Prognostic importance of pulmonary hypertension in patients with heart failure

Pulmonary hypertension is a well-known complication in heart failure, but its prognostic importance is less well established. This study assessed the risk associated with pulmonary hypertension in patients with heart failure with preserved or reduced left ventricular (LV) ejection fractions. Patients with known or presumed heart failure (n = 388) underwent the echocardiographic assessment of pulmonary systolic pressure and LV ejection fraction. Patients were followed for up to 5.5 years. Increased pulmonary pressure was associated with increased short- and long-term mortality (p <0.0001 and p = 0.003, respectively). This relation was also present when stratifying patients by reduced or preserved LV function. A Cox proportional-hazards model apportioned a 9% increase in mortality per 5 mm Hg increase in right ventricular systolic pressure (p = 0.0008), independent of age and known chronic obstructive lung disease, heart failure, and impaired renal function. In conclusion, pulmonary hypertension is associated with increased short- and long-term mortality in patients with reduced LV ejection fractions and also in patients with preserved LV ejection fractions.     

Prognostic importance of the serum magnesium concentration in patients with congestive heart failure

Magnesium abnormalities are common in patients with congestive heart failure but the clinical and prognostic significance of an abnormal serum magnesium concentration in this disorder has not been investigated. Therefore, the relation between serum magnesium concentration and the clinical characteristics and long-term outcome of 199 patients with chronic heart failure was evaluated. The serum magnesium concentration was less than 1.6 mEq/liter in 38 patients (19%), within the normal range in 134 patients (67%) and greater than 2.1 mEq/liter in 27 patients (14%). Patients with hypomagnesemia had more frequent ventricular premature complexes and episodes of ventricular tachycardia than did patients with a normal serum magnesium concentration (p less than 0.05). Even though the two groups were similar with respect to severity of heart failure and neurohormonal variables, patients with a low serum magnesium concentration had a significantly worse prognosis during long-term follow-up (45% versus 71% 1 year survival, p less than 0.05). Patients with hypermagnesemia had more severe symptoms, greater neurohormonal activation and worse renal function than did patients with a normal serum magnesium concentration but tended to have fewer ventricular arrhythmias. Hypermagnesemic patients had a worse prognosis than did those with a normal magnesium concentration (37% versus 71% 1 year survival, p less than 0.05). In conclusion, the measurement of serum magnesium concentration provides important clinical and prognostic information in patients with chronic heart failure.     

Prognostic importance of atrial natriuretic peptide in patients with chronic heart failure

Several circulating neurohormones have been shown to have prognostic significance in patients with chronic heart failure, but the relation between plasma levels of atrial natriuretic peptide and mortality in this disorder remains unknown. Plasma levels of immunoreactive atrial natriuretic peptide were measured in 102 patients in whom left ventricular ejection fraction, ventricular arrhythmias on ambulatory electrocardiographic recording and plasma levels of norepinephrine, renin activity, aldosterone and arginine vasopressin were also measured. Compared with patients with atrial natriuretic peptide concentrations below the median value of 125 pg/ml, patients with higher levels of the peptide had a higher plasma renin activity (8.9 +/- 1.8 versus 2.6 +/- 0.4 ng/ml per h) and plasma norepinephrine (858 +/- 116 versus 538 +/- 45 pg/ml), more frequent premature ventricular depolarizations (4,485 +/- 715 versus 2,004 +/- 495/day) and more advanced hemodynamic abnormalities (all p less than 0.05). During the subsequent 13 to 25 months of follow-up, patients with high levels of atrial natriuretic peptide had a significantly lower rate of survival than did those whose initial circulating peptide concentrations were normal or mildly increased (p = 0.01). These data indicate that, in patients with chronic heart failure, plasma atrial natriuretic peptide provides important prognostic information. This may relate to the ability of the hormone to reflect the interplay of several pathophysiologic factors that contribute to mortality in this disease.     

