post-bout 1 (mean +/- SD: 1.9 +/- 0.5 vs 1.4 +/- 0.3) and pre- to post-bout 3(2.0 +/- 0.5 vs 1.3 +/- 0.4) normalized after each 20-h recovery period. A similar pattern of change was observed in Vp. Cardiac troponin T was elevated in four individuals 1 h after bout 1 (range: 0.013-0.125 microg.L(-1)) but was undetectable thereafter except in one athlete.

CONCLUSION

Repeated bouts of prolonged exercise induce short-term reductions in diastolic filling and a cumulative decrease in systolic function, yet these alterations seem to have minimal clinical or functional impact. Elevated cTnT after the initial bout, but not thereafter, may represent an adaptive response to prolonged exercise.

Atrial fibrillation in patients hospitalized for congestive heart failure: The same prognostic influence independently of left ventricular systolic function?

Atrial fibrillation (AF) was described to be associated with an adverse prognosis in several studies of heart failure (HF). However, it is not clear whether it directly increased mortality or is only a marker for severity of HF.

AIMS

To determine the influence of AF on mortality of HF patients distinguishing between patients with preserved and deteriorated systolic function (SF).

METHOD AND RESULTS

1636 patients who, between 1991 and 2002 had been hospitalized in a Cardiology Service for HF, were studied. Survival (SV) data (mean follow-up time: 3.14 years) has shown that there was no difference in SV between patients with (540 patients of the whole group) and without AF in the group with preserved SF (presented in 38.7% of cases), however, in the group of patients with deteriorated SF (AF presented in 31.0% of cases), SV time was significantly (p=0.01) shorter among patients with AF, this association being independent of age, sex, aetiology, risk factors, clinical signs and pharmacological treatment; relative risk: 1.831(1.120-2.994).

CONCLUSION

AF is more prevalent among HF patients with preserved SF than among those with deteriorated SF, but only increases the risk of death among the latter.

Angiotensin-Converting Enzyme Inhibitors Prescription Is Associated With Longer Survival Among Patients Hospitalized for Congestive Heart Failure Who Have Preserved Systolic Function: A Long-Term Follow-Up Study

BACKGROUND

The use of inhibitors of angiotensin-converting enzyme (ACE) is strongly indicated by a diagnosis of congestive heart failure (CHF) with deteriorated systolic function (SF), but their effects on patients with CHF but no systolic deterioration have not been clarified. We focused this study on the evaluation of the influence of ACE inhibitors on survival among CHF patients with preserved SF, but also determined the effect of these drugs on the prognosis of our patients with deteriorated SF.

METHOD AND RESULTS

We studied 416 patients, aged 72.7 +/- 10.2 years, who between January 1, 1991, and December 31, 2001, were admitted to the cardiology service of a tertiary hospital for CHF and who fulfilled the requirements that left ventricular SF that had been evaluated echocardiographically during hospitalization was preserved and that data were available on medication at the time of their release from hospital. Two hundred four patients (49.0%) were men, 250 (60.8%) were hypertensive, and, in 171 (41.1%) cases, ischemic cardiopathy was the primary cause of the CHF. ACE inhibitors were prescribed to 210 patients (50.5%) on hospital release. Kaplan-Meier survival curve analysis showed that, among patients with preserved SF, a longer survival was associated with ACE inhibitors use (mean survival 6.14 years as compared with 4.57 years in the control group, P < .001; adjusted hazard ratio = 0.63, P = .012). Similar results were obtained in CHF patients with deteriorated SF in whom those taking ACE inhibitors had significantly longer life with mean survival 6.42 years compared with 5.03 years in the control group (P < .001; adjusted hazard ratio = 0.62, P = .001).

CONCLUSION

ACE inhibitors prescription is associated with a better prognosis of patients with CHF and preserved SF.