Long-term predictors of sudden and low output death in chronic congestive heart failure secondary to coronary artery disease

Post discharge management of heart failure patients: clinical findings at the first medical visit in a single-center study

BACKGROUND

The Post Discharge Management of patients with heart failure impact significantly their incomes. This study aims to analyze the clinical findings and management at the first medical visit of these patients in our context.

MATERIAL AND METHODS

This is a retrospective cross-sectional descriptive study on consecutive files of patients hospitalized for heart failure from January to December 2018 in our Department. We analyse data from the first post discharge medical visit including medical visit time, clinical conditions and management.

RESULTS

Three hundred and eight patients (mean age: 53.4 ± 17.0 years, 60% males) were hospitalized on median duration of 4 days [1-22 days]. One hundred and fifty-three patients (49,67%) were presented at the first medical visit after 66.53 days[0.06-369] on average, 10 (3.24%) patients died before this first medical visit and 145 (47.07%) had been lost to follow-up. The re-hospitalization and treatment non-compliance rates were 9.4% and 3.6%, respectively. Male gender (p = 0.048), renal failure (p = 0.010), and Vitamin K antagonist (VKA) /direct oral anticoagulant (DOAC) (p = 0.049) were the main lost to follow-up factors in univariate analysis without statistic signification in multivariate analysis. Hyponatremia (OR = 2.339; CI 95% = 0.908-6.027; p = 0.020) and atrial fibrillation (OR = 2.673; CI 95% = 1.321-5.408; p = 0.012) were the major mortality factors.

CONCLUSION

The management of patients with heart failure after discharge from hospital seems to be insufficient and inadequate. A specialized unit is required to optimize this management.

Right ventricular function and long-term clinical outcomes after cardiac resynchronization therapy: A cardiovascular magnetic resonance study

BACKGROUND

Right ventricular (RV) dysfunction has been linked to a poor response to cardiac resynchronization therapy (CRT). We sought to determine whether cardiovascular magnetic resonance (CMR)-derived measures of RV function influence clinical outcomes after CRT.

METHODS

In this retrospective study, we used cardiovascular magnetic resonance (CMR) to assess pre-implant RV volumes and RV ejection fraction (RVEF) in relation to clinical outcomes after CRT implantation.

RESULTS

Among 243 patients (age: 70.3 ± 10.8 years [mean ±. SD]; 68.7% male; 121 [49.8%]) with ischemic cardiomyopathy and 122 (50.2%) with non-ischemic cardiomyopathy, 141 (58%) after CRT-defibrillation and 102 (42%) after CRT-pacing, 101 (41.6.0%) patients died, 61 (25.1%) from cardiac causes and 24 (9.88%) from non-cardiac causes, over 5.87 years (median; interquartile range: 4.35-7.73). Two (0.82%) patients underwent cardiac transplantation and 4 (1.64%) had a left ventricular assist device. A total of 41 (16.9%) met the composite endpoint of sudden cardiac death, ventricular tachycardia or ventricular fibrillation. In univariate analyses, no measure of RV function was associated with total mortality or the arrhythmic endpoint. RVEF was associated with cardiac mortality on univariate analyses (HR per 10%: 0.82, 95% CI 0.70-0.96), but not on multivariate analyses that included left ventricular ejection fraction.

CONCLUSIONS

There is no relationship between measures of RV function, such as RV volumes and RVEF, and the long-term clinical outcome of CRT. These findings indicate that such measures should not be considered in patient selection. This article is protected by copyright. All rights reserved.

Changes in QRS Area and QRS Duration After Cardiac Resynchronization Therapy Predict Cardiac Mortality, Heart Failure Hospitalizations, and Ventricular Arrhythmias

Background

Predicting clinical outcomes after cardiac resynchronization therapy (CRT) and its optimization remain a challenge. We sought to determine whether pre‐ and postimplantation QRS area (QRS_area) predict clinical outcomes after CRT.

Methods and Results

In this retrospective study, QRS_area, derived from pre‐ and postimplantation vectorcardiography, were assessed in relation to the primary end point of cardiac mortality after CRT with or without defibrillation. Other end points included total mortality, total mortality or heart failure (HF) hospitalization, total mortality or major adverse cardiac events, and the arrhythmic end point of sudden cardiac death or ventricular arrhythmias with or without a shock. In patients (n=380, age 72.0±12.4 years, 68.7% male) undergoing CRT over 7.7 years (median follow‐up: 3.8 years [interquartile range 2.3–5.3]), preimplantation QRS_area ≥102 μVs predicted cardiac mortality (HR: 0.36; P<0.001), independent of QRS duration (QRSd) and morphology (P<0.001). A QRS_area reduction ≥45 μVs after CRT predicted cardiac mortality (HR: 0.19), total mortality (HR: 0.50), total mortality or heart failure hospitalization (HR: 0.44), total mortality or major adverse cardiac events (HR: 0.43) (all P<0.001) and the arrhythmic end point (HR: 0.26; P<0.001). A concomitant reduction in QRS_area and QRSd was associated with the lowest risk of cardiac mortality and the arrhythmic end point (both HR: 0.12, P<0.001).

Conclusions

Pre‐implantation QRS_area, derived from vectorcardiography, was superior to QRSd and QRS morphology in predicting cardiac mortality after CRT. A postimplant reduction in both QRS_area and QRSd was associated with the best outcomes, including the arrhythmic end point.

Long-term clinical outcomes of cardiac resynchronization therapy with or without defibrillation: impact of the aetiology of cardiomyopathy

Aims

There is a continuing debate as to whether cardiac resynchronization therapy-defibrillation (CRT-D) is superior to CRT-pacing (CRT-P), particularly in patients with non-ischaemic cardiomyopathy (NICM). We sought to quantify the clinical outcomes after primary prevention of CRT-D and CRT-P and identify whether these differed according to the aetiology of cardiomyopathy.

Methods and results

Analyses were undertaken in the total study population of patients treated with CRT-D (n = 551) or CRT-P (n = 999) and in propensity-matched samples. Device choice was governed by the clinical guidelines in the United Kingdom. In univariable analyses of the total study population, for a maximum follow-up of 16 years (median 4.7 years, interquartile range 2.4–7.1), CRT-D was associated with a lower total mortality [hazard ratio (HR) 0.72] and the composite endpoints of total mortality or heart failure (HF) hospitalization (HR 0.72) and total mortality or hospitalization for major adverse cardiac events (MACE; HR 0.71) (all P < 0.001). After propensity matching (n = 796), CRT-D was associated with a lower total mortality (HR 0.72) and the composite endpoints (all P < 0.01). When further stratified according to aetiology, CRT-D was associated with a lower total mortality (HR 0.62), total mortality or HF hospitalization (HR 0.63), and total mortality or hospitalization for MACE (HR 0.59) (all P < 0.001) in patients with ischaemic cardiomyopathy (ICM). There were no differences in outcomes between CRT-D and CRT-P in patients with NICM.

Conclusion

In this study of real-world clinical practice, CRT-D was superior to CRT-P with respect to total mortality and composite endpoints, independent of known confounders. The benefit of CRT-D was evident in ICM but not in NICM.

