Prevalence of heart failure and systolic ventricular dysfunction in older Australians: the Canberra Heart Study

OBJECTIVE: To estimate the prevalence of heart failure (HF) and left ventricular (LV) systolic dysfunction in a population-based sample of older Australians. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional survey of 2000 randomly selected residents of Canberra, aged 60-86 years, conducted between February 2002 and June 2003. Participants were assessed by history, physical examination by a cardiologist, and echocardiography. MAIN OUTCOME MEASURES: Age- and sex-specific prevalence rates of clinical HF and LV systolic dysfunction (defined as LV ejection fraction < or = 50%). RESULTS: Of 1846 people eligible for our study, 1388 (75%) agreed to participate and 1275 completed all investigations (mean age, 69.4 years; 50% men). In the study sample, 72 subjects (5.6%; 95% CI, 4.4%-7.1%) had clinical HF that had been previously diagnosed and was confirmed by our assessment. A further 0.6% (95% CI, 0.3%-1.2%) had undiagnosed clinical HF (ie, evidence of structural heart disease and symptoms/signs of cardiac insufficiency without a previous diagnosis of clinical HF). Thus, the overall prevalence of clinical HF in the sample was 6.3% (95% CI, 5.0%-7.7%). Clinical HF increased in prevalence with advancing age (a 4.4-fold increase from the 60-64-years age group to the 80-86-years age group; P < 0.0001). Of the 75 subjects (5.9%; 95% CI, 4.7%-7.3%) with LV systolic dysfunction, 44 (59%) were in the preclinical stage of disease. CONCLUSION: Diagnosed HF cases represent the "tip of the iceberg" for the national burden of HF and LV systolic dysfunction. Clinically identifiable HF cases can remain undiagnosed, and the majority of people with LV systolic dysfunction are in a preclinical stage of the disease.     

Systolic and diastolic heart failure in the community

Context  The heart failure (HF) syndrome is heterogeneous. While it can be defined by ejection fraction (EF) and diastolic function, data on the characteristics of HF in the community are scarce, as most studies are retrospective, hospital-based, and rely on clinically indicated tests. Further, diastolic function is seldom systematically assessed based on standardized techniques. Objective  To prospectively measure EF, diastolic function, and brain natriuretic peptide (BNP) in community residents with HF. Main Outcome Measures  Echocardiographic measures of EF and diastolic function, measurement of blood levels of BNP, and 6-month mortality. Design, Setting, and Participants  Olmsted County residents with incident or prevalent HF (inpatients or outpatients) between September 10, 2003, and October 27, 2005, were prospectively recruited to undergo assessment of EF and diastolic function by echocardiography and measurement of BNP. Results  A total of 556 study participants underwent echocardiography at HF diagnosis. Preserved EF (50%) was present in 308 (55%) and was associated with older age, female sex, and no history of myocardial infarction (all P<.001). Isolated diastolic dysfunction (diastolic dysfunction with preserved EF) was present in 242 (44%) patients. For patients with reduced EF, moderate or severe diastolic dysfunction was more common than when EF was preserved (odds ratio, 1.67; 95% confidence interval [CI], 1.11-2.51; P = .01). Both low EF and diastolic dysfunction were independently related to higher levels of BNP. At 6 months, mortality was 16% for both preserved and reduced EF (age- and sex-adjusted hazard ratio, 0.85; 95% CI, 0.61-1.19; P = .33 for preserved vs reduced EF). Conclusions  In the community, more than half of patients with HF have preserved EF, and isolated diastolic dysfunction is present in more than 40% of cases. Ejection fraction and diastolic dysfunction are independently related to higher levels of BNP. Heart failure with preserved EF is associated with a high mortality rate, comparable to that of patients with reduced EF.      

