Coronary artery disease, coronary revascularization, and outcomes in chronic advanced systolic heart failure

Background

Associations between coronary artery disease (CAD) and outcomes in systolic heart failure (HF) and that between coronary artery bypass graft (CABG) surgery and outcomes in patients with HF and CAD have not been examined using propensity-matched designs.

Methods

Of the 2707 patients with advanced chronic systolic HF in the Beta-Blocker Evaluation of Survival Trial (BEST), 1593 had a history of CAD, of whom 782 had prior CABG. Using propensity scores for CAD we assembled a cohort of 458 pairs of CAD and no-CAD patients. Propensity scores for prior CABG in those with CAD were used to assemble 500 pairs of patients with and without CABG. Matched patients were balanced on 68 baseline characteristics.

Results

All-cause mortality occurred in 33% and 24% of matched patients with and without CAD respectively, during 26 months of median follow-up (hazard ratio {HR} when CAD was compared with no-CAD, 1.41; 95% confidence interval {CI}, 1.11-1.81; P = 0.006). HR's (95% CIs) for CAD-associated cardiovascular mortality, HF mortality, and sudden cardiac death (SCD) were 1.53 (1.17-2.00; P = 0.002), 1.44 (0.92-2.25; P = 0.114) and 1.76 (1.21-2.57; P = 0.003) respectively. CAD had no association with hospitalization. Among matched patients with HF and CAD, all-cause mortality occurred in 32% and 39% of those with and without prior CABG respectively (HR for CABG, 0.77; 95% CI, 0.62-0.95; P = 0.015).

Conclusions

In patients with advanced chronic systolic HF, CAD is associated with increased mortality, and in those with CAD, prior CABG seems to be associated with reduced all-cause mortality but not SCD.     

Impact of body composition, fat distribution and sustained weight loss on cardiac function in obesity

Background

Older age is an independent predictor of all-cause mortality in patients with mild to moderate heart failure (HF). Whether older age is also an independent predictor of mortality in patients with more advanced HF is unknown.

Methods

Of the 2707 Beta-Blocker Evaluation of Survival Trial (BEST) participants with ambulatory chronic HF (New York Heart Association class III/IV and left ventricular ejection fraction < 35%), 1091 were elderly (≥ 65 years). Propensity scores for older age, estimated for each of the 2707 patients, were used to assemble a cohort of 603 pairs of younger and older patients, balanced on 66 baseline characteristics.

Results

All-cause mortality occurred in 33% and 36% of younger and older matched patients respectively during 4 years of follow-up (hazard ratio {HR} associated with age ≥65 years, 1.05; 95% confidence interval {CI}, 0.87-1.27; P = 0.614). HF hospitalization occurred in 38% and 40% of younger and older matched patients respectively (HR, 1.01; 95% CI, 0.84-1.21; P = 0.951). Among 603 pairs of unmatched and unbalanced patients, all-cause mortality occurred in 28% and 36% of younger and older patients respectively (HR, 1.34; 95% CI, 1.10-1.64; P = 0.004) and HF hospitalization occurred in 34% and 40% of younger and older unmatched patients respectively (HR, 1.24; 95% CI, 1.03-1.50; P = 0.024).

Conclusion

Significant bivariate associations suggest that older age is a useful marker of poor outcomes in patients with advanced chronic systolic HF. However, lack of significant independent associations suggests that older age per se has no intrinsic effect on outcomes in these patients.     

Elevated resting heart rate is associated with greater risk of cardiovascular and all-cause mortality in current and former smokers

Background

Elevated resting heart rate is associated with mortality in general populations. Smokers may be at particular risk. The association between resting heart rate (RHR), smoking status and cardiovascular and total mortality was investigated in a general population.

Methods

Prospective study of 16,516 healthy subjects from the Copenhagen City Heart Study. 8709 deaths, hereof 3821 cardiovascular deaths, occurred during 33 years of follow-up.