Prognostic value of hyponatremia in patients with severe chronic heart failure

In order to evaluate the incidence and the prognostic value of hyponatremia (hypoNa) in patients (pts) with severe chronic heart failure (SCHF), the authors studied 161 consecutive pts (113M, 48F ages sixty-seven +/- ten) with SCHF in NYHA class III-IV. The cause of SCHF was ischemic in 64 pts, hypertensive in 39, valvular in 14, alcohol-related in 3, and idiopathic in 41. Pretreatment hypoNa (less than 135 mmol/L) was found in 64/161 pts (40%) (Group I); Na+ was less than 125 in 10 pts, 125-130 in 19, and 131-135 mmol/L in 35; 42/64 pts (66%) of Group I were in NYHA class IV at admission. In the pts with pretreatment Na+ less than 125 mmol/L, hypoNa was persistent and refractory to high-dose furosemide (less than 500 mg/day) and water restriction. Cardiovascular mortality of Group I pts was 69% within twenty-four months (34 pts died of low-output syndrom and 10 suddenly). All pts with Na+ less than 130 mmol/L died within six months. The 20 pts who normalized Na+ are alive, and in NYHA class II-III (follow-up: twenty-six +/- fifteen, six to sixty months). Pts without hypoNa were 97/161 (Group II), and 58/97 (60%) are alive (follow-up: thirty +/- eighteen, five to fifty-eight months), whereas 39 pts died (27 suddenly, 9 of low-output syndrome, and 3 of extracardiac disease) within twenty-four months. The mortality rate of Group II was significantly lower (40% vs 69%, p less than 0.001) compared with Group I. The two groups were similar for age, sex, and cause and duration of SCHF.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prognostic importance of serum sodium concentration and its modification by converting-enzyme inhibition in patients with severe chronic heart failure

Although past reports have identified a variety of prognostic factors in patients with severe chronic heart failure, previous studies have not evaluated the interaction of prognostic variables and drug treatment. We analyzed the association of 30 clinical, hemodynamic, and biochemical variables with survival in 203 consecutive patients with severe heart failure; all variables were assessed just before initiation of treatment with a variety of vasodilator drugs, and all patients were subsequently followed for 6 to 94 months. By regression analysis, pretreatment serum sodium concentration was the most powerful predictor of cardiovascular mortality, with hyponatremic patients having a substantially shorter median survival than did patients with a normal serum sodium concentration (164 vs 373 days, p = .006). The unfavorable prognosis for hyponatremic patients appeared to be related to the marked elevation of plasma renin activity that we noted in these individuals (10.0 +/- 2.0 ng/ml/hr), since hyponatremic patients fared significantly better when treated with angiotensin converting-enzyme inhibitors than when treated with vasodilator drugs that did not interfere with angiotensin II biosynthesis (median survival 232 vs 108 days, p = .003). In contrast, there was no selective benefit of converting-enzyme inhibition on the survival of patients with a normal serum sodium concentration, in whom plasma renin activity was low (1.9 +/- 0.3 ng/ml/hr). This interaction between serum sodium concentration, drug treatment, and long-term outcome suggests that the renin-angiotensin system may exert a deleterious effect on the survival of some patients with chronic heart failure, which can be antagonized by converting enzyme inhibition, and provides a clinical counterpart for the similar prognostic role that has been postulated for angiotensin II in experimental preparations of heart failure.     

Prognostic importance of chronic kidney disease in Japanese patients with chronic heart failure.

BACKGROUND: Renal insufficiency is common in patients with chronic heart failure (CHF), so to improve the prognosis of patients with cardiovascular risks clinical guidelines recommend estimating the glomerular filtration rate (GFR), which detects chronic kidney disease more accurately than does the serum creatinine level alone. However, the clinical usefulness of the estimated GFR (eGFR) in Japanese CHF patients is still unclear. METHODS AND RESULTS: Of 1,278 patients registered in a Japanese CHF registry, termed the Chronic Heart Failure Analysis and Registry in the Tohoku District study, the study population included 920 symptomatic patients with sufficient data. Baseline eGFR (ml .min(-1) . 1.73 m(-2)) was calculated using the Cockcroft-Gault equation. Patients were divided into three groups based on eGFR: > or =60, 30-59, and <30 ml . min(-1) .1.73 m(-2). Kaplan-Meier analysis revealed that the incidence of the combined event of all-cause death and admission because of CHF was significantly higher in patients with reduced eGFR and such patients were older and more frequently had an ischemic etiology of CHF, a higher prevalence of diabetes, lower hemoglobin level, and higher B-type natriuretic peptide level. Multivariate Cox regression analysis showed that reduced eGFR was significantly associated with the combined endpoint. CONCLUSIONS: GFR should be evaluated in all Japanese patients with CHF to improve risk stratification and treatment.     

