QRS prolongation in the prediction of clinical cardiac events in patients with acute heart failure: analysis of data from the Korean Acute Heart Failure Registry

Current approaches to preventing heart failure readmissions and decompensated disease

Heart failure is a resource-intensive condition to manage and typically involves a multi-disciplinary and multi-modality approach leading to an expensive treatment paradigm. It is worth noting that hospital admissions constitute over 80% of heart failure management costs. In the past two decades, healthcare systems have developed new ways of following patients remotely to prevent them from being readmitted to the hospital. However, despite these efforts, hospital admissions have still increased. Many successful readmission reduction programs prioritize education and self-care to increase patients' awareness of their disease and promote lasting lifestyle changes. While socioeconomic factors impact success, interventions tend to be effective when medication adherence and guideline-directed medical therapy are emphasized. Monitoring intracardiac pressure can improve resource allocation efficiency and has demonstrated significant reductions in readmissions with improved quality of life in outpatient and remote settings. Data from several studies focused on remote monitoring devices strongly suggest that understanding congestion using physiological biomarkers is an effective management strategy. Since most cases of heart failure are first presented in acute hospitalization settings, immediate access to intracardiac pressure for treatment and decision-making purposes could result in substantial management improvements. However, a notable technology gap needs to be addressed to enable this at a low cost with less reliability on scarce specialist care resources. Contemporary evidence is conclusive that direct hemodynamic are the vital signs in heart failure with the highest clinical utility. Therefore, future ability to obtain these insights reliably using non-invasive methods will be a paradigm-changing technology.

Analysis Of Re-Hospitalizations For Patients With Heart Failure Caused By Coronary Heart Disease: Data Of First Event And Recurrent Event

BACKGROUND

The re-hospitalization rate of patients with heart failure remains at a high level, and studies of the subject have focused mainly on event-time outcomes. In addition to using re-hospitalization data with the outcomes of the event-time-count, this study introduces the conditional frailty model, which could help obtain more reasonable results.

MATERIALS AND METHODS

This prospective observational cohort study enrolled 1484 patients with heart failure caused by coronary heart disease. The outcomes of heart failure readmissions and the case report form data were collected. Based on the traditional Cox model with event-time outcomes, the mixed effects of a conditional frailty model were added to analyze the event-time-count longitudinal data.

RESULTS

The Cox regression model showed that non-manual work, diastolic dysfunction, and better medical compensation increased the risk of heart failure readmission, whereas treatment with beta-blockers decreased the risk. The conditional frailty model further revealed that age, female sex, non-manual work, better medical compensation, longer QRS duration, and treatment with percutaneous coronary intervention increased the risk of heart failure readmission.

CONCLUSION

This study obtained more reliable, reasonable results based on longitudinal data and a mixed model. The results could provide more clinical epidemiological evidence for the management of heart failure.

Electrocardiographic characteristics in patients with heart failure and normal ejection fraction: A systematic review and meta-analysis

BACKGROUND

Little is known about ECG abnormalities in patients with heart failure and normal ejection fraction (HeFNEF) and how they relate to different etiologies or outcomes.

METHODS AND RESULTS

We searched the literature for peer-reviewed studies describing ECG abnormalities in HeFNEF other than heart rhythm alone. Thirty five studies were identified and 32,006 participants. ECG abnormalities reported in patients with HeFNEF include atrial fibrillation (prevalence 12%-46%), long PR interval (11%-20%), left ventricular hypertrophy (LVH, 10%-30%), pathological Q waves (11%-18%), RBBB (6%-16%), LBBB (0%-8%), and long JTc (3%-4%). Atrial fibrillation is more common in patients with HeFNEF compared to those with heart failure and reduced ejection fraction (HeFREF). In contrast, long PR interval, LVH, Q waves, LBBB, and long JTc are more common in patients with HeFREF. A pooled effect estimate analysis showed that QRS duration ≥120 ms, although uncommon (13%-19%), is associated with worse outcomes in patients with HeFNEF.

CONCLUSIONS

There is high variability in the prevalence of ECG abnormalities in patients with HeFNEF. Atrial fibrillation is more common in patients with HeFNEF compared to those with HeFREF. QRS duration ≥120 ms is associated with worse outcomes in patients with HeFNEF. Further studies are needed to address whether ECG abnormalities correlate with different phenotypes in HeFNEF.

Prognostic Implication of Ventricular Conduction Disturbance Pattern in Hospitalized Patients with Acute Heart Failure Syndrome

Background and Objectives

Conflicting data exist regarding the prognostic implication of ventricular conduction disturbance pattern in patients with heart failure (HF). This study investigated the prognostic impact of ventricular conduction pattern in hospitalized patients with acute HF.

Methods

Data from the Korean Acute Heart Failure registry were used. Patients were categorized into four groups: narrow QRS (<120 ms), right bundle branch block (RBBB), left bundle branch block (LBBB), and nonspecific intraventricular conduction delay (NICD). The NICD was defined as prolonged QRS (≥120 ms) without typical features of LBBB or RBBB. The primary endpoint was the composite of all-cause mortality or rehospitalization for HF aggravation within 1 year after discharge.

Results

This study included 5,157 patients. The primary endpoint occurred in 39.7% of study population. The LBBB group showed the highest incidence of primary endpoint followed by NICD, RBBB, and narrow QRS groups (52.5% vs. 49.7% vs. 44.4% vs. 37.5%, p<0.001). In a multivariable Cox-proportional hazards regression analysis, LBBB and NICD were associated with 39% and 28% increased risk for primary endpoint (LBBB hazard ratio [HR], 1.392; 95% confidence interval [CI], 1.152–1.681; NICD HR, 1.278; 95% CI, 1.074–1.520) compared with narrow QRS group. The HR of RBBB for the primary endpoint was 1.103 (95% CI, 0.915–1.329).