Results

In multivariate Cox models with time-dependent covariates RHR was significantly associated with both cardiovascular and total mortality. Current and former smokers had, irrespective of tobacco consumption, greater relative risk of elevated RHR compared to never smokers. The relative risk of all-cause mortality per 10 bpm increase in RHR was (95% CI): 1.06 (1.01-1.10) in never smokers, 1.11 (1.07-1.15) in former smokers, 1.13 (1.09-1.16) in moderate smokers, and 1.13 (1.10-1.16) in heavy smokers. There was no gender difference. The risk estimates for cardiovascular and all-cause mortality were essentially similar.In univariate analyses, the difference in survival between a RHR in the highest (> 80 bpm) vs lowest quartile (< 65 bpm) was 4.7 years in men and 3.6 years in women. In multivariate analyses, the difference was about one year in never smokers and about two years in current and former smokers.

Conclusions

In a healthy population resting heart rate is associated with total and cardiovascular mortality. Elevated resting heart rate is associated with greater risk in subjects with a history of smoking than in never smokers.     

Recommendation of Low-Salt Diet and Short-term Outcomes in Heart Failure with Preserved Systolic Function

Background

Dietary sodium indiscretion frequently contributes to hospitalizations in elderly heart failure patients. Animal models suggest an important role for dietary sodium intake in the pathophysiology of heart failure with preserved systolic function. The documentation and effects of hospital discharge recommendations, particularly for sodium-restricted diet, have not been extensively investigated in heart failure with preserved systolic function.

Methods

We analyzed 1700 heart failure admissions to Michigan community hospitals. We compared documentation of guideline-based discharge recommendations between preserved systolic function and systolic heart failure patients with chi-squared testing, and used logistic regression to identify predictors of 30-day death and hospital readmission in a prespecified follow-up cohort of 443 patients with preserved systolic function. We hypothesized that patients who received a documented discharge recommendation for sodium-restricted diet would have lower 30-day adverse event rates.

Results

Heart failure patients with preserved systolic function were significantly less likely than systolic heart failure patients to receive discharge recommendations for weight monitoring (33% vs 43%) and sodium-restricted diet (42% vs 53%). Upon propensity score-adjusted multivariable analysis, patients with preserved systolic function who received a documented sodium-restricted diet recommendation had decreased odds of 30-day combined death and readmission (odds ratio 0.43, 95% confidence interval, 0.24-0.79; P = .007). No other discharge recommendations predicted 30-day outcomes.

Conclusions

Clinicians document appropriate discharge instructions less frequently in heart failure with preserved systolic function than systolic heart failure. Selected heart failure patients with preserved systolic function who receive advice for sodium-restricted diet may have improved short-term outcomes after hospital discharge.     

Impairment of autonomic reactivity is a feature of heart failure whether or not the left ventricular ejection fraction is normal

Background

Autonomic dysfunction (AD) is associated with morbidity and mortality in patients with systolic heart failure (SHF). The extent of AD when LV ejection fraction is preserved (HF-NEF), is unclear. Our objectives were: 1) quantitative assessment of autonomic function in SHF and HF-NEF; and 2) exploration of relationships among AD, symptoms and cardiac function.

Methods

This was an observational study of patients newly referred from primary care with a heart failure diagnosis; 21 SHF, 20 HF-NEF patients and 21 normal subjects were recruited. All subjects underwent clinical evaluation, 6-minute walk test (6MWT), Minnesota Questionnaire (MLWHFQ) and echocardiography. Autonomic assessment included haemodynamic responses to standing, deep breathing and handgrip. Concomitant blood pressure variability (BPV) and heart rate variability (HRV) parameters were also derived.

Results

There were significant differences in all haemodynamic responses between SHF, HF-NEF and normal. Log transformed (ln) low frequency spectral component of BPV was lower in SHF (4.1 ± 0.3) than HF-NEF (4.2 ± 0.4) and normal (4.4 ± 0.1; p = 0.001 SHF vs HF-NEF and vs normal). Ln LF/HF was greater in normal than HF-NEF and SHF (1.5 ± 0.7 vs 0.9 ± 1.0 vs 0.6 ± 0.6; p = 0.003). Autonomic modulations correlated negatively with severity of heart failure.

Conclusions

Autonomic responses in heart failure were blunted and the attenuation of responses correlated strongly with symptomatic and functional markers of disease severity. Autonomic dysfunction is a feature of the heart failure syndrome but is not dependent on ejection fraction.     