不同病因所致心力衰竭的预后分析

目的：探讨不同病因所致心力衰竭（心衰）对患者预后的影响。方法：回顾性分析2007年1月~2010年12月兰州大学第一医院心内科收治住院的556例心衰患者的临床资料,并进行电话随访,确认患者是否死亡。根据引起心衰的病因不同将研究对象分为冠心病组、高血压病组、扩张型心肌病组（扩心病组）、心脏瓣膜病组和多病因组。Cox比例风险模型评价不同病因组患者的预后差异,并建立Kaplan Meier生存曲线。结果：共纳入分析患者513人,截止随访结束,死亡231人,占45%;不同病因组患者的年龄、心功能分级、左室射血分数等指标有明显差异（P〈0.05）;多因素Cox比例风险模型分析显示冠心病组和扩心病组的死亡风险分别为心脏瓣膜病组的2.517倍（P〈0.05）和2.480倍（P〈0.05）。结论：心衰患者不同病因的预后不同。     

Prognostic importance of comorbidities in heart failure with preserved left ventricular ejection fraction

The relative impact of comorbidities and parameters of left ventricular diastolic function on clinical outcome has not been thoroughly investigated in patients who are hospitalized for heart failure decompensation and found to have preserved ejection fraction. We identified 98 HFpEF patients among 1452 patients admitted with acute heart failure. Clinical characteristics, hemoglobin levels, estimated glomerular filtration rate (eGFR), B-type natriuretic peptide (BNP) and Doppler-echocardiographic parameters were analyzed. The primary end point of the study combined death and rehospitalization for decompensated heart failure after the index hospitalization. Mean age was 76 ± 9 years. LV ejection fraction, E/E (a) ratio, and estimated systolic pulmonary artery pressure were 61 (55-67)%, 12.9 (9.4-15.1), 40 (32-46) mmHg, respectively. BNP values, hemoglobin and eGFR were 287 (164-562) pg/mL, 11.3 (10.4-12.4) g/dL and 45 (37-74) mL/min/m(2), respectively. During a mean follow-up of 17 ± 11 months, 56% reached the primary endpoint of the study: 31 died and 24 were re-hospitalised for heart failure. Diabetes [HR = 1.76 (1.03-3.00), P = 0.039], lower systolic blood pressure [HR = 0.99 (0.97-0.99), P = 0.016], hemoglobin [HR = 0.62 (0.49-0.76), P < 0.0001], and eGFR [HR = 0.98 (0.97-0.99), P = 0.004] were associated with a poor outcome. Neither BNP nor echocardiographic parameters were correlated with outcome. Comorbidities primarily correlate with outcome in patients with HFpEF.     

Prognostic value of cytokines and neurohormones in severe heart failure

BACKGROUND AND OBJECTIVES: The screening of candidates for heart transplantation continues to present difficulties. High plasma levels of cytokines and neurohormones have been associated with a poor prognosis in heart failure but their usefulness for identifying candidates for heart transplantation is still not established. METHODS: In 83 patients (59 11 years old), with systolic left ventricular dysfunction and New York Heart Association functional class III-IV, we assessed levels of aldosterone, atrial natriuretic peptide, plasma renin activity, angiotensin II, norepinephrine, endothelin, interleukin-6 and tumor necrosis factor-alpha. RESULTS: Over the following year, 13 patients died and 26 received heart transplantation. Mean ejection fraction was 23 6%, end-diastolic and end-systolic diameters were 73 10 and 60 10 mm, respectively. Univariate analysis identified the following variables to be associated with poor prognosis: angiotensin II (p = 0.001), norepinephrine (p = 0.003), plasma renin activity (p = 0.02), systolic blood pressure (p = 0.006), end-diastolic diameter (p = 0.02) and end-systolic diameter (p = 0.04). Multivariate regression analysis identified the following variables to be independent predictors of death or need for heart transplantation: a low cardiac index (p = 0.007), plasma angiotensin II (p = 0.001) and pulmonary capillary wedge pressure (p = 0.04) The sensitivity and specificity of angiotensin II for predicting poor outcome was only moderate according to interpretation of the receiver operating curves. CONCLUSIONS: Although plasma angiotensin II was the best neurohormone for identifying patients with severe heart failure and the worst prognosis, its sensitivity and specificity for predicting death or the need for heart transplantation was limited. The decision to transplant should continue to be based on clinical and hemodynamic parameters.     

