Congestive heart failure with preserved left ventricular systolic function after acute myocardial infarction: clinical and prognostic implications

AIMS: To characterise the prevalence, in-hospital complications, management, and long-term outcome of patients with congestive heart failure but preserved left ventricular systolic function after acute myocardial infarction. METHODS: 3166 consecutive patients screened for entry in the Bucindolol Evaluation in Acute Myocardial Infarction Trial with definite acute myocardial infarction and echocardiographic assessment of left ventricular systolic function were included between 1998 and 1999 in this prospective observational study. Main outcome measures were occurrences of in-hospital complications and all cause mortality. RESULTS: Congestive heart failure was seen during hospitalisation in 1464 patients (46%), 717 patients had preserved left ventricular systolic function (wall motion index > or =1.3 corresponding to ejection fraction > or =0.40), and 732 patients had systolic dysfunction (wall motion index <1.3). One year mortality in patients with no heart failure, heart failure with preserved systolic function, and heart failure with systolic dysfunction were 6, 22 and 35%, P<0.0001. Unadjusted risk of death from all causes associated with heart failure and preserved systolic function was 3.3 (95% CI 2.8-4.0), and after adjustment for baseline characteristics and left ventricular systolic function in multivariate Cox proportional hazards analysis the risk was 2.1 (95% CI 1.7-2.6), P<0.0001. CONCLUSIONS: Congestive heart failure is frequently present in patients with preserved left ventricular systolic function, and is associated with increased risk of in-hospital complications and death following acute myocardial infarction.     

急性心力衰竭患者肌钙蛋白I水平与基础病因及其预后的相关性

目的:探讨肌钙蛋白I(cTnI)在急性心力衰竭(AHF)患者中水平和变化与基础病因及AHF预后的关系。方法: 84例确诊的AHF患者,按病因分为缺血性心脏病(IHD)组(26例)、心脏瓣膜病(VHD)组(17例)、扩张型心肌病（DCM）组(25例)、高血压性心脏病(HHD)组(16例)。入院即刻与病情缓解时分别测定cTnI浓度。据入院即刻浓度分为cTnI(+)(14例)和cTnI(-)(70例)两组;据cTnI浓度分为入院即刻与病情缓解时均为cTnI(+)(1组)、入院即刻cTnI(+)与病情缓解时cTnI(-)(2组)、入院即刻与病情缓解时均为cTnI(-)(3组)3组。记录住院期间病情缓解时间,出院后1、3、6、12个月再入院及死亡例数,分析cTnI浓度与病因及其预后的相关性。结果: ①入院即刻与病情缓解时IHD组cTnI浓度均较DCM、HHD两组明显升高(分别P<0.01、P<0.05);IHD、VHD、HHD 3组缓解时cTnI浓度均较入院即刻明显回降(分别P<0.05、P<0.01、P<0.05)。 ②cTnI(+)组缓解时间较cTnI(-)组长(P<0.01)。入院即刻cTnI浓度与缓解时间呈正相关(r=0.286,P<0.01)。③cTnI(+)组住院期间病死率高于cTnI(-)组(P<0.05);出院后12个月cTnI(+)组病死率明显高于cTnI(-)组(P<0.01)。cTnI(+)组住院期间及出院后12个月累积心源性病死率明显高于cTnI(-)组(P<0.01)。出院后1、3、6、12个月cTnI(+)组再入院率较cTnI(-)组明显升高(分别P<0.05、P<0.01、P<0.01、P<0.01)。治疗前后cTnI均阳性组住院期间及出院后12个月累积病死率较治疗前后阳转阴组和均阴性组明显升高(均P<0.01)。结论: AHF患者cTnI水平及治疗前后的变化与基础病因及其预后相关。     

The role of plasma biomarkers in acute heart failure. Serial changes and independent prognostic value of NT-proBNP and cardiac troponin-T