Benefit of specialized clinics for the treatment of patients with heart failure

Background

Current guidelines recommend special attention for heart failure (HF) patients in dedicated outpatient units.

Aims and methods

In this observational cohort study we sought to determine whether an equivalent benefit is achieved in all HF patients treated in specialized heart failure clinics. Patients were stratified to patients recently referred and those who already receiving long-term care (> 1 year). Data were collected at baseline and after 12 months.

Results

474 patients were prospectively observed. 130 subjects were recently referred and 344 subjects had received long-term care. During follow-up of recently referred patients, enhancement of neurohumoral pharmacotherapy was achieved in 67% (p < 0.001), which was paralleled by a reduction in NT-proBNP (baseline 1779 pg/ml [range 458;4685]; after 12 months 668 pg/ml [range 167;1690]; p < 0.001) and improvement in quality of life score, measured by the Minnesota Living with Heart Failure Questionnaire by 8 points [range 0;23]; (at baseline 34 points [range 16;59], and after 12 months 15 points [range 5;42]; p = 0.04). In contrast, these parameters were unchanged in long-term care patients. Hospitalization for HF and other cardiovascular causes was higher in patients recently referred, and all-cause mortality was comparable in both groups.

Conclusions

This comprehensive analysis of chronic HF patients treated in a specialized HF outpatient clinic confirmed the potential to optimize pharmacotherapy paralleled by improvements in quality of life and NT-proBNP levels in patients referred within the first 12 months. Prolonged management of HF patients after this optimization of maintenance therapy yields little additional benefit.     

Effects of B-Blockers on outcome of patients with Chagas' cardiomyopathy with chronic heart failure

Background

A few studies have shown a beneficial effect of B-Blocker therapy on cardiac function and functional status in patients with chronic heart failure secondary to Chagas' cardiomyopathy.

Methods

The medical charts of patients routinely followed from January, 2000 to January, 2007 were reviewed to collect clinical, standard laboratory tests, 12-lead electrocardiogram, chest X-Ray, and Doppler echochardiogram variables. A Cox proportional hazards model was used to establish independent predictors of all-cause mortality for patients with Chagas' cardiomyopathy with chronic heart failure.

Results

A total of 231 consecutive patients were enrolled in the study. Median follow up was 19 (7, 46) months. Twenty (9%) patients underwent heart transplantation and 120 (52%) died during the investigation. Left ventricular systolic dimension (hazard ratio = 1.04; 95% confidence interval = 1.02 to 1.06; p < 0.005) and need of inotropic support (hazard ratio = 1.80; 95% confidence interval 1.2 to 2.60; p = 0,03), were positively associated, whereas B-Blocker therapy (HR = 0.34; 95% confidence interval 0.23 to 0.51; p < 0.0005) was negatively associated with mortality. Mortality was significantly lower in patients taking in comparison to those not taking B-Blockers. Patients taking a mean daily dose of carvedilol > or = to 9.375 mg had a marked decrease in mortality in comparison to those not on carvedilol therapy.

Conclusion

B-Blockers are effective, not detrimental, and may improve survival in Chagas' disease patients with chronic heart failure. A randomized trial is necessary to confirm these findings.     

Mortality trends for 23,505 Medicare patients hospitalized with heart failure in Northeast Ohio, 1991 to 1997

Background

Clinical trials have identified major therapeutic advances for heart failure (HF), but the degree to which survival has improved among the general population of patients with HF is not known. This study analyzed mortality trends from 1991 to 1997 for 23,505 Medicare patients hospitalized with a first admission for HF at 29 Northeast Ohio hospitals.

Methods

We linked databases from the Cleveland Health Quality Choice (CHQC) program and Medicare to allow identification of first admissions for HF and death date. We adjusted for changes in admission illness severity using chart data from CHQC (eg, vital signs, do-not-resuscitate status, comorbid conditions, and laboratory results). Logistic regression was used to analyze trends in risk-adjusted mortality.

