Is the Ability index superior to the NYHA classification for assessing heart failure?

Heart Failure Risk Predictions and Prognostic Factors in Adults With Congenital Heart Diseases

In recent decades the number of adults with congenital heart diseases (ACHD) has increased significantly. This entails the need for scrupulous evaluation of the current condition of these patients. The ACHD population is one of the most challenging in contemporary medicine, especially as well-known scales such as the NYHA classification have very limited application. At the moment, there is a lack of universal parameters or scales on the basis of which we can easily capture the moment of deterioration of our ACHD patients' condition. Hence it is crucial to identify factors that are widely available, cheap and easy to use. There are studies showing more and more potential prognostic factors that may be of use in clinical practice: thorough assessment with echocardiography and magnetic resonance imaging (e.g., anatomy, ventricular function, longitudinal strain, shunt lesions, valvular defects, pericardial effusion, and pulmonary hypertension), cardiopulmonary exercise testing (e.g., peak oxygen uptake, ventilatory efficiency, chronotropic incompetence, and saturation) and biomarkers (e.g., N-terminal pro-brain type natriuretic peptide, growth-differentiation factor 15, high-sensitivity troponin T, red cell distribution width, galectin-3, angiopoietin-2, asymmetrical dimethylarginine, and high-sensitivity C-reactive protein). Some of them are very promising, but more research is needed to create a specific panel on the basis of which we will be able to assess patients with specific congenital heart diseases.

Predicting 15-Year Mortality in Adults With Congenital Heart Disease Using Disease Severity and Functional Indices

BACKGROUND

Disease severity and functional indices are widely used for risk stratification of patients with congenital heart disease (CHD). The predictive value of these classification systems for assessing long-term mortality is unknown. We aimed to determine and compare the predictive value of disease severity and functional indices for 15-year mortality in adults with CHD.

METHODS

Between 2000 and 2002, we categorized 629 patients with CHD (median age, 24 years; 60% were men) on 5 indices: disease complexity scores based on criteria of Task Force 1 of the 32nd Bethesda Conference; Disease Severity Index; New York Heart Association functional class; Ability Index; and Congenital Heart Disease Functional Index (CHDFI). Harrell's concordance statistics index (C-index) was calculated for each classification system through Cox hazard regression analysis to evaluate their performance on predicting all-cause and cardiac mortality over the subsequent 15 years.

RESULTS

Over the 15-year follow-up period, 40 patients died, resulting in a mortality rate of 4.56 per 1000 person-years. The CHDFI showed the highest discrimination ability for all-cause mortality (C-index = 0.74; P < 0.001) and cardiac mortality (C-index = 0.76; P < 0.001). The C-index for the other classifications ranged from 0.58 to 0.71 for all-cause mortality and 0.55 to 0.67 for cardiac mortality. The CHDFI showed statistical superiority toward the Disease Severity Index (P < 0.01).

CONCLUSIONS

These results suggest that the Task Force 1 of the 32nd Bethesda Conference, New York Heart Association functional class, Ability Index, and CHDFI could aid in predicting long-term mortality. The CHDFI demonstrated the highest discrimination ability and emphasizes the importance to integrate both anatomic and physiological variables to predict long-term mortality.

Angiopoietin-2 in adults with congenital heart disease and heart failure

Background

Chronic heart failure is an important cause for morbidity and mortality in adults with congenital heart disease (ACHD). While NT-proBNP is an established biomarker for heart failure of non-congenital origin, its application in ACHD has limitations. The angiogenic factors Angiopoietin-1 and -2 (Ang-1, Ang-2), vascular endothelial growth factor (VEGF), and soluble receptor tyrosine kinase of the Tie family (sTie2) correlate with disease severity in heart failure of non-congenital origin. Their role in ACHD has not been studied.

Methods

In 91 patients Ang-2 and NT-proBNP were measured and related to New York Heart Association class, systemic ventricular function and parameters of cardiopulmonary exercise testing. Ang-1, VEGF, and sTie2 were also measured.

Results

Ang-2 correlates with NYHA class and ventricular dysfunction comparable to NT-proBNP. Further, Ang-2 showed a good correlation with parameters of cardiopulmonary exercise testing. Both, Ang-2 and NT-proBNP identified patients with severely limited cardiopulmonary exercise capacity. Additionally, Ang-2 is elevated in patients with a single ventricle physiology in contrast to NT-proBNP. VEGF, Ang-1, and sTie2 were not correlated with any clinical parameter.

Conclusion

The performance of Ang-2 as a biomarker for heart failure in ACHD is comparable to NT-proBNP. Its significant elevation in patients with single ventricle physiology indicates potential in this patient group and warrants further studies.

Commonalities and differences in correlates of depressive symptoms in men and women with heart failure

OBJECTIVE

(i) To compare the prevalence and severity of depressive symptoms between men and women enrolled in a large heart failure (HF) registry. (ii) To determine gender differences in predictors of depressive symptoms from demographic, behavioral, clinical, and psychosocial factors in HF patients.

METHODS

In 622 HF patients (70% male, 61 ± 13 years, 59% NYHA class III/IV), depressive symptoms were assessed by the Patient Health Questionnaire (PHQ-9). Potential correlates were age, ethnicity, education, marital and financial status, smoking, exercise, body mass index (BMI), HF etiology, NYHA class, comorbidities, functional capacity, anxiety, and perceived control. To identify gender-specific correlates of depressive symptoms, separate logistic regression models were built by gender.