AIMS: Brain natriuretic peptide (BNP), NT-proBNP and troponins are useful for the assessment of patients with heart failure. Few data exist about their serial changes and their prognostic value in patients with acute heart failure (AHF). METHODS AND RESULTS: NT-proBNP and troponin-T plasma levels were measured at baseline, after 6, 12, 24, 48 h and at discharge in 116 consecutive patients with AHF and no evidence of acute coronary syndrome. NT-proBNP levels were 4421 pg/mL at baseline, declined after 24 h and reached their nadir at 48 h (2703 pg/mL). Troponin-T was detectable in 48% of patients. During a median follow-up of 184 days, 52 patients died or had a non-fatal cardiovascular hospitalisation. At a multivariable analysis including clinical and echo-Doppler variables, NT-proBNP plasma levels at discharge, detectable troponin-T plasma levels, and NYHA class at discharge were the only independent prognostic factors. CONCLUSION: In patients with AHF, NT-proBNP levels decline 24 h after the initiation of intravenous therapy and troponin-T is detectable in 48% of cases. NT-proBNP levels at discharge, detectable troponin-T levels, NYHA class and serum sodium have independent prognostic value.     

A very high frequency index of heart rate variability for evaluation of left ventricular systolic function and prognosis in chronic heart failure patients using five-minute electrocardiogram

Objective A novel index based on fi-equency-domain analysis of heart rate variability （HRV） was tested on patients with reduced left ventricular systolic function. This index, namely VHFI, was defined as the very high frequency （VHF） component of the power spectrum normalized to represent its relative value in proportion to the total power minus the very low frequency component. Methods Patients （n = 130） were divided into a study group, consisting 66 patients with decreased left ventricular systolic function, and a control group, consisting 64 patients with normal heart structure and function and without severe coronary artery stenosis （〈 50%）. Results VHFI in the study group was significantly higher than that in the control group （19.17 ± 13.35 vs 11.37 ± 10.77, P 〈 0.001）. Cardiac events occurred in 18 patients during follow-up （33.34 i 3.26 months）. Defining the positive test as VHFI =15 and negative test as VHFI 〈15, achieved a sensitivity of 57.58% and a specificity of78.13% for predicting decreased left ventricular systolic function, and achieved a sensitivity of 66.67% and a specificity of 64.29% for predicting cardiac events. Univariate Cox regression analysis showed that positive VHFI test was an independent variable in predictive cardiac events. Conclusions The results suggest that VHFI is a useful tool for quick evaluation of left ventricular systolic function and prediction of prognosis     

Prevalence and prognostic significance of atrial fibrillation in outpatients with heart failure due to left ventricular systolic dysfunction

INTRODUCTION: Atrial fibrillation (AF) is common in patients with heart failure (HF) due to left ventricular systolic dysfunction (LVSD), with conflicting prognostic data. The aim of our study was to assess the prevalence and incidence of AF in patients with HF and to determine the prognostic impact of baseline AF and the development of new onset AF. METHODS AND RESULTS: We included 1019 outpatients with HF due to LVSD; follow-up time ranged from 3 to 64 months. At baseline 26.4% of patients had AF. Of the 284 patients with a follow-up ECG and baseline SR, 18.7% developed new onset AF. Patients with AF were older (p<0.001), more often male (p=0.04), and more likely to have a history of stroke (p=0.03), but were less likely to have IHD (p<0.001). Baseline rhythm was independent of LVEF and NYHA-class. Baseline AF was associated with increased all-cause mortality (HR 1.38; CI 1.07-1.78, p=0.01) and all-cause mortality/hospitalisation (HR 1.43; CI 1.22-1.68, p<0.001). When adjusted for baseline covariates, baseline AF was independently associated with an increased risk of experiencing the combined endpoint (HR 1.29; CI 1.05-1.58; p=0.02), but did not predict all-cause mortality. By multivariable analyses, new-onset AF was associated with increased risk of all-cause mortality/hospitalisation (HR 1.45; CI 1.05-2.00; p=0.02). CONCLUSION: In outpatients with HF due to LVSD, AF is a common co-morbidity, which adversely affects morbidity and mortality outcomes.     