Results

At baseline (1991), crude inhospital, 30-day and 1-year mortality rates were 6.4%, 8.6% and 36.5%, respectively. Between 1991 and 1997, mean length of stay declined steeply from 9.2 days to 6.6 days (P < .001 for trend). Risk-adjusted inhospital mortality also declined markedly (absolute-decline −3.7%, 95% CI −4.3 to −3.0), a 52.8% relative decrease. However, the decline in 30-day mortality was only −1.4% (95% CI −2.5 to −0.1, P < .05), a 15.3% relative decrease. The 1-year mortality declined −5.3% (95% CI −3.2 to −7.4, P < .001), a 14.6% relative decrease.

Conclusions

Long-term mortality for patients hospitalized with HF improved from 1991 to 1997, although mortality remains very high. The 30-day mortality declined far less than inhospital mortality, indicating that mortality shortly after discharge increased. This raises concerns that the marked reduction in length of stay is causing adverse consequences.     

Incidence of first heart failure hospitalisation and mortality in Aboriginal and non-Aboriginal patients in Western Australia, 2000–2009

Objectives

To compare the incidence of first heart failure (HF) hospitalisation, antecedent risk factors and 1-year mortality between Aboriginal and non-Aboriginal populations in Western Australia (2000–2009).

Methods

A population-based cohort aged 20–84 years comprising Aboriginal (n = 1013; mean 54 ± 14 years) and non-Aboriginal patients (n = 16,366; mean 71 ± 11 years) with first HF hospitalisation was evaluated. Age and sex-specific incidence rates and HF antecedents were compared between subpopulations. Regression models were used to examine 30-day and 1-year (in 30-day survivors) mortality.

Results

Aboriginal patients were younger, more likely to reside in rural/remote areas (76% vs 23%) and to be women (50.6% vs 41.7%, all p < 0.001). Aboriginal (versus non-Aboriginal) HF incidence rates were 11-fold higher in men and 23-fold in women aged 20–39 years, declining to about 2-fold in patients aged 70–84 years.Ischaemic and rheumatic heart diseases were more common antecedents of HF in younger (< 55 years) Aboriginal versus non-Aboriginal patients (p < 0.001). Hypertension, diabetes, chronic kidney disease, renal failure, chronic obstructive pulmonary disease, and a high Charlson comorbidity index (>= 3) were also more prevalent in younger and older Aboriginal patients (p < 0.001). Although 30-day mortality was similar in both subpopulations, Aboriginal patients aged < 55 years had a 1.9 risk-adjusted hazard ratio (HR) for 1-year mortality (p = 0.015).

Conclusions

Aboriginal people had substantially higher age and sex-specific HF incidence rate and prevalence of HF antecedents than their non-Aboriginal counterparts. HR for 1-year mortality was also significantly worse at younger ages, highlighting the urgent need for enhanced primary and secondary prevention of HF in this population.     

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 ≤ 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.     

Body mass, fitness and survival in veteran patients: another obesity paradox?

Purpose

The paradox of obesity in patients with heart failure (HF) also has been observed in non-HF veteran patients. Veterans had to have met military fitness requirements at the time of their enlistment. Therefore, we assessed the relation of body mass index (BMI) to mortality in a clinical cohort of non-HF veterans, adjusting for fitness.

Methods

After excluding HF patients (n = 580), the study population comprised 6876 consecutive patients (mean age 58 [±11] years) referred for exercise testing. Patients were classified by BMI category: normal weight (BMI 18.5-24.9 kg/m²), overweight (BMI 25.0-29.9 kg/m²), or obese (BMI ≥30.0 kg/m²). The association between BMI, fitness, other clinical variables, and all-cause mortality was assessed by Cox proportional hazards analysis.

Results

During a mean (±SD) follow-up of 7.5 ± 4.5 years, a total of 1571 (23%) patients died. In a multivariate analysis including clinical, risk factor, and exercise test data, higher BMI was associated with better survival. Expressing the data by BMI category, obese patients were 22% less likely to die (relative risk [RR] = 0.78, 95% confidence interval [CI], 0.69-0.90, P <.001) than patients of normal weight. After further adjustment for cardiorespiratory fitness (CRF), this relationship strengthened such that mortality risk for the obese category was 35% lower (RR = 0.65, 95% CI, 0.57-0.76, P <.001), versus the normal weight category.