Long-Term Outcomes of Cardiac Resynchronization Therapy Using Apical Versus Nonapical Left Ventricular Pacing

Background Experimental evidence indicates that left ventricular ( LV ) apical pacing is hemodynamically superior to nonapical LV pacing. Some studies have shown that an LV apical lead position is unfavorable in cardiac resynchronization therapy. We sought to determine whether an apical LV lead position influences cardiac mortality after cardiac resynchronization therapy. Methods and Results In this retrospective observational study, the primary end point of cardiac mortality was assessed in relation to longitudinal (basal, midventricular, or apical) and circumferential (anterior, lateral, or posterior) LV lead positions, as well as right ventricular (apical or septal), assigned using fluoroscopy. Lead positions were assessed in 1189 patients undergoing cardiac resynchronization therapy implantation over 15 years. After a median follow-up of 6.0 years (interquartile range: 4.4-7.7 years), an apical LV lead position was associated with lower cardiac mortality than a nonapical position (adjusted hazard ratio: 0.74; 95% confidence interval, 0.56-0.99) after covariate adjustment. There were no differences in total mortality or heart failure hospitalization. Death from pump failure was lower with apical than nonapical positions (adjusted hazard ratio: 0.69; 95% confidence interval, 0.51-0.94). Compared with a basal position, an apical LV position was also associated with lower risk of sudden cardiac death (adjusted hazard ratio: 0.34; 95% confidence interval, 0.13-0.93). No differences emerged between circumferential LV lead positions or right ventricular positions with respect to any end point. Conclusions In recipients of cardiac resynchronization therapy, an apical LV lead position was associated with better long-term cardiac survival than a nonapical position. This effect was due to a lower risk of pump failure and sudden cardiac death.

Cardiac Resynchronization Therapy Using Quadripolar Versus Non-Quadripolar Left Ventricular Leads Programmed to Biventricular Pacing With Single-Site Left Ventricular Pacing: Impact on Survival and Heart Failure Hospitalization

Background

In cardiac resynchronization therapy (CRT), quadripolar (QUAD) left ventricular (LV) leads are less prone to postoperative complications than non‐QUAD leads. Some studies have suggested better clinical outcomes.

Methods and Results

Clinical events were assessed in 847 patients after CRT‐pacing or CRT‐defibrillation using either QUAD (n=287) or non‐QUAD (n=560), programmed to single‐site site LV pacing. Over a follow‐up period of 3.2 years (median [interquartile range, 1.90–5.0]), QUAD was associated with a lower total mortality (adjusted hazard ratio [aHR]: 0.32, 95% confidence interval [CI], 0.20–0.52), cardiac mortality (aHR: 0.36, 95% CI, 0.20–0.65), and heart failure (HF) hospitalization (aHR: 0.62, 95% CI, 0.39–0.99), after adjustment for age, sex, New York Heart Association class, HF etiology, device type (CRT‐pacing or CRT‐defibrillation), comorbidities, atrial rhythm, medication, left ventricular ejection fraction, and creatinine. Death from pump failure was lower with QUAD (aHR: 0.33; 95% CI, 0.18–0.62), but no group differences emerged with respect to sudden cardiac death. There were no differences in implant‐related complications. Re‐interventions for LV displacement or phrenic nerve stimulation, which were lower with QUAD, predicted total mortality (aHR: 1.68, 95% CI, 1.11–2.54), cardiac mortality (aHR: 2.61, 95% CI, 1.66–4.11) and HF hospitalization (aHR: 2.09, 95% CI, 1.22–3.58).

Conclusions

CRT using QUAD, programmed to biventricular pacing with single‐site LV pacing, is associated with a lower total mortality, cardiac mortality, and HF hospitalization. These trends were observed for both CRT‐defibrillation and CRT‐pacing, after adjustment for HF cause and other confounders. Re‐intervention for LV lead displacement or phrenic nerve stimulation was associated with worse outcomes.

BNP and ANP as diagnostic and predictive markers in heart failure with left ventricular systolic dysfunction

Background

The prevalence of chronic heart failure (CHF) with systolic dysfunction is increasing. Plasma natriuretic peptides have been envisaged as diagnostic and predictive markers.

Aims

To investigate the relationship between the levels of B-type natriuretic peptide (BNP) and A-type natriuretic peptide (ANP) and the clinical and functional parameters of CHF in outpatients with CHF at baseline, compared with normal healthy controls; to find out the differences in a randomised controlled trial between patients treated with an angiotensin-converting enzyme (ACE) inhibitor, captopril, or an angiotensin receptor blocker (ARB), irbesartan. These differences were assessed throughout the six-month treatment period and at the sixth month.

Methods Plasma BNP (pmol/L) and ANP (pmol/L) were

determined in 68 hypertensive patients with dilated cardiomyopathy, NYHA class III-IV and ejection fraction (EF) <40%, and in 26 normal controls. Statistical analysis for BNP and ANP was done by Student's t-test. The patient group was randomly subdivided into two subgroups of 34 patients, each treated with either an ARB, irbesartan, or an ACE inhibitor (ACE-I), captopril. BNP and ANP were measured in both subsamples and correlated with clinical, functional and neurohormonal parameters throughout a follow-up period of six months and at the sixth month.

Results

The mean EF in the patient sample was 33.43±6.52% and in the controls was 61.96 ±3.53% (p=0.000). The mean BNP (pmol/L) in patients was 44.78±54.36 and in the controls was 7.12±8.28 (p=0.000) and the mean ANP (pmol/L) was 30.32±25.97 in patients and 11.18±7.92 in controls (p=0.000). A statistically significant difference was found between patients and healthy controls. Significant correlations were found between natriuretic peptides and EF. Between the baseline phase and the sixth month, BNP and ANP decreased significantly in the ARB group. At the sixth month, both BNP and ANP were lower in the ARB group. Evidence of clinical benefit was found with both ARB or ACE-I treatment throughout the six months, with patients moving from classes III and IV to class II NYHA. Improvement of EF was also found, with transition of patients with lower EF (even <30%) to higher values. EF was higher in the ARB group at the sixth month.

Conclusions

BNP and ANP can be useful diagnostic tools in hypertensive CHF patients with moderate-to-severe LV dysfunction. The decrease in BNP and ANP in the ARB group throughout six months, as well as the lower value at the sixth month, suggest a prognostic value of these parameters.

Absolute survival after cardiac resynchronization therapy according to baseline QRS duration: a multinational 10-year experience: data from the Multicenter International CRT Study

BACKGROUND

In the major trials of cardiac resynchronization therapy (CRT), the survival benefit of the therapy, relative to control subjects, increases with QRS duration. In the non-CRT heart failure population, however, a wide QRS duration is associated with a shorter survival. Relative survival benefit from a therapy, however, is not synonymous with a longer absolute survival. We sought to determine whether baseline QRS duration relates to the absolute survival after CRT.

METHODS AND RESULTS

In this prospective, longitudinal, observational study, 3,319 consecutive patients undergoing CRT (QRS 120-149 ms 26%, QRS 150-199 ms 58%, and QRS ≥200 ms 16%) were assessed in relation to mortality over 10 years. Overall mortality rates (per 100 patient-years) were 9.2%, 9.3%, and 13.3% in the 3 groups, respectively (all P < .001). Cardiac mortality rates were 6.2, 6.0, and 9.9 per 100 patient-years, respectively (all P < .001). Compared with the QRS 120-149 ms group, cardiac mortality was highest in the QRS ≥200 ms group (hazard ratio [HR] 1.72 [95% CI 1.35-2.19], P < .001), independent of age, gender, New York Heart Association class, presence of atrial fibrillation, heart failure etiology, and left ventricular ejection fraction. Median survival after CRT was longest in patients with a width of QRS 120-149 ms and shortest in patients with a QRS ≥200 ms (P < .001). In multivariable analyses, a QRS ≥200 ms emerged as a powerful independent predictor of both overall (HR 1.44 [95% CI 1.07-1.94], P = .017) and cardiac mortality (HR 1.59 [95% CI 1.14-2.24], P = .007).