Pathophysiological characterization of isolated diastolic heart failure in comparison to systolic heart failure

Context  Many older patients with symptoms of congestive heart failure have a preserved left ventricular ejection fraction (LVEF). However, the pathophysiology of this disorder, presumptively termed diastolic heart failure (DHF), is not well characterized and it is unknown whether it represents true heart failure. Objective  To assess the 4 key pathophysiological domains that characterize classic heart failure by systematically performing measurements in older patients with presumed DHF and comparing these results with those from age-matched healthy volunteers and patients with classic systolic heart failure (SHF). Design and Setting  Observational clinical investigation conducted in 1998 in a general community and teaching hospital in Winston-Salem, NC. Participants  A total of 147 subjects aged at least 60 years. Fifty-nine had isolated DHF defined as clinically presumed heart failure, LVEF of at least 50%, and no evidence of significant coronary, valvular, or pulmonary disease. Sixty had typical SHF (LVEF 35%). Twenty-eight were age-matched healthy volunteer controls. Main Outcome Measures  Left ventricular structure and function, exercise capacity, neuroendocrine function, and quality of life. Results  By echocardiography, mean (SE) LVEF was 60% (2%) in patients with DHF vs 31% (2%) in those with SHF and 54% (2%) in controls. Mean (SE) LV mass-volume ratio was markedly increased in patients with DHF (2.12 [0.14] g/mL) vs those with SHF (1.22 [0.14] g/mL) (P<.001) and vs controls (1.49 [0.17] g/mL) (P = .002). Peak oxygen consumption by expired gas analysis during cycle ergometry was similar in the DHF and SHF groups (14.2 [0.5] and 13.1 [0.5] mL/kg per minute, respectively; P = .40) and in both was markedly reduced compared with healthy controls (19.9 [0.7] mL/kg per minute) (P = .001 for both). Ventilatory anaerobic threshold was similar in the DHF and SHF groups (9.1 [0.3] and 8.7 [0.3] mL/kg per minute, respectively; P<.001) and in both was reduced compared with healthy controls (11.5 [0.4] mL/kg per minute) (P<.001). Norepinephrine levels were similar in the DHF (306 [64] pg/mL) and SHF (287 [62] pg/mL) groups (P = .56) and in both were markedly increased vs healthy controls (169 [80] pg/mL) (P = .007 and .03, respectively). Brain natriuretic peptide was substantially increased in both the DHF (56 [30] pg/mL) and the SHF (154 [28] pg/mL) groups compared with healthy controls (3 [38] pg/mL) (P = .02 and .001, respectively). Quality-of-life decrement score as assessed by the Minnesota Living with Heart Failure Questionnaire was substantially increased from the benchmark score of 10 in both groups (SHF: 43.8 [3.9]; DHF: 24.8 [4.4]). Conclusion  Patients with isolated DHF have similar though not as severe pathophysiologic characteristics compared with patients with typical SHF, including severely reduced exercise capacity, neuroendocrine activation, and impaired quality of life.      

2D-STI对舒张性心力衰竭患者左心室心肌收缩功能的评估价值

目的：探讨超声二维斑点追踪技术(2D-STI)评估舒张性心力衰竭(DHF)患者左心室心肌收缩功能的临床价值。方法将2012年12月至2014年12月于我科接受治疗的120例DHF患者作为DHF组,以120例健康者作为正常组。利用常规超声对两组人群进行评估,同时应用2D-STI软件自动将各室壁等分为基底段、中间段、心尖段,同法分析心尖四腔心切面、心尖两腔心切面,共得到18个心肌节,分析两组受检者纵向和径向各18心肌节段收缩期峰值应变。结果正常组与DHF组患者在舒张末期左心室最大内径分别为(4.75±0.48) d/cm和(5.16±0.64) d/cm,收缩末期左心房最大内径分别为(3.61±0.53) d/cm和(3.99±0.81) d/cm,差异均有统计学意义(P<0.05);在心室舒张早期,正常组与DHF组患者二尖瓣口血流峰速(E)分别为(76.44±14.11) v· cm-1· s-1和(64.27±14.72) v· cm-1· s-1,E/A比值为(1.18±0.26)和(0.84±0.31),差异均有统计学意义(P<0.05);与正常组比较,DHF组患者左室18节段的径向和纵向收缩期峰值应变有明显降低趋势,差异具有统计学意义(P<0.05)。结论2D-STI可以准确定量评估舒张性心力衰竭患者左心室心肌收缩功能,对临床工作具有指导意义。     

Plasma natriuretic peptides for community screening for left ventricular hypertrophy and systolic dysfunction: the Framingham heart study