Conclusions

As has been observed in HF patients, obesity was associated with a substantially lower mortality risk in a clinical population of non-HF veterans. Higher CRF and obesity in later life may account for an obesity paradox in this population.     

Comparable long-term mortality risk associated with individual sulfonylureas in diabetes patients with heart failure

Aims

The aim was to investigate the outcomes of individual sulfonylureas in patients with heart failure (HF).

Methods

All patients hospitalized with HF for the first time in 1997-2006, alive 30 days after discharge, and who received anti-diabetic monotherapy with glimepiride (n = 1097), glibenclamide (glyburide) (n = 1031), glipizide (n = 557), gliclazide (n = 251), or tolbutamide (n = 541) were identified from nationwide registers. Risk of all-cause mortality was assessed by multivariable Cox regression models.

Results

Over the median observational time of 744 (Inter Quartile Range 268-1451) days, 2242 patients (64%) died. The analysis demonstrated similar hazard ratio (HR) for mortality for treatment with glimepiride (1.10 [95% confidence interval 0.92-1.33]), glibenclamide (1.12 [0.93-1.34]), glipizide (1.14 [0.93-1.38]), tolbutamide (1.04 [0.85-1.26]), and gliclazide (reference). Grouped according to pancreatic specificity, i.e., with tolbutamide, glipizide, and gliclazide as specific, and glibenclamide, and glimepiride as non-specific agents, no differential prognosis was found between the two groups (HR 1.04 [0.96-1.14], for non-specific, compared to pancreas specific agents). The prognosis was not dependent on prior acute myocardial infarction or ischemic heart disease (p for interactions >0.3).

Conclusions

In current clinical practice, it is unlikely that there are considerable differences in risk of mortality associated with individual sulfonylureas in patients with heart failure.     

Event-free survival in adults with heart failure who engage in self-care management

Background

Self-care management in heart failure (HF) involves decision-making to evaluate, and actions to ameliorate symptoms when they occur. This study sought to compare the risks of all-cause mortality, hospitalization, or emergency-room admission among HF patients who practice above-average self-care management, those who practice below-average self-care management, and those who are symptom-free.

Methods

A secondary analysis was conducted of data collected on 195 HF patients. A Cox proportional hazards model was used to examine the association between self-care management and event risk.

Results

The sample consisted of older (mean ± standard deviation = 61.3 ± 11 years), predominantly male (64.6%) adults, with an ejection fraction of 34.7% ± 15.3%; 60.1% fell within New York Heart Association class III or IV HF. During an average follow-up of 364 ± 288 days, 4 deaths, 82 hospitalizations, and 5 emergency-room visits occurred as first events. Controlling for 15 common confounders, those who engaged in above-average self-care management (hazard ratio, .44; 95% confidence interval, .22 to .88; P < .05) and those who were symptom-free (hazard ratio, 0.48; 95% confidence interval, .24 to .97; P < .05) ran a lower risk of an event during follow-up than those engaged in below-average self-care management.

Conclusion

Symptomatic HF patients who practice above-average self-care management have an event-free survival benefit similar to that of symptom-free HF patients.     

Predictors of left ventricular recovery in a cohort of peripartum cardiomyopathy patients recruited via the internet

Background

Peripartum cardiomyopathy (PPCM) is the onset of acute heart failure without demonstrable cause during the last month of pregnancy or within five months after delivery. The purpose of this study was to create a prospective registry of PPCM patients with the assistance of the internet and identify clinical factors predictive of ejection fraction (EF) recovery.

Methods

Patients with PPCM were identified by novel web-based methods. Subjects were categorized as recovered (EF > 50) or nonrecovered (EF < 50) and compared on the basis of demographic and clinical variables.

Results

Fifty-five subjects met criteria for inclusion. There was a statistically significant association between diagnosis during third trimester and persistent systolic dysfunction (25% vs. 4.7%, p = 0.03). Gestational hypertension and breastfeeding were significantly associated with EF recovery (48.8% vs. 16.7%, p = 0.046, and 39.5% vs. 8.3%, p = 0.04, respectively). EF normalization occurred in all patients with EF₁ ≥ 35%.