Effect of a heart failure clinic on survival and hospital readmission in patients discharged from acute hospital care

Ambulatory care by physicians especially devoted to the management of heart failure (HF) has been reported to have beneficial effects. The aim of this work was to assess the effect of outpatient management at a HF clinic, as compared with care by the usual assistant physician, on prognosis of HF patients. In this non-randomised study, we prospectively followed 339 patients after a hospitalisation index for HF, in order to compare prognosis between two groups of HF patients according to the ambulatory assistance setting: either a specific outpatient clinic (n=157) or the usual assistant physician (n=182). The outcomes assessed were all-cause death or cardiac-cause rehospitalisation during the first month after discharge and survival over the longer term. The risk of dying or being readmitted during the first month after discharge was significantly lower in patients followed at the HF clinic (adjusted odds ratio 0.23; 95% CI 0.12-0.46). Patients followed in the HF clinic also had an independent significantly lower hazard of dying during a longer-term follow up of average length 373 days (adjusted hazard ratio 0.52; 95% CI 0.34-0.81). The results support the fact that a multidisciplinary and permanently available medical staff might be of relevance in improving outcomes in HF patients.     

Treatment with ramipril improves systolic function even in patients with mild systolic dysfunction and symptoms of heart failure after acute myocardial infarction

Background: Clinical signs of heart failure such as pulmonary rales and dyspnea, ventricular dysfunction, and ventricular arrhythmia are independent predictors of a poor prognosis after acute myocardial infarction (AMI). Hypothesis: The study aimed to assess the effect of ramipril treatment on mildly depressed left ventricular (LV) systolic function, assessed by atrioventricular (AV) plane displacement in patients with congestive heart failure after AMI. Methods:The study was a substudy in the Acute Infarction Ramipril Efficacy Study, a double-blind, randomized, placebo-controlled trial of ramipril versus placebo in patients with symptoms of heart failure after AMI. In all, 56 patients were included in the main study, 4 refused to participate in the substudy, and 4 were excluded for logistical reasons. Echocardiography was performed at entry and after 6 months. Patients who underwent coronary artery bypass grafting during the follow-up period were excluded. Results: At baseline, the patients had modest LV dysfunction, and mean AV plane displacement of 9.7 mm. During follow-up, AV plane displacement increased in ramipril-treated patients from 9.5 to 10.9 mm (p < 0.01). No statistically significant changes were seen in the placebo group. Conclusions: Ramipril improves LV systolic function in patients with clinical signs of heart failure and only modest systolic dysfunction after AMI. Measurement of AV plane displacement is a simple and reproducible method for detection of small changes in systolic function and may be used instead of ejection fraction in patients with poor image quality.     

Right bundle branch block and long-term mortality in patients with acute congestive heart failure

OBJECTIVES: Risk stratification in acute congestive heart failure (ACHF) is poorly defined. The aim of the present study was to assess the impact of right bundle brunch block (RBBB) on long-term mortality in patients presenting with ACHF. METHODS AND RESULTS: The initial 12-lead electrocardiogram was analysed for RBBB in 192 consecutive patients presenting with ACHF to the emergency department. The primary endpoint was all-cause mortality during 720-day follow-up. This study included an elderly cohort (mean age 74 years) of ACHF patients. RBBB was present in 27 patients (14%). Age, sex, B-type natriuretic peptide levels and initial management were similar in patients with RBBB when compared with patients without RBBB. However, patients with RBBB more often had pulmonary comorbidity. A total of 84 patients died during follow-up. Kaplan-Meier analysis revealed that mortality at 720 days was significantly higher in patients with RBBB when compared with patients without RBBB (63% vs. 39%, P = 0.004). In Cox proportional hazard analysis, RBBB was associated with a two-fold increase in mortality (hazard ratio 2.18, 95% CI 1.26-3.66; P = 0.003). This association persisted after adjustment for age and comorbidity. CONCLUSIONS: RBBB is a powerful predictor of mortality in patients with ACHF. Early identification of this high-risk group may help to offer tailored treatment in order to improve outcome.     

Excessive ventilation during early phase of exercise: a new predictor of poor long-term outcome in patients with chronic heart failure