CONCLUSIONS

At long-term follow-up, absolute overall and cardiac survival after CRT is similar in patients with a preimplant QRS duration of 120 to 149 ms and 150 to 199 ms but markedly shorter in patients with a QRS ≥200 ms.

Left ventricular midwall fibrosis as a predictor of mortality and morbidity after cardiac resynchronization therapy in patients with nonischemic cardiomyopathy

OBJECTIVES

The aim of this study was to determine whether left ventricular (LV) midwall fibrosis, detected by midwall hyperenhancement (MWHE) on late gadolinium enhancement cardiovascular magnetic resonance (CMR) imaging, predicts mortality and morbidity in patients with dilated cardiomyopathy (DCM) undergoing cardiac resynchronization therapy (CRT).

BACKGROUND

Midwall fibrosis predicts mortality and morbidity in patients with DCM.

METHODS

Patients with DCM with (+) or without (-) MWHE (n = 20 and n = 77, respectively) as well as 161 patients with ischemic cardiomyopathy (ICM) undergoing CRT (n = 258) were followed up for a maximum of 8.7 years.

RESULTS

Among patients with DCM, +MWHE predicted cardiovascular mortality (hazard ratio [HR]: 18.6; 95% confidence intervals [CI]: 3.51 to 98.5; p = 0.0008), total mortality or hospitalization for major adverse cardiovascular events (HR: 7.57; 95% CI: 2.71 to 21.2; p < 0.0001), and cardiovascular mortality or heart failure hospitalizations (HR: 9.56; 95% CI: 2.72 to 33.6; p = 0.0004), independent of New York Heart Association class, QRS duration, atrial fibrillation, LV volumes, LV ejection fraction, and a CMR-derived measure of dyssynchrony. Among patients with DCM and ICM, the risk of cardiovascular mortality for DCM +MWHE (adjusted HR: 18.5; 95% CI: 3.93 to 87.3; p = 0.0002) was similar to that for ICM (adjusted HR: 21.0; 95% CI: 5.06 to 87.2; p < 0.0001). Both DCM +MWHE and ICM were predictors of pump failure death as well as sudden cardiac death. LV reverse remodeling was observed in DCM -MWHE and in ICM but not in DCM +MWHE.

CONCLUSIONS

Midwall fibrosis is an independent predictor of mortality and morbidity in patients with DCM undergoing CRT. The outcome of DCM with midwall fibrosis is similar to that of ICM. This relationship is mediated by both pump failure and sudden cardiac death.

Renin as a biomarker of cardiovascular disease in clinical practice

The search for novel circulating blood biomarkers as predictors of cardiovascular (CV) risk and prognosis is a continuing field of interest in clinical medicine. Biomarkers from several pathophysiological pathways, including markers of organ damage, of inflammation, of the atherosclerotic process and of the coagulation pathway, have been investigated in the last decades. A particular interest has been raised for neurohormonal factors. The role of the activation of the sympathetic system and the renin-angiotensin-aldosterone system (RAAS) in the development of CV diseases has been extensively explored. Renin is the first limiting step of the RAAS and its role as a biomarker to improve CV risk stratification still remains a topic of debate. Several studies have shown that elevated plasma renin activity is associated with increased morbidity and mortality in patients with CV disease. The aim of this paper is to critically evaluate the evidence on the role of renin as a biomarker of CV risk and prognosis. With the new advances of pharmacological treatment acting on the RAAS, the effect of elevated levels of renin on the prognosis of these patients becomes even more intriguing.

Measuring and targeting aldosterone and renin in atherosclerosis-a review of clinical data

Our understanding of the development and progression of atherosclerosis has increased substantially over the past decades. A significant role for the renin-angiotensin-aldosterone system (RAAS) in this process has gained appreciation in recent years. Preclinical and clinical studies have associated components of the RAAS with various cardiovascular disease conditions. Classically known for its contribution to hypertension, dysregulation of the system is now also believed to promote vascular inflammation, fibrosis, remodeling, and endothelial dysfunction, all intimately related to atherosclerosis. The reduction in cardiovascular mortality and morbidity, as seen with the use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, supports the concept that RAAS is involved in the pathogenesis of atherosclerotic disease. However, the underlying molecular mechanisms of the pathophysiology remain to be completely understood. Evidence points toward additional benefit from therapeutic approaches aiming at more complete inhibition of the system and the possible utility of renin or aldosterone in the prediction of cardiovascular outcome. This review will summarize the current knowledge from clinical studies regarding the presumptive role of renin and aldosterone in the prediction and management of patients with atherosclerosis. For this purpose, a literature search was performed, focusing on available clinical data regarding renin or aldosterone and cardiovascular outcome.

Cardiac resynchronization therapy guided by late gadolinium-enhancement cardiovascular magnetic resonance

BACKGROUND

Myocardial scarring at the LV pacing site leads to incomplete resynchronization and a suboptimal symptomatic response to CRT. We sought to determine whether the use of late gadolinium cardiovascular magnetic resonance (LGE-CMR) to guide left ventricular (LV) lead deployment influences the long-term outcome of cardiac resynchronization therapy (CRT).

METHODS

559 patients with heart failure (age 70.4 ± 10.7 yrs [mean ± SD]) due to ischemic or non-ischemic cardiomyopathy underwent CRT. Implantations were either guided (+CMR) or not guided (-CMR) by LGE-CMR prior to implantation. Fluoroscopy and LGE-CMR were used to localize the LV lead tip and and myocardial scarring retrospectively. Clinical events were assessed in three groups: +CMR and pacing scar (+CMR+S); CMR and not pacing scar (+CMR-S), and; LV pacing not guided by CMR (-CMR).

RESULTS

Over a maximum follow-up of 9.1 yrs, +CMR+S had the highest risk of cardiovascular death (HR: 6.34), cardiovascular death or hospitalizations for heart failure (HR: 5.57) and death from any cause or hospitalizations for major adverse cardiovascular events (HR: 4.74) (all P < 0.0001), compared with +CMR-S. An intermediate risk of meeting these endpoints was observed for -CMR, with HRs of 1.51 (P = 0.0726), 1.61 (P = 0.0169) and 1.87 (p = 0.0005), respectively. The +CMR+S group had the highest risk of death from pump failure (HR: 5.40, p < 0.0001) and sudden cardiac death (HR: 4.40, p = 0.0218), in relation to the +CMR-S group.

CONCLUSIONS

Compared with a conventional implantation approach, the use of LGE-CMR to guide LV lead deployment away from scarred myocardium results in a better clinical outcome after CRT. Pacing scarred myocardium was associated with the worst outcome, in terms of both pump failure and sudden cardiac death.

Cardiac resynchronization therapy guided by late gadolinium-enhancement cardiovascular magnetic resonance

BACKGROUND

Myocardial scarring at the LV pacing site leads to incomplete resynchronization and a suboptimal symptomatic response to CRT. We sought to determine whether the use of late gadolinium cardiovascular magnetic resonance (LGE-CMR) to guide left ventricular (LV) lead deployment influences the long-term outcome of cardiac resynchronization therapy (CRT).

METHODS

559 patients with heart failure (age 70.4 ± 10.7 yrs [mean ± SD]) due to ischemic or non-ischemic cardiomyopathy underwent CRT. Implantations were either guided (+CMR) or not guided (-CMR) by LGE-CMR prior to implantation. Fluoroscopy and LGE-CMR were used to localize the LV lead tip and and myocardial scarring retrospectively. Clinical events were assessed in three groups: +CMR and pacing scar (+CMR+S); CMR and not pacing scar (+CMR-S), and; LV pacing not guided by CMR (-CMR).

