Non-Gaussian heart rate as an independent predictor of mortality in patients with chronic heart failure

BACKGROUND: Morbidity and mortality due to chronic heart failure remain unacceptably high despite effective drug therapies, and the search for a better risk predictor is ongoing. Statistics derived from beat-to-beat fluctuations in heart rate or heart rate variability (HRV) have been used for this purpose, but the current predictability level is low or moderate at best. OBJECTIVE: The purpose of this study was to evaluate whether a recently proposed non-Gaussian index of HRV is a significant and independent mortality predictor in patients with congestive heart failure (CHF). METHODS: Twenty-four-hour Holter ECGs from 108 CHF patients were evaluated. Thirty-nine (36.1%) of the patients died during the follow-up period of 33 +/- 17 months. Cox proportional hazards regression analysis was performed to determine factors related to all-cause mortality. The factors evaluated derived from clinical information, including plasma brain natriuretic peptide, conventional time- and frequency-domain and fractal HRV measures, and a recently proposed non-Gaussian index lambda of HRV. RESULTS: The short-term (<40 beats) non-Gaussian index lambda(40) (hazard ratio per increment of unit standard deviation 1.64, 95% confidence interval [1.23, 2.18], P <.001) and the long-term (<1,000 beats) index lambda(1000) (hazard ratio 1.42, 95% confidence interval [1.07, 2.18], P <.02), together with brain natriuretic peptide (hazard ratio 2.26, 95% confidence interval [1.45, 3.53], P <.001), are significant univariate risk predictors of mortality. In a multivariate model, lambda(40) (1.49, [1.13, 1.96], P <.005) and brain natriuretic peptide (2.39, [1.53, 3.75], P <.001) are independent predictors of the survival statistics of patients. None of the conventional HRV measures have predicted the mortality of patients in a significant and independent manner. CONCLUSION: The results of this study indicate the usefulness of the short-term non-Gaussian index of HRV for risk prediction in patients with CHF.     

Low systolic blood pressure at admission predicts long-term mortality in heart failure with preserved ejection fraction

Background

Systolic blood pressure (SBP) at hospital admission predicts in-hospital and postdischarge mortality in patients with left ventricular systolic dysfunction. The relationship between admission SBP and mortality in heart failure with preserved (≥50%) ejection fraction (HFPEF) is still unclear.

Methods and Results

We aimed to investigate the relationship between admission SBP and 5-year outcome in 368 consecutive patients hospitalized for new-onset HFPEF. Five-year all-cause mortality rates according to admission SBP categories (<120, 120–139, 140–159, 160–179, and ≥180 mm Hg) were 75 ± 7%, 53 ± 6%, 52 ± 7%, 55 ± 4%, and 60 ± 7%, respectively (P = .029). Survival analysis showed an inverse relation between admission SBP and mortality with increased risk of death for SBP <120 mm Hg. SBP <120 mm Hg independently predicted 5-year all-cause mortality (adjusted hazard ratio [HR] 1.69, 95% confidence interval [CI] 1.08–2.63) and cardiovascular mortality (adjusted HR 1.89, 95% CI 1.21–2.97). In patients discharged alive, after adjustment for medical treatment at discharge, admission SBP <120 mm Hg remained predictive of all-cause mortality (adjusted HR 1.52, 95% CI 1.04–2.43) and cardiovascular mortality (adjusted HR 1.69, 95% CI 1.06–2.73). There was no interaction between any of the therapeutic classes and outcome prediction of SBP.

Conclusions

In HFPEF, low SBP (<120 mm Hg) at the time of hospital admission is associated with excess long-term mortality. Further studies are required to determine the mechanism of this association.     