窦性心率震荡对老年人慢性心功能不全预后的预测价值

目的 探讨窦性心率震荡(HRT)对老年慢性心功能不全(CHF)患者预后的预测价值.方法 选择本院2006年10月至2009年5月住院的老年CHF患者96例,记录其相关临床资料,并进行超声心动图、动态心电图检查.应用相应的分析软件对动态心电图检查结果进行分析,比较不同心功能分级患者窦性HRT指标变化的差异;随访9～28个月,终点事件为患者心源性死亡,采用Logisitc回归法分析窦性HRT、年龄、高血压、糖尿病、心肌梗死、左室射血分数(LVEF)、血管紧张素转换酶抑制剂(ACEI)、β受体阻滞剂对CHF患者死亡的预测能力. 结果 按照震荡初始和震荡斜率结果进行HRT分类,HRT的主要参数正常在心功能Ⅱ级(60.0%)与Ⅲ级(45.0%)者比较差异无统计学意义(χ~2=1.60,P>0.05);心功能Ⅲ级与Ⅳ级者(16.7%)比较差异无统计学意义(χ~2=1.43,P>0.05);但心功能Ⅱ级与Ⅳ级者比较差异有统计学意义(χ~2=9.84,P<0.05),HRT在心功能Ⅳ级组明显减弱.平均随访(18.0±9.6)个月,96例患者中,心源性死亡34例,分析显示CHF患者死亡与HRT、低LVEF(≤45%)、年龄(≥65岁)、糖尿病、心肌梗死及心功能分级相关. 结论 窦性HRT指标对老年人CHF预后有良好的预测能力.     

低钠血症对慢性心力衰竭患者预后的影响

目的：探讨低钠血症对慢性心力衰竭（CHF）患者预后的影响。方法：按血钠水平86例CHF患者被分为正常血钠组（52例）和低钠血症组（34例），按常规CHF治疗后，比较两组左室射分数（LVEF）、CHF纠正时间和死亡率。结果：与正常血钠组比较，低钠血症组LVEF显著降低，心力衰竭纠正时间显著延长．死亡率显著升高（P均〈0.05）。结论：低钠血症是CHF患者影响预后的重要影响因素。     

Prognostic impact of workload in patients with congestive heart failure

Aims Recent data underline the prognostic value of cardiopulmonary exercise parameters (eg, peak oxygen consumption [PVO2]), percentage of predicted oxygen consumption [ppVO₂], ventilation, and workload) in patients with congestive heart failure. These parameters were not yet compared in a multivariate analysis. Methods and Results To detect the superiority of one of these parameters, in a prospective 1-year follow-up study we investigated 226 patients with heart failure. The end point of the study was combined death and prioritization for urgent cardiac transplantation within 1 year. Cardiopulmonary exercise testing was performed with evaluation of peak oxygen consumption, percentage of predicted peak oxygen consumption, peak carbon dioxide production, ventilation, workload, anaerobic threshold, and ventilation/carbon dioxide production ratio. All variables were univariate predictors of 1-year mortality and urgent transplantation. Multivariate analysis demonstrated that only workload and ventilation were independently related to 1-year mortality and urgent cardiac transplantation, whereas peak oxygen consumption or percentage of predicted peak oxygen consumption did not reach statistical significance in this model. Conclusion Workload on bicycle stress test correlates to 1-year mortality. More important, workload is a more powerful predictor of 1-year survival compared with established markers such as pVO₂ or ppVO₂. (Am Heart J 2002;143:308-12.)     