RESULTS

Over a maximum follow-up of 9.1 yrs, +CMR+S had the highest risk of cardiovascular death (HR: 6.34), cardiovascular death or hospitalizations for heart failure (HR: 5.57) and death from any cause or hospitalizations for major adverse cardiovascular events (HR: 4.74) (all P < 0.0001), compared with +CMR-S. An intermediate risk of meeting these endpoints was observed for -CMR, with HRs of 1.51 (P = 0.0726), 1.61 (P = 0.0169) and 1.87 (p = 0.0005), respectively. The +CMR+S group had the highest risk of death from pump failure (HR: 5.40, p < 0.0001) and sudden cardiac death (HR: 4.40, p = 0.0218), in relation to the +CMR-S group.

CONCLUSIONS

Compared with a conventional implantation approach, the use of LGE-CMR to guide LV lead deployment away from scarred myocardium results in a better clinical outcome after CRT. Pacing scarred myocardium was associated with the worst outcome, in terms of both pump failure and sudden cardiac death.

Atrial fibrillation and the risk of death in patients with heart failure: a literature-based meta-analysis

BACKGROUND

Heart failure (HF) and atrial fibrillation (AF) are common, associated with significant morbidity and mortality, and frequently coexist. It is uncertain from published data if the presence of AF in patients with HF is associated with an incremental adverse outcome. The aim of this study was to combine the results of all studies investigating prognosis for patients with HF and AF compared with those in sinus rhythm (SR) to asses the mortality risk associated with this arrhythmia.

METHODS

Electronic databases were searched (Biological Abstracts, Current Contents, EMBASE, Medline, Medline In-progress, PubMed and Scopus), to 31 December 2006, using the key words congestive heart failure, heart failure, ventricular dysfunction, atrial fibrillation, atrial flutter, sinus rhythm, prognosis, outcome, death and hospitalization. Bibliographies of retrieved publications were hand searched. Studies were eligible if they included a HF population and if outcomes were reported by cardiac rhythm (AF or SR). Studies were reviewed by predetermined protocol (including quality assessment). Data were pooled using a random effects model.

RESULTS

Twenty studies were included (from 3380 initially identified) representing 32946 patients (10819 deaths). Nine randomized controlled trials (RCT) were included. The prevalence of AF was 15%, crude mortality rates were 46% (AF) and 33% (SR). The odds ratio for death was 1.33 (95% confidence interval (CI) 1.12-1.59) for AF compared with SR. Eleven observational studies were included. The prevalence of AF was 23%, crude mortality rates were 38% (AF) and 25% (SR). The odds ratio for death was 1.57 (95% CI 1.20-2.05) for AF compared with SR.

CONCLUSION

This meta-analysis demonstrates that AF is associated with worse outcomes for patients with HF compared with those with SR. Further research is required to determine whether the adverse outcome associated with AF is related to the arrhythmia itself, or to variables, such as HF severity, patient age and comorbidity.

Nocturnal oxygen therapy prevents progress of congestive heart failure with central sleep apnea

BACKGROUND

Sleep disordered breathing has been reported to be associated with congestive heart failure (CHF). Nocturnal oxygen has been shown to abolish apnea. The aim of this study is to examine whether nocturnal oxygen reduces sympathetic nerve activity, and prevents progress of CHF.

METHODS

93 patients with left ventricular ejection fractions < 60%, were examined with overnight saturation monitoring for an oxygen desaturation index. Subjects with oxygen desaturation of 4% > or = 4/h were examined with polysomnography. Apnea-hypopnea index (AHI) was calculated as the total number of episodes of apnea and hypopnea per hour of sleep. We started nocturnal oxygen for the patients with AHI > or = 20. Urinary and plasma catecholamines concentrations, serum brain natriuretic peptide, human atrial natriuretic peptide, and endothelial nitric oxide synthase levels were measured before and after starting oxygen.

RESULTS

Compared among the three groups, CHF with central sleep apnea (CHF-CSA) group had significantly higher 24-h urinary adrenaline (CHF-CSA: 4.411+/-2.940 micromol/day, CHF with obstructive sleep apnea (CHF-OSA): 2.686+/-1.084 micromol/day, CHF without apnea (CHF-N): 3.178+/-1.778 micromol/day, P<0.05). Oxygen therapy significantly decreased AHI and 4 serum BNP levels (from 91.75+/-80.35 pg/ml to 52.75+/-45.70 pg/ml, mean change=33.85 pg/ml, P=0.0208). Serum eNOS levels were lower in CHF-CSA group and CHF-OSA group than in CHF-N group (CHF-CSA: 15.89+/-10.75 pg/ml, CHF-OSA: 7.46+/-3.91 pg/ml, CHF-N: 27.33+/-14.83 pg/ml, P<0.05).

CONCLUSIONS

Nocturnal oxygen may prevent progress of CHF with central sleep apnea.

Comparison of Active Renin Concentration and Plasma Renin Activity as a Prognostic Predictor in Patients With Heart Failure

BACKGROUND

Plasma renin activity (PRA) may be limited to angiotensinogen levels, which decrease in patients with heart failure (HF) because of liver congestion.

METHODS AND RESULTS

To evaluate whether the plasma active renin concentration (ARC) is a more useful prognostic predictor than PRA, the plasma levels of ARC, PRA, angiotensin II, aldosterone, brain natriuretic peptide (BNP), norepinephrine, and hemodynamic parameters were measured in 214 consecutive HF patients who were already taking angiotensin-converting enzyme inhibitors (ACEI) or angiotensin-receptor blockers (ARB). Median follow-up period was 1,197 days. Of the clinical variables, including pulmonary capillary wedge pressure, right atrial pressure, left ventricular ejection fraction, and neurohumoral factors, only high plasma levels of log ARC (p<0.0001) and log BNP (p=0.0009), but not log PRA, were significant independent prognostic predictors. Log ARC/PRA ratio was significantly higher in nonsurvivors than in survivors. Log ARC/PRA significantly correlated with pulmonary capillary wedge pressure (r=0.305, p<0.0001), right atrial pressure (r=0.222, p=0.0011), and log BNP (r=0.242, p=0.0004).

CONCLUSIONS

Plasma ARC is superior to PRA and a high plasma ARC is an independent prognostic predictor in HF patients who are already receiving ACEI or ARB.

Plasma catecholamines: follow-up on 10-year study in health and cardiovascular disease

The predictive value of blood pressure (BP), heart rate (HR), and catecholamines in terms of any subsequent development of cardiovascular disease was investigated. Systolic (S) and diastolic (D) BP, HR, epinephrine (E) and norepinephrine (NE) were measured three times a year in 1980, 1984, and 1989 on 20 clinically healthy subjects, 18 patients with 'essential hypertension', and 22 patients with angina pectoris. Of the 22 patients in the latter group, 15 died during a 2-year follow-up (1990-1991). Each individual data series was analyzed by single cosinor to assess the circannual variation. Results were summarized by population-mean cosinor for each group. Parameter tests were used to compare the circannual rhythm characteristics among the different patient groups. A circannual rhythm was invariably demonstrated on a group basis (P < 0.05). Differences in MESOR and/or circannual amplitude were found among the different groups. In particular, patients with angina pectoris who will die within the 2-year follow-up differ in terms of their E and NE from all other patient groups, a difference already detected at the beginning of the study, more than 10 years before they die. A similar separation is not achieved in terms of BP or HR.