Associations of short‐ and long‐term mortality with admission blood pressure in Chinese patients with different heart failure subtypes

It remains unknown whether systolic (SBP) and diastolic (DBP) pressure on admission are associated with short‐ and long‐term mortality in Chinese patients with heart failure with preserved (HFpEF), mildly reduced (HFmrEF), and reduced (HFrEF) ejection fraction. In 2706 HF patients (39.1% women; mean age, 68.8 years), we assessed the risk of 30‐day, 1‐year, and long‐term (> 1 year) mortality with 1‐SD increment in SBP and DBP, using multivariable logistic and Cox regression, respectively. During a median follow‐up of 4.1 years, 1341 patients died. The 30‐day, 1‐year, and long‐term mortality were 3.5%, 16.7%, and 39.4%, respectively. In multivariable‐adjusted analyses additionally accounted for DBP or SBP, a higher SBP conferred a higher risk of long‐term mortality (hazard ratio, 1.11; 95% CI, 1.02‐1.22; p = .017) and a lower DBP was associated with a higher risk of all types of mortality (p ≤ .011) in all HF patients. Independent of potential confounders including DBP or SBP, in patients with HFpEF, higher SBP and lower DBP levels predicted a higher risk of long‐term mortality with hazard ratios amounting to 1.16 (95% CI, 1.04–1.29; p = .007) and .89 (95% CI, .80–.99; p = .028), respectively. In patients with HFmrEF and HFrEF, irrespective of adjustments of potential confounders, DBP was associated with 1‐year mortality with odds ratios ranging from .49 to .62 (p ≤ .006). In conclusion, lower DBP and higher SBP levels on admission were associated with a higher risk of different types of all‐cause mortality in Chinese patients with different HF subtypes. Our observations highlight that admission BP may help to improve risk stratification.     

Physician specialty and mortality among elderly patients hospitalized with heart failure

BACKGROUND: Whether specialty care improves survival among patients with heart failure remains controversial. METHODS: We evaluated specialty care and outcomes in 25869 Medicare beneficiaries hospitalized with heart failure in the United States from 1998 through 1999. Patients were classified based on the specialty of their attending physician: cardiologist, internist, general physician, or family physician. The primary outcome of interest was all-cause mortality within 30 days of admission. RESULTS: Cardiologists were attending physicians for 26%, internists for 50%, and general and family physicians cared for the remainder. Mortality at 30 days was lowest for patients cared for by cardiologists (8.8%), higher for patients cared for by internists (10.0%, relative risk [RR] = 1.07; 95% confidence interval [CI]: 0.97 to 1.19; P = 0.059) and general physicians (11.1%, RR = 1.26; 95% CI: 0.99 to 1.58; P = 0.086), and highest for patients cared for by family physicians (12.0%, RR = 1.31; 95% CI: 1.15 to 1.49; P <0.001). Patients cared for by family physicians remained at higher 30-day mortality rates whether with (RR = 1.30; 95% CI: 1.11 to 1.52) or without consultation with cardiologists (RR = 1.31; 95% CI: 1.13 to 1.52). CONCLUSION: Hospitalized patients with heart failure had lower 30-day mortality when treated by cardiologists than when they were treated by other physicians. Although these differences were modest (RR = 1.07) for internists, they were substantial for general physicians (RR = 1.26) and family physicians (RR = 1.31); of note was that inpatient cardiology consultation did not appear to change this relation.     

Clinical characteristics and one-year mortality according to admission renal function in patients with a first acute heart failure hospitalization

Introduction and Objectives

Chronic kidney disease is related to poor outcomes in patients with heart failure (HF). Few studies have assessed whether renal function influences one-year mortality risk in patients admitted for the first time for acute HF.

Plasma brain natriuretic peptide--an independent predictor of cardiovascular mortality in acute heart failure

PURPOSE: To examine the prognostic importance of both plasma atrial natriuretic and B-(brain natriuretic peptide) following an episode of acute heart failure. SUBJECTS AND METHODS: A prospective cohort of 91 patients admitted into hospital with acute heart failure were recruited. After initial in-hospital management plasma ANP and BNP levels were measured by radioimmunoassay, and echocardiography was performed on the same day. Patients were followed up for 12 months and the main outcome measure was cardiovascular death. RESULTS: Plasma ANP and BNP levels were significantly higher in patients who died of a cardiovascular cause within 12 months (P<0.001 and P<0.0001, respectively) or at 1-month (P<0.05 and P<0.001) after recruitment. By Kaplan-Meier estimated life-table curves, patients with above median plasma ANP or BNP levels had significantly higher 1-year mortality (42.5% vs. 11.6%, both P<0.005). By multivariate Cox proportional hazard regression analysis, the plasma BNP level was the most important prognostic factor predicting mortality (chi2 = 18.3, P<0.0001), followed by age (chi2 = 11.5, P<0.001). Other factors including ANP, left ventricular ejection fraction by M-mode echocardiography, pulmonary arterial pressure, sex, cause of heart failure as well as New York Heart Association class were not significant. CONCLUSION: A plasma BNP level has independent and at least short-term prognostic significance in patients admitted with acute heart failure. This non-invasive and readily available blood test should be considered for risk stratification in patients with acute heart failure.     