BACKGROUND: Studies demonstrating prognostic value of excessive exercise ventilation in chronic heart failure (CHF) have focused on data derived from the whole cardiopulmonary exercise test (CPET). Whether ventilatory response to early phase of exercise is useful for risk stratification in CHF is unknown. METHODS AND RESULTS: We evaluated 216 patients with systolic CHF who underwent CPET (age: 60+/-11 years, NYHA class [I/II/III/IV]: 18/104/77/17). Ventilatory response to exercise (slope of regression line relating ventilation to carbon dioxide production) was calculated from the whole exercise test (VE-VCO(2)-all) and from the first 3 min of exercise (early phase - VE-VCO(2)-3 min). During follow-up (mean: 40+/-20 months, >3 years in survivors), 89 (41%) CHF patients died. High VE-VCO(2)-all and VE-VCO(2)-3 min predicted poor outcome in single predictor analyses, and in multivariable models when adjusted for prognosticators (age, NYHA class, ejection fraction, peak VO(2)) (P<0.0001). In receiver operating characteristic curve analysis, areas under curve for 3-year follow-up were similar for VE-VCO(2)-all and VE-VCO(2)-3 min. VE-VCO(2)-3 min maintained its prognostic value in patients taking beta-blockers (P<0.0001) and those unable to perform maximal CPET (P=0.0009). CONCLUSIONS: In CHF patients, excessive ventilation assessed over the first 3 min predicts poor outcome. Assessment of ventilatory response to exercise for prognostic stratification may be extended to patients unable to perform maximal CPET.     

舒张性心力衰竭与收缩性心力衰竭临床特征的比较

目的:探讨舒张性心力衰竭和收缩性心力衰竭患者临床特征的差异。方法:选择心力衰竭患者253例,其中舒张性心力衰竭118例,收缩性心力衰竭135例。登记患者的临床资料,分析各组患者临床特征的差异。所有患者均检测N末端脑钠尿肽前体(NT-proBNP)及高敏C反应蛋白(hs-CRP)。结果:舒张性心力衰竭和收缩性心力衰竭均以老年患者居多,前者以女性多见(56.8%),并发高血压病(81.4%)及心房颤动(26.3%)均高于于后者(前项P0.01,后项P0.05),并发冠心病(45.8%)少于后者(P0.01);两组NT-proBNP及hs-CRP均随着NYHA心功能分级增加而显著升高(P0.01),舒张性心力衰竭组NT-proBNP低于收缩性心力衰竭组(P0.01),但hs-CRP两组间差异无统计学意义。结论:与收缩性心力衰竭相比,舒张性心力衰竭于老年女性更多见,高血压病患病率及心房颤动发生率较高,NT-proBNP水平较低。     

Prognostic factors in patients hospitalized with acute heart failure syndrome

Each year,there are over one million hospitalizations for acute heart failure syndrome(AHFS)in the United States alone, with a similar number in Western Europe.These patients have very high short-term(2-6 months)mortality and readmission rates,while the healthcare system incurs substantial costs,Until recently,the clinical characteristics,management patterns,and outcomes of these patients have been poorly understood and,in consequence,risk stratification for these patients has not been well defined.Several risk prediction models that can accurately identify high-risk patients have been developed in the last year using data from clinical trials,large registries or administrative databases.Use of multi-variable risk models at the time of hospital admission or discharge offers better risk stratification and should be encouraged,as it allows for appropriate allocation of existing resources and development of clinical trials testing new treatment strategies for patients admitted with AHFS.The emerging observation that the prognosis for the ensuing three to six months may be obtained at presentation for AHFS has major implications for development of future therapies.     

心房颤动对慢性收缩性心力衰竭患者和射血分数正常心力衰竭患者预后的影响

目的 探讨心房颤动（简称房颤）对慢性收缩性心力衰竭（CSHF）及慢性射血分数正常心力衰竭（HF-PSF）住院患者预后的影响。方法 前瞻性分析武汉地区4家三级甲等教学医院848例心力衰竭（简称心衰）患者,根据左室射血分数分为CSHF组（n=560）、HFPSF组（n=288）。 每组根据有无房颤又分为房颤与非房颤亚组。 单因素Kaplan-Meier曲线分别分析CSHF和HFPSF患者房颤亚组和非房颤亚组总死亡 、 心脏泵功能衰竭死亡（心衰死亡）、 心源性猝死和栓塞相关死亡的差异 。多因素Cox风险比例模型分别比较CSHF和HFPSF患者房颤亚组与非房颤亚组不同预后的差异。 结果 单因素分析发现, CSHF和HFPSF组房颤亚组与非房颤亚组总死亡无差异。CSHF组中与非房颤亚组（n=374）相比,房颤亚组（n = 186）心衰死亡增高（P = 0. 01）、栓塞相关死亡增加（P0.05）。 多因素Cox风险比例模型分析发现房颤增加CSHF患者栓塞相关死亡风险（HR = 2. 106,95% CI：1. 436 - 2.719,P〈0. 01）。 结论 房颤对CSHF和HFPSF患者预后的影响存在差异,仅增加CSHF患者栓塞相关死亡风险。房颤影响CSHF患者预后的原因可能不在于心律失常本身而在于其并发症。     