Effect of baseline or changes in adrenergic activity on clinical outcomes in the beta-blocker evaluation of survival trial

BACKGROUND

Adrenergic activation is thought to be an important determinant of outcome in subjects with chronic heart failure (CHF), but baseline or serial changes in adrenergic activity have not been previously investigated in a large patient sample treated with a powerful antiadrenergic agent.

METHODS AND RESULTS

Systemic venous norepinephrine was measured at baseline, 3 months, and 12 months in the beta-Blocker Evaluation of Survival Trial (BEST), which compared placebo treatment with the beta-blocker/sympatholytic agent bucindolol. Baseline norepinephrine level was associated with a progressive increase in rates of death or death plus CHF hospitalization that was independent of treatment group. On multivariate analysis, baseline norepinephrine was also a highly significant (P<0.001) independent predictor of death. In contrast, the relation of the change in norepinephrine at 3 months to subsequent clinical outcomes was complex and treatment group-dependent. In the placebo-treated group but not in the bucindolol-treated group, marked norepinephrine increase at 3 months was associated with increased subsequent risks of death or death plus CHF hospitalization. In the bucindolol-treated group but not in the placebo-treated group, the 1st quartile of marked norepinephrine reduction was associated with an increased mortality risk. A likelihood-based method indicated that 18% of the bucindolol group but only 1% of the placebo group were at an increased risk for death related to marked reduction in norepinephrine at 3 months.

CONCLUSIONS

In BEST, a subset of patients treated with bucindolol had an increased risk of death as the result of sympatholysis, which compromised the efficacy of this third-generation beta-blocker.

Prognostic importance of the oxidized product of catecholamines, adrenolutin, in patients with severe heart failure

OBJECTIVES

The purpose of this study was to assess whether adrenolutin, the inert product of the highly reactive molecules aminochromes, is increased in severe chronic heart failure and whether it is associated with a poor prognosis.

BACKGROUND

Experimental evidence suggests that oxidative products of catecholamines, aminochromes, are more cardiotoxic than unoxidized catecholamines and may be increased in heart failure.

METHODS

Adrenolutin was measured at baseline and at 1 and 3 months in 263 patients with chronic New York Heart Association class III or IV heart failure and a left ventricular ejection fraction of 22% +/- 7%. Adrenolutin levels were compared with normal levels, and their relation to prognosis was evaluated.

RESULTS

Baseline adrenolutin was increased (55 +/- 90 pg/mL vs 8.4 +/- 9.1 pg/mL for control, P <.02) and remained increased at 1 month (49 +/- 65 pg/mL). During a mean follow-up of 309 +/- 148 days (22-609 days), 57 patients died. Baseline adrenolutin levels correlated with mortality rates by univariate and multivariate analyses (relative risk 1.06, 95% CI 1.01-1.10 for each 17.9-pg/mL rise, P =.032). Left ventricular ejection fraction (P =.013) and New York Heart Association class (P =.009) were the only other variables associated with survival. Age, sex, plasma creatinine, plasma N-terminal atrial natriuretic peptide, and plasma norepinephrine levels were not retained in our model. Adrenolutin levels 1 month after random assignment were not significantly correlated with total mortality rate (P =.061) but were correlated with mortality rate from low output (relative risk 1.14, 95% CI 1.06-1.22, P =.002).

CONCLUSIONS

Plasma adrenolutin is increased in patients with heart failure and correlates with a poor prognosis independent of other important predictors of survival. This finding has potentially important pathophysiologic, prognostic, and therapeutic implications.

Serum to urinary sodium concentration ratio is an estimate of plasma renin activity in congestive heart failure

We investigated the relationship between plasma renin activity (PRA) and serum ([sNa(+)]) and urinary ([uNa(+)]) sodium concentrations in 124 congestive heart failure (CHF) patients (II-IV NYHA class) and 20 healthy subjects. According to PRA (> or <3 ng ml(-1) h(-1)) and [sNa(+)] (> or <135 mEq l(-1)), patients were classified as Group A (normal PRA and normal [sNa(+)], n=39), Group B (increased PRA and normal [sNa(+)], n=62) and Group C (low [sNa(+)], n=23). Measurements were performed at rest and, in 26 cases, after extracorporeal ultrafiltration (UF). At rest, [sNa(+)] and [uNa(+)], and their difference ([sNa(+)]-[uNa(+)]), were linearly correlated with PRA, but the values did not allow differentiation of control subjects from patients or differentiation of patients with from those without renin-angiotensin system (RAS) activation. Conversely, the [sNa(+)]/[uNa(+)] ratio showed the best correlation with PRA (r=0.79, P<0.0001). UF-induced PRA changes were linearly correlated with [sNa(+)]/[uNa(+)] ratio changes (r=0.67, P=0.002), but not with those of [sNa(+)], [uNa(+)] and [sNa(+)]-[uNa(+)]. In CHF, the [sNa(+)]/[uNa(+)] ratio best correlates with PRA and reflects the basal activity as well as the rapid changes (as those induced by UF) of the RAS. Therefore, it can be considered a strong and easily available marker of PRA.

B-type natriuretic peptide predicts sudden death in patients with chronic heart failure

BACKGROUND

Given the high incidence of sudden death in patients with chronic heart failure (CHF) and the efficacy of implantable cardioverter-defibrillators, an appropriate tool for the prediction of sudden death is desirable. B-type natriuretic peptide (BNP) has prognostic significance in CHF, and the stimuli for its production cause electrophysiological abnormalities. This study tests BNP levels as a predictor of sudden death.

METHODS AND RESULTS

BNP levels, in addition to other neurohormonal, clinical, and hemodynamic variables, were obtained from 452 patients with a left ventricular ejection fraction (LVEF) < or =35%. For prediction of sudden death, only survivors without heart transplantation (HTx) or a mechanical assist device and patients who died suddenly were analyzed. Up to 3 years, 293 patients survived without HTx or a mechanical assist device, 89 patients died, and 65 patients underwent HTx. Mode of death was sudden in 44 patients (49%), whereas 31 patients (35%) had pump failure and 14 patients (16%) died from other causes. Univariate risk factors of sudden death were log BNP (P=0.0006), log N-terminal atrial natriuretic peptide (P=0.003), LVEF (P=0.005), log N-terminal BNP (P=0.006), systolic blood pressure (P=0.01), big endothelin (P=0.03), and NYHA class (P=0.04). In the multivariate model, log BNP level was the only independent predictor of sudden death (P=0.0006). Using a cutoff point of log BNP <2.11 (130 pg/mL), Kaplan-Meier sudden death-free survival rates were significantly higher in patients below (99%) compared with patients above (81%) this cutoff point (P=0.0001).

CONCLUSION

BNP levels are a strong, independent predictor of sudden death in patients with CHF.

Risk stratification in middle-aged patients with congestive heart failure: prospective comparison of the Heart Failure Survival Score (HFSS) and a simplified two-variable model

AIMS

The performance of a US-American scoring system (Heart Failure Survival Score, HFSS) was prospectively evaluated in a sample of ambulatory patients with congestive heart failure (CHF). Additionally, it was investigated whether the HFSS might be simplified by assessment of the distance ambulated during a 6-min walk test (6'WT) instead of determination of peak oxygen uptake (peak VO(2)).

METHODS AND RESULTS

In 208 middle-aged CHF patients (age 54+/-10 years, 82% male, NYHA class 2.3+/-0.7; follow-up 28+/-14 months) the seven variables of the HFSS: CHF aetiology; heart rate; mean arterial pressure; serum sodium concentration; intraventricular conduction time; left ventricular ejection fraction (LVEF); and peak VO(2), were determined. Additionally, a 6'WT was performed. The HFSS allowed discrimination between patients at low, medium and high risk, with mortality rates of 16, 39 and 50%, respectively. However, the prognostic power of the HFSS was not superior to a two-variable model consisting only of LVEF and peak VO(2). The areas under the receiver operating curves (AUC) for prediction of 1-year survival were even higher for the two-variable model (0.84 vs. 0.74, P<0.05). Replacing peak VO(2) with 6'WT resulted in a similar AUC (0.83).