Context  Several reports have suggested the usefulness of plasma brain natriuretic peptide (BNP) as a screening test for left ventricular hypertrophy (LVH) and systolic dysfunction (LVSD). Prior studies were limited by small sample sizes and selection bias and none compared the diagnostic performance of these peptides in men and women. Objectives  To examine the usefulness of natriuretic peptides for screening for elevated LV mass and LVSD in the community. Design, Setting, and Participants  Community-based prospective cohort study of 3177 participants (1707 women) from the Framingham Study who attended a routine examination in 1995-1998. Main Outcome Measures  Receiver operating characteristic (ROC) curves, test sensitivity, specificity, positive and negative predictive values, and likelihood ratios for identifying elevated LV mass (sex-specific 90th percentile or higher of LV mass/[height]²), LVSD (ejection fraction 50% and/or fractional shortening <29%), and moderate to severe LVSD (ejection fraction 40% and/or fractional shortening <22%) at different discrimination limits of plasma BNP and N-terminal proatrial natriuretic peptide (NT-ANP), with echocardiography as the criterion standard. Results  The areas under the ROC curves for elevated LV mass or LVSD were at or below 0.75 for both peptides, were higher for men compared with women, and were similar for BNP and NT-ANP. The diagnostic performance of natriuretic peptides for LVSD improved in women but not in men when select high-risk subgroups were targeted. Discrimination limits based on high specificity (0.95) yielded better positive predictive values and likelihood ratios compared with age- and sex-specific reference limits yet only identified less than one third of participants who had elevated LV mass or LVSD. Conclusion  In our large community-based sample, the performance of BNP and NT-ANP for detection of elevated LV mass and LVSD was suboptimal, suggesting limited usefulness of natriuretic peptides as mass screening tools.      

应用气体代谢指标判定慢性充血性心力衰竭患者的运动耐受能力

目的 观察应用心肺运动试验(CPET)评价慢性充血性心力衰竭(CHF)患者的运动耐受能力.方法 2007年8月至2009年3月在上海同济医院心内科就诊的CHF患者.经心脏超声检测后确定左室射血分数(LVEF)<.045的患者37例为CHF组,其中冠心病患者27例,扩张型心肌病患者10例,再分为NYHA Ⅱ级和NYHA Ⅲ级亚组.LVEF>0.5的冠心病患者为对照组34例.实施心肺运动试验.结果 (1)CHF组:无氧代谢阈值氧耗量(VO2AT)、峰值氧耗量、无氧代谢阈值负荷、峰值运动负荷均低于对照组[VO2AT:(11.3±2.3)ml·kg-1·min-1比(12.8±2.5)ml·kg-1·min-1,P<0.05];峰值氧耗量[(15.2±4.3)ml·kg-1·min-1比(17.2±3.9)ml.kg-1·min-1,P<0.05];无氧代谢阈值负荷[(25.2±18.8)J·s-1比(45.6±18.7)J·s-1,P<0.01];峰值运动负荷[(54.9+22.5)J·s-1比(80.3±21.6)J·s-1,P<0.01].CO2通气当量斜率[(36.7±6.7)比(30.3±4.3),P<0.01]高于对照组;(2)CHF组NYHAI级患者VO2AT、峰值氧耗量与对照组比较,差异无统计学意义(P>0.05);无氧代谢阔值负荷、、峰值运动负荷均低于对照组(均P<0.05);通气当量斜率高于对照组(P<0.01).NYHAⅢ级患者VO2AT、峰值氧耗量、无氧代谢阈值负荷、峰值运动负荷均低于对照组(均P<0.01);CO2通气当量斜率高于对照组(P<0.01).(3)经相关分析显示,VO2AT、峰值氧耗量、无氧代谢阈值负荷、峰值运动负荷、CO2通气当量斜率均与LVEF无相关性(均P>0.05);与NYHA分级旱负相关(均P<0.01);CO2通气当量斜率与NYHA分级旱正相关(r=0.652,P<0.01);均与左室质最指数无相关性(P>0.05).结论 CHF患者运动耐力、心肺储备功能下降;随着心功能下降,运动耐力下降,通气效率下降.气体代谢分析是安全、准确、科学地检测运动耐力的方法.