Conclusions

LBBB and NICD were independently associated with an increased risk of 1-year adverse event in hospitalized patients with HF, whereas the prognostic impacts of RBBB were limited.

Trial Registration

ClinicalTrials.gov Identifier: NCT01389843

Temporal Trends of Hospitalized Patients with Heart Failure in Korea

Heart failure (HF) is an important cardiovascular disease because of its increasing prevalence, significant morbidity, high mortality and rapidly expanding health care costs. The number of HF patients is increasing worldwide and Korea is no exception. Temporal trends of four representative Korean hospitalized HF registries-the Hallym HF study, the Korean Multicenter HF study, the Korean Heart Failure (KorHF) registry and the Korean Acute Heart Failure (KorAHF) registry showed mild survival improvement reflecting overall HF patient care development in Korea despite the increased severity of enrolled patients with higher incidence of multiple comorbidities. Moreover, device therapies such as implantable cardioverter defibrillator and cardiac resynchronization therapy and definitive treatment such as heart transplantation have been increasing in Korea as well. To prevent HF burden increase, it is essential to set up long term effective prevention strategies for better control of ischemic heart disease, hypertension and diabetes, which might be risk factors for HF development. Moreover, proper HF guidelines, performance measures, and performance improvement programs might be necessary to limit HF burden as well.

QRS Duration Is a Predictor of Adverse Outcomes in Heart Failure With Preserved Ejection Fraction

OBJECTIVES

This study examined the relationship between baseline QRS duration and clinical outcomes in subjects enrolled in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) trial.

BACKGROUND

Heart failure with preserved ejection fraction (HFPEF) is a heterogeneous clinical syndrome. Whether QRS duration identifies HFPEF subjects at an increased risk of adverse outcomes has not been well studied.

METHODS

QRS duration was analyzed as a dichotomous variable (≥120 ms or <120 ms) and as a continuous variable to determine its relation to the primary outcome (composite of cardiovascular death, aborted cardiac arrest, or HF hospitalization [HFH]) and to each component of the primary outcome. Multivariate analyses were conducted in the entire study cohort as well as in separate analyses for subjects enrolled only from North and South America, or from Russia and Georgia.

RESULTS

The QRS duration of ≥120 ms was independently associated with an increased risk of the primary outcome (p = 0.009) and HFH (p = 0.003) in the entire study cohort and in the subset enrolled in the Americas. There was a linear relation of QRS duration with risk of the primary outcome and HFH. No interaction was observed between treatment with spironolactone and QRS duration. The risk of adverse outcomes was increased independently of the type of conduction abnormality underlying prolonged QRS duration.

CONCLUSIONS

This post hoc analysis demonstrated that prolonged QRS duration identifies HFPEF subjects at a higher risk of adverse clinical outcomes and that spironolactone had a similar effect on outcomes independent of QRS duration. (Aldosterone Antagonist Therapy for Adults With Heart Failure and Preserved Systolic Function [TOPCAT]; NCT00094302).

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.

Eight-Year Prognostic Value of QRS Duration in Patients With Known or Suspected Coronary Artery Disease Referred for Myocardial Perfusion Imaging

QRS duration is of prognostic relevance in patients with several underlying heart diseases. Short-term data also show the prognostic value of QRS duration in lower risk groups of patients. The aim of this study was to investigate the long-term prognostic value of QRS duration in patients with known or suspected coronary artery disease. The study cohort consisted of 512 patients (308 men, mean age 60 ± 11 years) who underwent myocardial perfusion imaging (MPI) for the evaluation of suspected or known coronary artery disease. Follow-up data were collected to assess the prognostic value of QRS duration, alongside clinical characteristics and MPI results. End points were cardiac death and cardiac death or nonfatal myocardial infarction (MI). During a mean follow-up of 8.6 ± 5.2 years, 290 patients (60%) died, with 139 deaths (27%) attributable to cardiac causes. Nonfatal MI occurred in 28 patients (6%), and 127 patients (25%) underwent late coronary revascularization (>3 months). Patients with QRS duration <120 ms had annualized cardiac death rates and cardiac death or nonfatal MI rates of 2.2% and 2.3%, respectively, compared with those of 4.1% and 4.4% in patients with QRS duration ≥120 ms. Multivariate models identified QRS duration ≥120 ms as an independent predictor of both end points, on top of clinical characteristics and MPI results. In conclusion, QRS duration ≥120 ms is an independent predictor of cardiac death and cardiac death or nonfatal MI, after adjustment for clinical characteristics and MPI results.

Prognostic Factors in Hospitalization for Heart Failure in Asia

The hospitalized heart failure (HF) population is becoming a significant economic burden to Asian countries because of the growing elderly population, increased prevalence of HF, and recurrent rehospitalization. A targeted treatment strategy is needed with prognostic factors that can reduce mortality or rehospitalization after discharge. The accepted prognostic factors include age, low systolic blood pressure, ischemic heart disease, reduced left ventricular function, hyponatremia, and renal dysfunction. Prognostic factors for clinical outcomes in hospitalized patients with HF may be different in Asian people. Further research leading to better understanding of the characteristics of Asian patients hospitalized with HF is warranted.