CONCLUSION

The HFSS continued to predict survival when applied to this patient sample. However, the HFSS was inferior to a two-variable model containing only LVEF and either peak VO(2) or 6'WT. As the 6'WT requires no sophisticated equipment, a simplified two-variable model containing only LVEF and 6'WT may be more widely applicable, and is therefore recommended.

Cardiac and renal dysfunction in chronic heart failure: relation to neurohumoral activation and prognosis

BACKGROUND

In chronic heart failure (CHF), cardiac dysfunction is considered the major determinant of neurohumoral activation but the role of renal impairment has not been defined. We investigated the relationship between both cardiac and renal dysfunction and neurohumoral activation, and their possible influence on prognosis.

METHODS

Hemodynamics, renal function, plasma neurohormones, and long-term follow-up were evaluated in 148 CHF patients, grouped according to systolic volume index (SVI) and serum creatinine (CRE) values: SVI > 28 mL/m2 and CRE < 1.5 mg/dL (group I, n = 55), SVI < 28 mL/m2 and CRE < 1.5 mg/dL (group II, n = 37), SVI > 28 mL/m2 and CRE > 1.5 mg/dL (group III, n = 25), SVI < 28 mL/m2 and CRE > 1.5 mg/dL (group IV, n = 31).

RESULTS

Neurohormones progressively increased from Group I through IV and correlated with both cardiac and renal function. The hemodynamic pattern was similar in patients with normal or abnormal renal function, whereas neurohormones were only moderately increased in the former group and markedly increased in the latter group. Long-term survival progressively decreased from Group I through IV and was significantly poorer in patients with renal dysfunction.

CONCLUSIONS

Our study confirms that, in CHF, neurohumoral activation is strictly related to long-term survival and that many factors contribute to its development and progression; among these, cardiac and renal dysfunction seem to play a major role.

Short- and long-term risk factors for sudden death in patients with stable angina

Sudden death is most common and often the first manifestation of coronary heart disease although its risk is difficult to predict. It has been studied mainly in patients with severe ventricular arrhythmia or recent myocardial infarction, but little is known about the different risk factors for short- and long-term risk of sudden death in patients with stable angina. To assess risk factors for sudden death in patients with stable angina and angiographically proven coronary artery disease, 319 consecutive patients were recruited prospectively and followed-up. Patients with clinical heart failure or recent myocardial infarction were excluded. Clinical, angiographic and biological variables were recorded. The association between each variable and the risk of sudden death was assessed in univariate and logistic multivariate analysis. There were 25 sudden deaths during the follow-up period (97+/-29 months). The univariate predictors in the short-term (2 years) were: peripheral arterial disease, left ventricular hypertrophy, low density lipoprotein cholesterol and ejection fraction. The independent predictors were: peripheral arterial disease (relative risk: 6.3), ejection fraction (relative risk 1.05) and low density lipoprotein (relative risk: 1.8). In the long-term (8-10 years), body mass index, coronary score, ejection fraction and fibrinogen were univariate predictors. Only body mass index (relative risk: 1. 2), ejection fraction (relative risk: 1.06) and fibrinogen (relative risk: 2) remained independent predictors. The risk factors for sudden death in stable angina were time-dependent, peripheral arterial disease appeared as the best predictor with LDL for short time, and body mass index (obesity: index >27) and fibrinogen for long time. Ejection fraction was the only time-independent predictor.

Chronic beta-blocker treatment in patients with advanced heart failure. Effects on neurohormones

BACKGROUND

To date, the use of beta-blockers in treating patients with chronic heart failure gains support, this since several large clinical trials reported reduced mortality after chronic beta-blockade. Part of these beneficial effects may result from inhibition of deleterious neurohormone activation that accompanies progression of chronic heart failure. The present study evaluates whether this neurohormone inhibition is preserved after chronic beta-blockade.

METHODS

In a retrospective analysis the neurohormonal profiles of patients with moderate to severe chronic heart failure were studied from three treatment subgroups: (1) Without beta-blockers or ACE-inhibitors (n=15), (2) without beta-blockers, with ACE-inhibitors (n=324), (3) with beta-blockers and ACE-inhibitors (n=31). Patients were on beta-blockers for an average period of 3.8 years. Plasma samples were obtained under controlled conditions.

RESULTS

Despite uneven group sizes, the groups were well matched for clinical characteristics. Plasma renin levels were significantly lower in patients treated adjunctively with beta-blockers. Plasma aldosterone and endothelin-I levels also tended to be lower after chronic beta-blockade, however, this did not reach statistical significance.

CONCLUSIONS

Chronic adjunctive beta-blocker treatment shows significantly lower plasma renin levels when compared to single ACE-inhibition. This persistent reduction of plasma neurohormone activation may concomitantly reduce the chance of neurohormones to escape from inhibition.

Implementing a congestive heart failure disease management program to decrease length of stay and cost

Congestive heart failure (CHF) is the most common reason for a hospital admission in the Medicare age group and is nearly double the rate of pneumonia, the next highest volume diagnosis. The economic burden of this debilitating, chronic disease demands a mechanism to improve quality of care while preventing unnecessary hospitalizations. Beginning in 1995, Evanston Northwestern Healthcare (ENH) created a disease management program involving a multidisciplinary team designed to decrease length of stay (national average = 6.2 days; ENH = 4 days), reduce costs, prevent readmissions (national 30-day readmission rate = 23%; ENH CHF Program = 2.3%), and improve compliance with the treatment regimen. Compliance monitoring through an automated telemanagement program reinforces education, identifies early warning signs and reduces the likelihood of hospitalization. After 18 months, telemanagement participants' compliance rate averages 89.5%. CHF hospitalization rates are 0.6/patient/year compared with the national benchmark of 1.7/patient/year. A disease management program consists of inpatient consultation, education, outpatient CHF clinic, cardiac home care, and compliance monitoring. Throughout this continuum, education must be communicated consistently by all team members. A CHF Assessment Guide assists the multidisciplinary team to thoroughly complete all education and address unique solutions to patients' needs.

Using a 6-minute walk test to predict outcomes in patients with left ventricular dysfunction

Maximal oxygen consumption (VO2MAX) is an independent variable that predicts outcomes in patients suffering from left ventricular dysfunction (LVD). Determining VO2MAX in a rehabilitation setting is not only costly and time-consuming but it would also be beyond many patients' physical abilities. This study's goal was to show that a simpler and less costly 6-minute walk test can predict mortality in patients with LVD. Sixty-six Phase 1 cardiac rehabilitation patients with LVD performed the 6-minute walk test upon admission and at discharge from a rehabilitation hospital. Upon discharge, the group that was able to walk significantly longer distances upon discharge had a higher survival rate 3 months after discharge. The 6-minute walk test can predict longer survival in patients with LVD and can provide valuable information for determining treatment plans, future prognosis, and home disposition of deconditioned LVD patients in a rehabilitation setting.

Development and prospective validation of a clinical index to predict survival in ambulatory patients referred for cardiac transplant evaluation

BACKGROUND

Risk stratification of patients with end-stage congestive heart failure is a critical component of the transplant candidate selection process. Accurate identification of individuals most likely to survive without a transplant would facilitate more efficient use of scarce donor organs.