Prognostic significance of hemoglobin levels in patients with heart failure

INTRODUCTION AND OBJECTIVES: To evaluate the prognostic significance of hemoglobin (Hb) levels in terms of 1-year mortality and hospital admissions due to heart failure (HF) during the first year of follow-up after the first visit to an outpatient HF unit. PATIENTS AND METHOD: Survival status and HF-related hospital admission rate at 1 year were analyzed for 337 patients admitted between August 2001 and March 2003. Plasma Hb level was measured at the first visit to the unit. RESULTS: 28 patients (8%) died and there were 158 HF-related hospital admissions in 66 patients. Plasma Hb level correlated strongly with survival at 1 year, and was 13.0 +/- 1.7 g/dL in patients who were alive after this time, versus 11.7 +/- 1.6 g/dL (P < .001) in patients who died. Plasma Hb level also correlated with HF-related need for hospital admission, and was 13.1 +/- 1.7 g/dL in patients who were not hospitalized, versus 12.2 +/- 1.7 g/dL (P < .001) in patients with at least one hospital admission. In the multivariate logistic regression analysis plasma Hb level remained statistically associated both with 1-year survival and with the need for HF-related hospital admission. On the basis of a cutoff value for anemia of Hb < 12 g/dL, 30% of the patients had anemia. One-year mortality was 17% in patients with anemia and 5% in patients without anemia (P < .001). Among patients without anemia, 31% had at least one HF-related hospital admission, whereas only a 15% of the patients without anemia needed to be hospitalized for HF (P = .001). CONCLUSIONS: Plasma Hb levels correlated inversely with mortality and with HF-related hospital admissions at 1 year. The prevalence of anemia (Hb < 12 g/dL) in the population with HF studied here was high and had independent prognostic value.     

Prognostic evaluation of ambulatory patients with advanced heart failure

Previous heart failure (HF) risk models have included clinical and noninvasive variables and have been derived largely from clinical trial databases or decompensated HF registries. The importance of hemodynamic assessment is less established, particularly in ambulatory patients with advanced HF. In this study, 513 consecutive ambulatory patients (mean age 54+/-11 years, mean left ventricular ejection fraction 20+/-9%) with symptomatic HF who underwent diagnostic right-sided cardiac catheterization as part of outpatient assessment from 2000 to 2005 were reviewed. After a total of 1,696 patient-years of follow-up, 139 (27%) patients had died and 116 (23%) had undergone cardiac transplantation. The 1- and 2-year overall survival rates (defined as freedom from death or cardiac transplantation) were 77% and 67%, respectively. Overall, 65% of patients had elevated intracardiac filling pressures, and 40% had cardiac indexes<2.2 L/min/m2. In multivariate analysis, mean pulmonary arterial pressure, cardiac index, and the severity of mitral regurgitation were the 3 strongest predictors of all-cause mortality and cardiac transplantation. Renal dysfunction was also an independent predictor of all-cause mortality. When a clinical model for Cox multivariate analysis of all-cause mortality was compared with a model that also included cardiac index and mean pulmonary arterial pressure, the chi-square score increased from 45 to 69 (p<0.0001). In conclusion, in ambulatory patients with advanced HF, hemodynamic and renal function assessments remain strong independent predictors of all-cause mortality.     

The prognostic importance of anemia in patients with heart failure

Physiologic studies have suggested that anemia could adversely affect the cardiovascular condition of patients with heart failure. Yet, the prognostic importance of this treatable condition is not well established by epidemiologic studies. We sought to determine the prognostic value of hematocrit level in a cohort of elderly patients hospitalized with heart failure.We studied a consecutive sample of 2281 patients aged 65 years or older who had been admitted with a principal discharge diagnosis of heart failure. Multivariate Cox proportional hazards regression was conducted to test whether hematocrit level was an independent predictor of 1-year mortality and of hospital readmission.The mean (+/- SD) age of the patients was 79 +/- 8 years; 58% (n = 1324) were women. Their median hematocrit was 38% (25th to 75th percentile, 33% to 42%). Lower hematocrits were associated with a higher mortality. After adjusting for demographic and clinical factors, each 1% lower hematocrit was associated with a 2% greater 1-year mortality (P = 0.007). Compared with patients with a hematocrit >42%, those with a hematocrit < or =27% had a 40% greater 1-year mortality (hazard ratio [HR] = 1.40; 95% confidence interval [CI]: 1.02 to 1.92; P = 0.04). This increased risk was similar to that conferred by traditional risk factors, including a left ventricular ejection fraction < or =20% (HR = 1.50; 95% CI: 1.20 to 1.86). Lower hematocrits were also associated with a greater risk of hospital readmission.Anemia is associated with an increased risk of death and rehospitalization in older patients with heart failure. Whether anemia is a direct cause of worse outcomes, or a marker for other causal factors, is not known.     

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.