Conclusions

Presence of gHTN, EF ≥ 35% at diagnosis, breastfeeding, and postpartum diagnosis were all significantly associated with recovery of systolic function. Internet recruitment may be a valuable tool for studying PPCM.     

Does previous hypertension affect outcome in acute heart failure?

Background

The effect of previous long-term hypertension on mortality in acute heart failure (HF), regardless of blood pressure values, has not been well studied.

Methods

Acute Heart Failure Database (AHEAD) — Czech HF registry enrolled 4153 consecutive patients with acute HF. We excluded severe forms (cardiogenic shock, pulmonary oedema, right HF) and analysed 2421 patients with known presence or absence of previous hypertension. Demographic, clinical and laboratory profile, treatment and mortality rates were assessed and predictors of outcome were identified.

Results

Patients with previous hypertension (71.5%) were older, more of female gender, with worse pre-hospitalisation NYHA class, increased incidence of co-morbidities and higher left ventricular ejection fraction (LVEF). Although in-hospital mortality was similar in both cohorts (2.6%), survival at 1, 2 and 3-year was worse in the hypertensive group (75.6%, 65.9% and 58.7% vs. 80.7%, 74.2% and 69.8%; P < 0.001). Nevertheless, hypertension was not associated with mortality in multivariate analysis and stronger predictors of outcome were identified (P < 0.05): new-onset acute HF [hazard ratio (HR) 0.62] and increased body mass index (HR 0.68) proved to have a protective role. Advanced age (HR 1.86), diabetes (HR 1.45), lower LVEF (HR 1.28) and admission blood pressure (HR 1.54), elevated serum creatinine (HR 1.63), hyponatremia (HR 1.77) and anaemia (HR 1.40) were associated with worse survival.

Conclusion

Antecedent hypertension is frequent in patients with acute HF and contributes to organ and vascular impairment. However its presence has no independent influence on short- and medium-term mortality, which is influenced by other related co-morbidities.     

Cystatin C in Acute Heart Failure Without Advanced Renal Impairment

Background

The prognostic value of cystatin C relative to glomerular filtration rate (GFR) estimated by the Modification of Diet in Renal Disease Study (MDRD) equation modified for Japan has not been investigated in acute heart failure patients with normal to moderately impaired renal function. More accurate detection of mild renal impairment might improve the risk stratification of heart failure patients, especially patients with normal to moderately impaired renal function.

Methods

Cystatin C and creatinine levels were measured on admission in 328 consecutive patients hospitalized for worsening chronic heart failure with a GFR estimated by MDRD equation modified for Japan ≥30 mL/min/1.73 m².

Results

During a median follow-up period of 915 days, there were 52 (16%) cardiac deaths. In stepwise Cox regression analyses including cystatin C and GFR estimated by MDRD equation modified for Japan (either as continuous variables or as variables categorized into quartiles), cystatin C (P <.0001), but not GFR estimated by MDRD equation modified for Japan, was independently associated with cardiac mortality. Adjusted relative risk according to the quartiles of these markers and Kaplan-Meier analyses revealed that the cystatin C was a better marker to separate low-risk from high-risk patients. Furthermore, receiver-operating characteristic curve analyses of these markers revealed that cystatin C showed a higher precision in predicting cardiac mortality.

Conclusion

Measurements of cystatin C might improve early risk stratification compared with GFR estimated by MDRD equation modified for Japan in acute heart failure patients with normal to moderately impaired renal function.     

Mortality rates and modes of death in heart failure patients with reduced versus preserved systolic function

Background

There are conflicting reports regarding the characteristics and mortality rates of heart failure patients with preserved (HFPSF) vs. reduced systolic left ventricular function (SHF).

Methods

We evaluated the clinical profiles, mortality rates and modes of death in 481 consecutive symptomatic heart failure patients. In 317(66%) patients LVEF was < 40% (SHF), and in 164(34%) LVEF ≥ 40% (HFPSF).