METHODS AND RESULTS

Multivariable proportional hazards survival models were developed with the use of data on 80 clinical characteristics from 268 ambulatory patients with advanced heart failure (derivation sample). Invasive and noninvasive models (with and without catheterization-derived data) were constructed. A prognostic score was determined for each patient from each model. Stratum-specific likelihood ratios were used to develop three prognostic-score risk groups. The models were prospectively validated on 199 similar patients (validation sample) by calculation of the area under the receiver operating characteristic curve for 1-year event-free survival, the censored c-index for event-free survival, and comparison of event-free survival curves for prognostic-score risk strata. Outcome events were defined as urgent transplant or death without transplant. The noninvasive model performed well in both samples, and increased performance was not attained by the addition of catheterization-derived variables. Prognostic-score risk groups derived from the noninvasive model in the derivation sample effectively stratified the risk of an outcome event in both samples (1-year event-free survival for derivation and validation samples, respectively: low risk, 93% and 88%; medium risk, 72% and 60%; high risk, 43% and 35%).

CONCLUSIONS

Selection of candidates for cardiac transplantation may be improved by use of this noninvasive risk-stratification model.

Refractory Heart Failure: A Therapeutic Approach

Optimal “triple therapy” for patients with chronic congestive heart failure (CHF) includes diuretics, digoxin, and either angiotensin-converting enzyme inhibitors or hydralazine plus nitrates. Refractory CHF is defined as symptoms of CHF at rest or repeated exacerbations of CHF despite “optimal” triple-drug therapy. Most patients with refractory CHF require hemodynamic monitoring and treatment in the intensive care unit. If easily reversible causes of refractory CHF cannot be identified, then more aggressive medical and surgical interventions are necessary. The primary goal of intervention is to improve hemodynamics to palliate CHF symptoms and signs (i.e., dyspnea, fatigue, edema). Secondary goals include improved vital organ and tissue perfusion, discharge from the intensive care unit, and, in appropriate patients, bridge to cardiac transplantation. Medical interventions include inotropic resuscitation (e.g., adrenergic agents, phosphodiesterase inhibitors, allied nonglycoside inodilators), load resuscitation (e.g., afterload and preload reduction with nitroprusside or nitroglycerin; preload reduction with diuretics and diuretic facilitators, such as dopaminergic agents or ultrafiltration), and electrical resuscitation (e.g., prevention of sudden death, correction of new or rapid atrial fibrillation, or dual chamber pacing in the setting of relative prolongation of the PR interval and diastolic mitral/tricuspid regurgitation). Surgical interventions are temporizing (e.g., intra-aortic balloon pump and other mechanical assist devices) or definitive (e.g., coronary artery revascularization, valvular surgery, and cardiac transplantation). Although these interventions may improve immediate survival in the short term, only coronary artery revascularization and cardiac transplantation have been shown to improve long-term survival.

Predictive value of hemostatic factors for sudden death in patients with stable angina pectoris

To assess hemostatic risk factors for sudden death in patients with stable angina, 323 consecutive patients were recruited prospectively. Patients with clinical heart failure or recent myocardial infarction were excluded. The following clinical variables were recorded: age, gender, smoking habits, hypertension, previous myocardial infarction, left ventricular hypertrophy, and severe ventricular arrhythmia. Angiographic variables included coronary extent, assessed from Jenkins' and mean atherosclerotic scores, and left ventricular ejection fraction. Lipid variables included total cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and apolipoproteins A-I and B. Hemostatic factors included fibrinogen, fibrinopeptide A, antithrombin III, factor VIII antigen, factor VIII coagulant, protein C, plasminogen, alpha 2 antiplasmin, euglobulin clot lysis time, tissue plasminogen activator before and after venous occlusion, and plasminogen activator inhibitor. There were 34 deaths, 19 of which were sudden during the follow-up period (60 +/- 17 months). The association between each variable and the risk of sudden death was assessed by calculating the relative risk with the Cox univariate model. All significant predictors from the univariate analysis were then incorporated in a Cox multivariate model to select the independent predictors of sudden death. The independent predictors of sudden death were left ventricular hypertrophy (p < 0.04), lower left ventricular ejection fraction (p < 0.04), and shorter euglobulin clot lysis time after venous occlusion (p < 0.02), whereas fibrinogen (p < 0.07) and Jenkins' score (p < 0.08) were borderline. Determination of hemostatic variables, especially those pertaining to dynamic fibrinolysis, may thus be of value in assessing risk of sudden death.

Neurohumoral variability in left ventricular dysfunction. SOLVD Investigators. Studies of Left Ventricular Dysfunction

The immediate and longer term variability of selected vasoactive- and volume-regulating neurohormones were measured in patients entering a substudy of the Studies of Left Ventricular Dysfunction--a randomized clinical trial in patients with left ventricular ejection fraction < or = 35%. The variability of these hormones has not been determined in a large cohort of patients. Immediate (short-term) variability was assessed by systematically comparing levels after 15 and 30 minutes of supine rest at the initial visit, and longer term variability was assessed by comparing 30-minute supine rest values at the initial visit with corresponding values taken at 30 minutes after 16 to 24 days of stable therapy. Initial values obtained at the first visit after 30-minute supine rest for all 209 patients were (mean +/- SEM) 512 +/- 21 pg/ml pg/ml for plasma norepinephrine, 1.9 +/- 0.2 ng/ml/hr for plasma renin activity, 3.0 +/- 0.1 pg/ml for plasma arginine vasopressin, and 129 +/- 5.3 pg/ml for plasma atrial natriuretic peptide. All variables were moderately increased relative to established normal values. There was a small but significant decrease from 15- to 30-minute supine posture in all neurohormones, except arginine vasopressin. In the presence of stable background therapy, no significant differences were found between measurements obtained after 30 minutes supine rest at the initial visit and 16 to 24 days later. Spearman correlation coefficients corresponding to immediate and longer term variability were high (range 0.55 to 0.79) (p < 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic value of neurohumoral activation in patients with an acute myocardial infarction: effect of captopril

OBJECTIVES

This study attempted to evaluate whether neurohumoral activation at the time of hospital discharge in postinfarction patients helps to predict long-term prognosis and whether long-term therapy with the angiotensin-converting enzyme inhibitor captopril modifies this relation.

BACKGROUND

Neurohumoral activation persists at the time of hospital discharge in a large number of postinfarction patients. The Survival and Ventricular Enlargement (SAVE) study demonstrated that the angiotensin-converting enzyme inhibitor captopril improves survival and decreases the development of severe heart failure in patients with left ventricular dysfunction (left ventricular ejection fraction < or = 40%) but no overt postinfarction heart failure.

METHODS

In 534 patients in the SAVE study, plasma neurohormone levels were measured a mean of 12 days after infarction. Patients were then randomized to receive captopril or placebo and were followed up for a mean (+/- SD) of 38 +/- 6 months (range 24 to 55). The association between activation of plasma neurohormones at baseline and subsequent cardiovascular mortality or the development of heart failure was assessed with and without adjustment for other important prognostic factors.

RESULTS

By univariate analysis, activation of plasma renin activity and aldosterone, norepinephrine, atrial natriuretic peptide and arginine vasopressin levels were related to subsequent cardiovascular events, whereas epinephrine and dopamine levels were not. By multivariate analysis, only plasma renin activity (relative risk 1.6, 95% confidence interval [CI] 1.0 to 2.5) and atrial natriuretic peptide (relative risk 2.2, 95% CI 1.3 to 3.8) were independently predictive of cardiovascular mortality, whereas the other neurohormones were not. Only plasma renin activity and aldosterone, atrial natriuretic peptide and arginine vasopressin were independent predictors of the combined end points of cardiovascular mortality, development of severe heart failure or recurrent myocardial infarction. Except for 1-year cardiovascular mortality, the use of captopril did not significantly modify these relations.