舒张性心力衰竭患者血浆Apelin-12水平变化

目的:探讨舒张性心力衰竭(心衰)患者血浆Apelin-12水平的变化及临床意义。方法:选择2010-01-2010-06期间在我院心内科住院的慢性心衰患者60例,舒张性心衰(A组)20例,收缩性心衰(B组)40例,后者再分为3个亚组,心功能Ⅱ级组9例,心功能Ⅲ级组20例,心功能Ⅳ级组11例。健康体检者20例为对照组。酶联免疫吸附法(ELISA)测定血浆Apelin-12水平。结果:A组和B组血浆Apelin-12水平均明显低于对照组[(1.55±0.18)ng/L,(0.91±0.15)ng/L∶(3.55±0.26)ng/L,均P<0.05],其中,A组高于B组,P<0.05。B组不同的心功能分级Apelin-12水平差异无统计学意义,P=0.126。结论:舒张性心衰患者和收缩性心衰患者,血浆Apelin-12水平均降低,与心功能分级无关。     

心房颤动对慢性收缩性心力衰竭患者远期预后影响分析

目的 探讨心房颤动(房颤)对慢性收缩性心力衰竭(chronic systolic heart failure,CSHF)住院患者远期预后的影响.方法 回顾性调查和分析湖北地区8地市12家三级甲等医院2000年至2010年CSHF住院患者资料,单因素Kaplan-Meier曲线分析房颤和非房颤组总死亡、心血管病死亡、心脏泵功能衰竭死亡(心力衰竭死亡)、心脏性猝死和栓塞相关死亡差异.多因素Cox生存分析确认心力衰竭患者不同预后的危险因素.结果 ①共16681例患者纳入本次研究.房颤组与非房颤组相比,年龄(64.54 ±13.61)岁比(62.19±15.07)岁(P＜0.01)、左心室射血分数(LVEF)37.43± 12.72比38.42±13.96(P＜0.01)、心功能Ⅲ～Ⅳ级(NYHA分级)患者(5547/81.49％比7121/72.12％,P＜0.01)和病因等因素存在差异.②单因素Kaplan-Meier曲线分析发现,房颤组和非房颤组在总死亡、心血管病死亡、心力衰竭死亡和栓塞相关死亡存在差异,而在心律失常相关的心脏性猝死两组间差异无统计学意义.③多因素Cox回归分析发现房颤不是总死亡、心血管病死亡、心力衰竭死亡和心脏性猝死增加的独立危险因素,而增加栓塞相关死亡(HR=2.134,95％ CI,1.846～2.430,P＜0.0l)结论 房颤不增加CSHF患者远期总死亡、心血管病死亡、心力衰竭死亡和心脏性猝死,而增加栓塞相关死亡.提示房颤引起CSHF患者远期预后不良的原因可能在于其并发症.     

Autonomic function in elderly patients with chronic heart failure

AIMS: Autonomic function (AF) is attenuated by heart failure (HF). Reports have been based on studies of young patients with systolic heart failure (SHF). However, HF is a disease of older patients who are more likely to have diastolic heart failure (DHF). We investigated whether age alters AF in elderly HF patients and whether the haemodynamic type of HF influences AF. METHOD AND RESULTS: Thirty-six elderly HF (Framingham criteria) patients (11 with SHF, 25 with DHF) and 21 matched healthy subjects underwent simple bedside AF tests. Compared with the reference values for healthy adults, the mean E:I ratios and the median 30:15 ratios standing were all essentially normal. The median 30:15 ratios tilt and the mean Valsalva ratios were all significantly below the reference value (P for all cases <0.050). Comparing three groups, there were no significant differences for mean E:I ratio (P=0.111), 30:15 tilt (P=0.619) and 30:15 standing (P=0.167), whereas there were significant differences for the mean Valsalva ratios (P=0.001). The mean Valsalva ratio of the SHF patients was significantly lower than that for the DHF patients (P<0.001) which in turn was significantly lower than the result of the healthy subjects (P<0.001). CONCLUSION: There is an age-related impairment in AF with further impairment occurring in patients with HF. However, the severity of autonomic dysfunction is less in patients with DHF compared with patients with SHF.     