动态血压联合家庭血压监测对慢性心力衰竭患者血压变异性及预后的指导意义

目的 对慢性心力衰竭（CHF）患者使用动态血压联合家庭血压监测,观察其对血压变异性（BPV）和预后的指导意义。方法 入选192例CHF患者随机分为联合监测组（n=97）和对照组（n=95）。对所有患者进行为期1年的随访,采用常规的门诊预约随访,随访间隔为1个月。联合监测组患者采用家庭血压监测模式进行CHF的监测随访,每日早晚测量的血压和脉率值通过手机传输给中央系统,由我院心血管内科专人负责中央系统维护和每位患者血压监测观察。当中央系统发现某位患者血压波动异常或脉率波动异常时,将电话通知该位患者增加血压、脉率测量次数或增加门诊随访次数,并及时调整CHF的治疗方案。所有患者在入组前、随访6月行动态血压监测,并收集记录所有数据。观察记录所有患者随访一年中的以下心血管事件：非计划性随访、心源性死亡、恶性心律失常、再次因心力衰竭住院。结果 入组前两组患者杓型血压患者所占比例没有统计学差异（P>0.05）。在随访6个月后,联合监测组患者杓型血压比例明显高于入组前水平（36.08% VS. 13.40%, P=0.004）,且高于随访6个月后对照组杓型血压患者比例（36.08% VS. 16.84%, P=0.012）。24h PR在入组前两组患者没有统计学差异（P>0.05）。在随访6个月后,两组患者的24h PR较入组前均明显降低（P<0.05）。6个月的随访后联合监测组患者24h PR明显低于对照组24h PR（70.14±13.42 VS. 77.02±16.15, P=0.002）。入组前两组患者24hSBPV和24hDBPV没有统计学差异（P>0.05）。随访6个月后联合监测组患者24hSBPV和24hDBPV均低于入组前水平,并低于随访6个月后对照组患者（P均<0.05）。联合监测组患者非计划性随访发生比例（11.34% VS. 24.21%, P=0.032）、再次住院发生比例（6.19% VS. 17.89%, P=0.023）和恶性心律失常发生比例（3.09% VS. 11.58%, P=0.047）明显低于对照组患者。结论 动态血压联合家庭血压监测模式较传统的门诊随访进一步降低血压变异性,增加杓型血压比例,并能改善CHF患者预后,值得临床推广。     

Lead aVR is a predictor for mortality in heart failure with preserved ejection fraction

BackgroundNormally, lead augmented vector right (aVR) has a negative T wave polarity (TaVR) in the electrocardiography (ECG). Positive TaVR and ST segment deviation in lead aVR (STaVR) have negative effects on mortality in heart failure with reduced ejection fraction patients.AimOur aim was to investigate the relationship between lead aVR changes and mortality in heart failure with preserved ejection fraction (HFpEF) patients.MethodsWe retrospectively examined 249 patients in 2011–2015 years (mean age 70.8 ± 11.9 years and follow-up period 38.3 ± 9.6 months). ECG, echocardiographic, and laboratory findings were recorded and compared in the study. Existence of positive TaVR, STaVR, and quantitative TaVR values were recorded and the absolute numerical values of TaVR and STaVR were recorded from the 12-lead surface ECG (T/STaVR ratio or vice versa).ResultsThe patients were divided into two groups: living (171) and deceased (78). Age, systolic blood pressure, left atrial diameter, QRS duration, positive TaVR frequency, STaVR, absolute value of TaVR, and ratio were significantly higher in the deceased group. Age (OR: 1.106), STaVR (OR: 2.349), TaVR (OR: 1.612), and T/STaVR ratio (OR: 5.156) were determined as independent predictors for mortality.ConclusionsST segment and T wave polarity changes in lead aVR closely associated with mortality in patients with HFpEF.     