RESULTS

Correlates of depressive symptoms in men were financial status (p = 0.027), NYHA (p = 0.001); functional capacity (p < 0.001); health perception (p = 0.043); perceived control (p = 0.002) and anxiety (p < 0.001). Correlates of depressive symptoms in women were BMI (p = 0.003); perceived control (p = 0.013) and anxiety (p < 0.001).

CONCLUSIONS

In HF patients, lowering depressive symptoms may require gender-specific interventions focusing on weight management in women and improving perceived functional capacity in men. Both men and women with HF may benefit from anxiety reduction and increased control.

Asymmetrical dimethylarginine--more sensitive than NT-proBNP to diagnose heart failure in adults with congenital heart disease

Background

Chronic heart failure is an important cause for morbidity and mortality in adults with congenital heart disease (ACHD). While NT-proBNP is an established biomarker for heart failure of non-congenital origin, its value in ACHD has limitations. Asymmetrical dimethylarginine (ADMA) correlates with disease severity and independently predicts adverse clinical events in heart failure of non-congenital origin. Its role in ACHD has not been investigated.

Methods

In 102 patients ADMA and NT-proBNP were measured and related to NYHA class, systemic ventricular function and parameters of cardiopulmonary exercise testing.

Results

In contrast to NT-proBNP ADMA differentiated between NYHA classes I-III. Both, ADMA and NT-proBNP showed a good correlation with parameters of cardiopulmonary exercise testing with comparable receiver-operating characteristic curves for identifying patients with severely limited cardiopulmonary exercise capacity.

Conclusion

ADMA seems to be a better biomarker than NT-proBNP for the assessment of NYHA class and as a good as NT-proBNP for the estimation of maximum exercise capacity in adults with congenital heart disease. Its use in clinical routine should be evaluated.

Circulating miR-423_5p fails as a biomarker for systemic ventricular function in adults after atrial repair for transposition of the great arteries

BACKGROUND

Recently, the microRNA miR-423_5p was identified as a biomarker for left ventricular heart failure. Its role in patients with a systemic right ventricle and reduced ejection fraction after atrial repair for transposition of the great arteries has not been evaluated.

METHODS

In 41 patients and 10 age- and sex-matched healthy controls circulating miR-423_5p concentration was measured and correlated to clinical parameters, cardiac functional parameters assessed by magnetic resonance imaging, and cardiopulmonary exercise testing.

RESULTS

Levels of circulating miR-423_5p showed no difference between patients and controls. Further, there was no correlation between miR-423_5p and parameters of cardiopulmonary exercise testing or imaging findings.

CONCLUSIONS

In patients with a systemic right ventricle and reduced ejection fraction miR-423_5p levels are not elevated. Therefore, circulating miR-423_5p is not a useful biomarker for heart failure in this patient group.

The initial slope of the VCO2/VO2-curve (s1) in cardiopulmonary exercise testing is a strong and independent predictor of outcome in patients with previous myocardial infarction

BACKGROUND

Detecting heart failure (HF) patients at risk is a relevant clinical problem. Our goal was to define associations of clinical HF-markers and exercise parameters with respect to their prognostic power in HF-patients.

METHODS

We performed cardiopulmonary exercise testing (CPET) in 103 ischemic HF-patients. CPET-parameters included peak VO(2), VO(2) at AT, peak oxygen pulse, minimal CO(2) and O(2) equivalents, VE/VCO(2) and s1, a motivation-independent and submaximal parameter representing the initial slope of the VCO(2)/VO(2)-curve that has not been described in HF-patients so far.

RESULTS

Median follow-up was 668 days. The combined endpoint of cardiovascular death and rehospitalization due to HF occurred in 14 patients. Patients with/without events differed significantly regarding their age, NYHA-class, LVEF and NT-proBNP serum-levels. Patients with events had significantly lower peak VO(2)- and higher s1-values. NT-proBNP serum-levels, NYHA-class and LVEF were significantly correlated with peak VO(2). Only age, peak VO(2) and s1 were independent predictors of adverse events. Using multivariate analysis, s1 was a strong and independent parameter with good sensitivity and specificity.

CONCLUSION

s1 is an independent and powerful predictor in HF-patients. Since s1 is independent of maximal exercise capacity, s1 might be more accurate for the evaluation of HF-patients not willing or unable to perform maximal exercise.

A novel stop mutation truncating critical regions of the cardiac transcription factor NKX2-5 in a large family with autosomal-dominant inherited congenital heart disease

We report on a familial screen of five female members in three generations affected by an autosomal-dominant inherited atrioventricular (AV) conduction block associated with atrial septal defects (ASD) and other congenital cardiovascular diseases (CCVD), such as pulmonary artery stenosis (PAS), patent foramen ovale (PFO) and ventricular septal defect (VSD). We tested the cardiac transcription factor NKX2-5 which is known to cause CCVD with variable phenotype and penetrance by direct sequencing of the two NKX2-5 coding exons in the index patient and identified a novel heterozygous c.325G> T mutation in exon 1 of the gene. This mutation co-segregated with the disease in the family and was present in all five affected family members, but not in 100 control chromosomes. The c.325G > T mutation is predicted to introduce a stop codon at amino-acid position 109 (p.E109X). The truncated protein lacks all of the functionally important domains of the cardiac transcription factor. Therefore, it is very likely that this novel mutation causes a complete loss of NKX2-5 function and haploinsufficiency is the pathophysiological mechanism underlying the disease in the family.