老年舒张性心力衰竭与收缩性心力衰竭患者左心形态及功能的超声评价

目的　探讨老年舒张性心力衰竭与收缩性心力衰竭患者超声左心形态、功能的特点。方法　对临床确诊的 30例老年左心室舒张性心力衰竭 (L VDHF)病例及 36例老年左心室收缩性心力衰竭 (L VSHF)病例进行超声检测 ,以2 0例正常人为对照组。结果　 1与 L VSHF组比较 ,L VDHF组左心房内径 (L AD)、左心室内径 (L VD)扩大程度小 ,但室间隔厚度 (IVST)、左心室后壁厚度 (PWT)增加。 2与对照组比较 ,L VDHF组 L AD、IVST、PWT增加 ,但L VD无显著性差异 ,L VSHF组 L VD显著性扩大。 3L VDHF组左心室射血分数 (L VEF)、心脏指数 (CI)与对照组比较无显著差异 ,而 L VSHF组 L VEF、CI减低。4与对照组比较 ,L VDHF组二尖瓣舒张早期流速峰值 (EPFV)、二尖瓣舒张早、晚期流速峰值比 (E/ A )、舒张早期减速度 (DC)减低 ,二尖瓣舒张晚期流速峰值 ((APFV )、等容舒张时间 (IRT)增高。L VDHF组上述指标与 L VSHF组无显著差异。结论　难以单纯从超声左心室舒张功能指标判断有无 L VDHF的存在 ,应综合分析判断。     

老年心衰患者血清尿酸水平的探讨

目的探讨老年心力衰竭患者的血清尿酸水平的意义.方法采用日本7020日立全自动生化仪速力法测定58例老年心力衰竭患者的血清尿酸.结果按心功能级别分组的血尿酸水平Ⅰ～Ⅱ级组(10例)261.59±70.13μmol/L;Ⅲ级组(15例)334.88±92.06μmol/L;Ⅳ级组(33例)459.58±105.6μmol/L.3组血清尿酸水平差异非常显著(P<0.01),心功能越差,血清尿酸水平越高(P<0.01);男女两组血清尿酸值比较,差异有显著意义(P<0.05).结论检测血清尿酸水平,为判断老年心力衰竭患者病情及其预后,提供一个有意义的生化指标.     

Association between prehospital time interval and short-term outcome in acute heart failure patients

Background

Acute heart failure (AHF) is one of the most frequently encountered cardiovascular conditions that can seriously affect the patient’s prognosis. However, the importance of early triage and treatment initiation in the setting of AHF has not been recognized.

Methods and Results

The Tokyo Cardiac Care Unit Network Database prospectively collected information of emergency admissions to acute cardiac care facilities in 2005–2007 from 67 participating hospitals in the Tokyo metropolitan area. We analyzed records of 1,218 AHF patients transported to medical centers via emergency medical services (EMS). AHF was defined as rapid onset or change in the signs and symptoms of heart failure, resulting in the need for urgent therapy. Patients with acute coronary syndrome were excluded from this analysis. Logistic regression analysis was performed to calculate the risk-adjusted in-hospital mortality. A majority of the patients were elderly (76.1 ± 11.5 years old) and male (54.1%). The overall in-hospital mortality rate was 6.0%. The median time interval between symptom onset and EMS arrival (response time) was 64 minutes (interquartile range [IQR] 26–205 minutes), and that between EMS arrival and ER arrival (transportation time) was 27 minutes (IQR 9–78 minutes). The risk-adjusted mortality increased with transportation time, but did not correlate with the response time. Those who took >45 minutes to arrive at the medical centers were at a higher risk for in-hospital mortality (odds ratio 2.24, 95% confidence interval 1.17–4.31; P = .015).

Conclusions

Transportation time correlated with risk-adjusted mortality, and steps should be taken to reduce the EMS transfer time to improve the outcome in AHF patients.