Tissue inhibitor of metalloproteinases levels in patients with chronic heart failure: an independent predictor of mortality

BACKGROUND: Matrix metalloproteinases (MMP) and their tissue inhibitors (TIMP) are involved in cardiac remodelling. The prognostic utility of TIMP is unknown in chronic heart failure (CHF). AIMS: We investigated the association of plasma levels of soluble MMP-9 and TIMP-1 with clinical, laboratory and echocardiographic parameters and estimated their prognostic value in the prediction of all-cause death. METHODS: MMP-9, TIMP-1, tumour necrosis factor-alpha, and amino-terminal pro-brain natriuretic peptide were measured in 249 consecutively enrolled CHF patients and 74 healthy individuals. RESULTS: After adjustment for age, sex and creatinine, levels of TIMP-1 (1640 vs. 735 ng/ml, P<0.001) but not MMP-9 were elevated in CHF patients compared to controls. During a median follow-up period of 2.5 years, 66 patients (27%) died. In multivariable Cox regression models TIMP-1 but not MMP-9 emerged as an independent predictor of all-cause death (hazard ratio per tertile, 3.5; 95% confidence interval [CI], 2.2-5.1). In addition to the full set of univariately predictive clinical and serological markers, information on TIMP-1 significantly increased the area under the receiver operating characteristic curve from 0.77 (95% CI, 0.71-0.84) to 0.87 (95% CI, 0.82-0.92). CONCLUSION: In stable CHF patients, TIMP-1 but not MMP-9 is of independent and incremental value regarding the prediction of all-cause death.     

The combined effect of blood pressure and C-reactive protein with the risk of mortality from coronary heart and cardiovascular diseases

Background and aimsBoth blood pressure and C-reactive protein (CRP) are individually associated with cardiovascular mortality risk. However, the combined effect of systolic blood pressure (SBP) and CRP on coronary heart disease (CHD) and cardiovascular disease (CVD) mortality risk, has not been studied.Methods and resultsWe evaluated the joint impact of SBP and CRP and the risk of mortality in the Kuopio Ischemic Heart Disease prospective cohort study of 1622 men aged 42–61 years at recruitment with no history of CVD. SBP and CRP were measured. SBP was categorized as low and high (cut-off 135 mmHg) and CRP as low and high (cut-off 1.54 mg/L) based on ROC curves. Multivariable adjusted hazard ratios (HRs) with confidence intervals (CI) were calculated.During a median follow-up of 28 years, 196 cases of CHD and 320 cases of CVD deaths occurred. Elevated SBP (>135 mmHg) combined with elevated (CRP >1.54 mg/L) were associated with CHD and CVD mortality (HR 3.41, 95% CI, 2.20–5.28, p < 0.001) and (HR 2.93, 95% CI, 2.11–4.06, p < 0.001) respectively after adjustment for age, examination year, smoking, alcohol consumption, BMI, Type 2 diabetes, energy expenditure, total cholesterol, serum HDL cholesterol, antihypertensive medication and use of aspirin.ConclusionThe combined effect of both high systolic blood pressure and high CRP is associated with increased risk of future CHD and CVD mortality as compared with both low SBP and low CRP levels in general male Caucasian population.     

Functional mitral regurgitation predicts 1-year mortality in elderly patients with systolic chronic heart failure