Results

Compared to the HFPSF group, SHF patients were predominantly younger males with ischemic etiology and less cardiovascular comorbidities such as obesity, hypertension, diabetes mellitus and atrial fibrillation. Over a mean follow-up period of 2 years, 148(31%) patients died. Overall mortality was similar between the two groups: 53(32%) HFPSF patients and 95(30%) SHF patients died (p = 0.6), even after adjusting for baseline variables, including age, gender and comorbidities (hazard ratio 1.09; 95% confidence interval 0.74-1.61; p = 0.67). In contrast to the similar mortality rates, the modes of death were different. SHF patients had higher death rates due to pump failure compared to the HFPSF group {32/95(34%) vs. 9/53(17%) patients, p = 0.03}. A trend towards higher rate of non-cardiac death was observed in HFPSF group {33/53(62%) patients vs. 45/95(47%) patients, respectively, p = 0.08}. The prevalence of arrhythmic death was similar in both groups {17/95(18%) vs. 10/53(19%) patients, p = 0.9}.

Conclusions

Although the characteristics of HFPSF and SHF patients are distinctively different, the mortality rates are similar. The mode of death is different among the two groups of patients, as pump failure death is significantly higher in SHF patients, while non-cardiac mortality is more prevalent in HFPSF patients.     

Effect of iodixanol and ioxilan on QT interval and renal function in patients with systolic heart failure

Background

Contrast media (CM) exposure is associated with a substantial risk of arrhythmias and nephrotoxicity. These adverse effects may be exacerbated in high-risk conditions such as heart failure, although no studies have evaluated newer CM agents in this population. This study evaluated the electrophysiologic and renal effects of two newer CM agents, iodixanol and ioxilan, in heart failure patients undergoing angiography.

Methods

Eighty-seven consecutive systolic heart failure patients who received either iso-osmolar iodixanol (n = 44) or low-osmolar ioxilan (n = 43), stratified for concomitant amiodarone, were evaluated for QT interval and serum creatinine changes in comparison to baseline. QT values were corrected according to three formulae: Bazett's correction, Fridericia formula, and Framingham equation.

Results

Baseline patient characteristics were not significantly different in the iodixanol versus ioxilan groups, except for myocardial infarction and renal disease. No significant change in mean QTc was observed after exposure to either CM agent compared to baseline. These results were unaffected by amiodarone. A significant improvement in serum creatinine from baseline was observed in the iodixanol group compared to the ioxilan group (−0.121 ± 0.35 mg/dL vs. 0.033 ± 0.23 mg/dL, respectively; p = 0.045).

Conclusions

No significant change in QTc interval was observed in patients receiving either iodixanol or ioxilan during angiography. Iodixanol appeared to improve short-term renal function in patients with heart failure and should be further investigated.     

Diabetes in heart failure: prevalence and impact on outcome in the population

Purpose

Little is known on the prevalence and prognostic importance of diabetes mellitus (DM) among individuals with heart failure (HF) in community-based cohorts.

Methods

Within Olmsted County, Minnesota, a random sample of all subjects with a first diagnosis of HF between 1979 and 1999 was validated using Framingham criteria. DM was validated using glycemic criteria.

Results

Among 665 subjects with HF (mean age 77 ± 12 years, 46% male), 20% had prior DM. Subjects with DM were younger, had greater body mass index (BMI), and lower left ventricular ejection fraction than subjects without diabetes. The prevalence of DM increased markedly over time (3.8% per year; 95% confidence interval [CI], 0.8 to 6.9; P = .024), independently of BMI, particularly in older subjects (odds ratio of having DM in 1999 compared with 1979 was 3.93 [95% CI, 1.57 to 9.83] in subjects ≥75 years vs. 1.11 [95% CI, .40 to 3.05] in subjects <75 years). Five-year survival was 37% among subjects with DM versus 46% among subjects without (P = .017). The risk of death associated with DM differed markedly according to clinical coronary artery disease (CAD) (P = .025). Subjects with DM and no CAD had a higher risk of death (relative risk [RR] = 1.79 [95% CI, 1.33 to 2.41]) than those with CAD (RR = 1.11 [95% CI, .81 to 1.51]), independently of age, sex, BMI, renal function, calendar year of HF, comorbidity and EF.

Conclusions

Among community-dwelling patients with HF, the prevalence of DM increased markedly over time. DM is associated with a large increase in mortality, particularly among subjects without clinical CAD, underscoring the importance of aggressive management of DM in HF.