BACKGROUND AND AIM: Mitral regurgitation (MR) has been demonstrated to be a powerful predictor of adverse outcome in middle-aged patients with chronic heart failure (CHF). In this study, we sought to define the prognostic impact of functional mitral regurgitation in a population of elderly patients with systolic CHF. METHODS: One hundred seventy-five outpatients aged >70 years with validated CHF and left ventricular ejection fraction <40% underwent clinical and echocardiographic evaluations at baseline. Mitral regurgitation was diagnosed by Color Doppler and quantified in 5 categorical values using a 0-4+ grading system. Outcome measures included 1-year mortality and hospitalization for worsening CHF. RESULTS: The distribution of patients according to the 5 different degrees of MR detected at baseline was: absent=11%, 1+=31%, 2+=38%, 3+=16%, 4+=4%. The relationship between MR and mortality was direct and approximately linear (r=0.39, p=0.00001). The prevalence of death in the 5 subgroups was 0%, 7%, 15%, 45%, 57%, respectively. Multivariate logistic regression analysis showed that MR was the strongest predictor of death (OR 4.47, 95% CI 1.50-13.0), independently of the presence of diabetes mellitus, older age and larger left ventricular end-diastolic volume. No association was found between MR and hospitalization for worsening CHF (r=0.08, p=0.41). CONCLUSIONS: This study establishes the direct and independent relationship between MR severity and one-year mortality among elders with systolic CHF. Conversely, MR does not provide useful information regarding the risk of subsequent hospitalization for worsening CHF.     

Anaemia is an independent predictor of poor outcome in patients with chronic heart failure

Background: Mild anaemia frequently occurs in patients with chronic heart failure (CHF), particularly in the advanced stages of the disease. The correction of anaemia with erythropoietin is a therapeutic possibility. The aim of this study was to assess prospectively the relationship between the prevalence of anaemia (haemoglobin level≤120 g/l) and prognosis in an unselected CHF population. Methods: All consecutive patients with a diagnosis of CHF admitted to our department between January 2000 and April 2000 were considered for the present study. Those with secondary causes of anaemia were excluded. Patients were followed up until November 2001 (>18 months in all survivors), and the end-point of the study was all-cause mortality. Results: A total of 176 patients were enrolled (mean age: 63 years, New York Heart Association (NYHA) classification I/II/III/IV: 15/81/51/29; left ventricular ejection fraction (LVEF): 42%, ischaemic aetiology in 62%). In the whole population the mean haemoglobin level was 140±15 g/l. Anaemia was found in 18 (10%) patients, and was significantly more common in women than in men (18 vs. 7%, respectively, P=0.02) and in those with most severe CHF symptoms (frequency in NYHA I/II/III/IV: 0/9/10/21%, respectively; NYHA IV vs. I–III, P=0.03), but not related to the other clinical indices. Univariate analysis revealed NYHA class III–IV (hazard ratio 3.8, 95% CI: 1.6–8.9, P=0.003), low LVEF <35% (hazard ratio 2.3, 95% CI: 1.0–4.9, P=0.04) and anaemia (hazard ratio 2.9, 95% CI: 1.2–7.2, P=0.02) as predictors of 18-month mortality. In multivariate analysis, anaemia remained an independent predictor of death when adjusted for NYHA class and LVEF (hazard ratio: 2.6, 95% CI: 1.0–6.5, P=0.04). In anaemic patients, 18-month survival was 67% (95% CI: 45–89%) compared to 87% (81–92%) in patients with a normal haemoglobin level (P=0.016). Conclusions: Mild anaemia is a significant and independent predictor of poor outcome in unselected patients with CHF. Correction of low haemoglobin level may become an interesting therapeutic option for CHF patients.     

心力衰竭患者的血压节律变化

目的观察心力衰竭(心衰)患者的血压节律变化。方法选择心衰患者104例(心衰组),行24 h动态血压监测。分别按基础心脏病病因和纽约心脏病协会心功能(NYHA)分级,心功能Ⅱ级34例,Ⅲ级35例,Ⅳ级35例。同期选择门诊及住院的有基础心脏病但无心衰患者82例作为对照组。观察心衰患者血压的昼夜节律变化。结果心衰组血压昼夜节律存在18例(17.3%),昼夜节律消失86例(82.7%),其中节律倒置38例(44.2%);对照组血压昼夜节律存在43例(52.4%),昼夜节律消失39例(47.6%),其中血压昼夜节律倒置10例(25.6%)。心衰组血压昼夜节律消失发生率明显高于对照组(P<0.05)。心衰组心功能Ⅱ级患者血压昼夜节律消失明显低于Ⅲ级、Ⅳ级患者(70.6%vs 85.7%vs 91.4%,P<0.05)。结论心衰患者血压昼夜节律消失明显升高,且随着心功能分级增加而增加,但与心脏病病因无关。