CONCLUSIONS

Neurohumoral activation at the time of hospital discharge in postinfarction patients is an independent sign of poor prognosis. This is particularly true for plasma renin activity and atrial natriuretic peptide. Except for 1-year cardiovascular mortality, captopril does not significantly modify these relations.

Clinical relevance and management of the major electrolyte abnormalities in congestive heart failure: hyponatremia, hypokalemia, and hypomagnesemia

Electrolyte disturbances are a common complication of CHF. CHF provides a perfect milieu for the development of these disturbances; renal dysfunction, elevation of neurohormonal substances, activation of the renin-angiotensin-aldosterone axis, and diuretic therapy represent the major contributory factors. Hyponatremia is closely aligned with an unfavorable clinical course. Hypokalemia is associated with increased ventricular dysrhythmias. Hypomagnesemia noted in advanced CHF can be accompanied by arrhythmias and refractory hypokalemia. CHF also offers the ideal milieu (diseased, ischemic, and arrhythmogenic myocardium; elevated catecholamines; and arrhythmogenic drugs) for the threatening clinical consequences (clinical deterioration, dysrhythmias, or death) of these disturbances. These consequences underscore the importance of the recognition, appreciation, and management of these electrolyte abnormalities.

Predicting death from progressive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy

Data were retrospectively reviewed on 528 consecutive patients hospitalized for treatment of advanced heart failure (left ventricular ejection fraction 0.2 +/- 0.07) and cardiac transplant evaluation, who were stabilized with medical therapy and discharged home. Predictors of heart failure death or rehospitalization for urgent transplantation were identified using the Cox proportional-hazards model. Within 1 year, 59 patients (11%) died suddenly and 70 (13%) died of heart failure or required urgent transplantation. A serum sodium < or = 134 mEq/liter, pulmonary arterial diastolic pressure > 19 mm Hg, left ventricular diastolic dimension index > 44 mm/m2, peak oxygen consumption during exercise testing < 11 ml/kg/min and the presence of a permanent pacemaker were independent predictors of hemodynamic deterioration. In the absence of these risk factors the risk of hemodynamic deterioration within 1 year from this study was only 2%. This risk increased to > 50% in the presence of hyponatremia and any 2 additional risk factors. Thus, patients with advanced heart failure at highest risk for progressive hemodynamic deterioration can be identified from clinical variables that could aid in triaging such patients to earlier cardiac transplantation.

Increased risk of progressive hemodynamic deterioration in advanced heart failure patients requiring permanent pacemakers

To determine the influence of long-term permanent pacing systems on survival in patients with severe left ventricular dysfunction, data from 557 consecutive patients hospitalized with advanced heart failure for cardiac transplant evaluation and discharged on medical therapy were reviewed. Permanent pacemakers were identified in 42 (8%) patients. One-year actuarial risk of death from heart failure or urgent transplantation in paced patients was higher (49%) than that of a control group, matched for the severity of heart failure (15%, p = 0.003). Sudden death did not differ between paced patients and controls.

Impact of converting enzyme inhibition on progression of chronic heart failure: results of the Munich Mild Heart Failure Trial

OBJECTIVE

Neurohormonal activation has major impact on the pathophysiology of congestive heart failure. The Munich Mild Heart Failure Trial was designed to test the hypothesis that interference with the renin-angiotensin system by angiotensin converting enzyme inhibition favourably influences the natural history of heart failure.

DESIGN AND PATIENTS

170 patients, median New York Heart Association (NYHA) class II, were randomised to double blind treatment with 25 mg captopril twice a day or placebo in addition to standard treatment for a median observation period of 2.7 years.

MAIN OUTCOME MEASURES

Progression of heart failure to NYHA class IV on an optimally adjusted standard treatment, death due to progressive heart failure, and sudden death.

RESULTS

Heart failure progressed to class IV in nine patients (10.8%) treated with captopril and in 23 patients (26.4%) treated with placebo (p = 0.01). The mean survival time until this end point was 223 days longer in the captopril group (Kaplan-Meier life table analysis; p = 0.02). Also, progressive deterioration to severe heart failure was a powerful predictor of total mortality and death from heart failure; 80% of deaths due to progressive heart failure occurred after this end point. There were fewer deaths caused by progressive heart failure in the captopril group than in the placebo group (4 v 11; p = 0.10) but similar numbers of sudden deaths (11 v 10). Progressive heart failure was the cause of death in 18.2% of all deaths in the captopril group and 50% in the placebo group. Total heart failure events (the end point on which power calculation was based) were also more common in the placebo group (19 v 32 events) but not significantly so. Total mortality was similar to both groups (22 of 83 v 22 of 87).

CONCLUSIONS

Angiotensin converting enzyme inhibition in conjunction with standard therapy early in the course of congestive heart failure slowed the progress of heart failure and thus favourably altered the natural history of the disease.

Biological risk factors for sudden death in patients with coronary artery disease and without heart failure

In a study of biological risk factors for sudden death in patients with coronary artery disease, 320 patients were, prospectively, recruited and followed-up over two years. None of the patients had heart failure or recent myocardial infarction. The following variables were recorded: previous acute myocardial infarction, hypertension, smoking habits, ventricular arrhythmia; the angiographic variables included: left ventricular ejection fraction, Jenkins' and mean atherosclerotic scores; lipid profile: cholesterol, triglycerides, high density lipoprotein cholesterol, low density lipoprotein cholesterol, apolipoproteins Al and B; hemostatic profile: fibrinogen, fibrinopeptide A, antithrombin III, factor VIII antigen, factor VIII coagulant, protein C, plasminogen, alpha 2-antiplasmin, euglobulin clot lysis time and tissue plasminogen activator before and after venous occlusion, tissue plasminogen activator inhibitor, platelet factor 4, beta-thromboglobulin. During the follow-up period, 12 of the patients died suddenly. In these patients, ejection fraction was lower: 49 +/- 16% versus 61 +/- 14% for the other patients (P less than 0.02), fibrinogen higher: 3.9 +/- 0.8 g/l versus 3.5 +/- 0.8 for the living patients (P less than 0.05) and protein C lower: 89 +/- 39% versus 111 +/- 39% (P = 0.06) for the other patients. In multivariate analysis: lower ejection fraction (P less than 0.008), older age (P less than 0.03) and lower protein C (P less than 0.01) were correlated with sudden death. Among the patients with coronary artery disease, the raised fibrinogen and the decreased protein C appeared to be risk factors for sudden cardiac death. These alterations reflected a prothrombotic state which might increase the ischemic risk, due to an acute thrombosis, leading to the fatal ventricular arrhythmia. Determination of these hemostatic variables might be a useful adjunct for assessment of the vital prognosis of patients with coronary artery disease, especially the risk of sudden death in addition to other known clinical, electrocardiographic, hemodynamic risk factors. This would also guide both the instigation of complementary investigations and appropriate therapy in such high risk group of patients.

Influence of severity of heart failure on the efficacy of angiotensin-converting enzyme inhibition

Angiotensin-converting enzyme (ACE) inhibition slowed the progression of congestive heart failure (CHF) in 170 patients who were randomly assigned to either captopril or placebo in the Munich Mild Heart Failure Trial. The two major end points were progression from New York Heart Association (NYHA) functional classes I, II, or III to class IV, despite optimal, adjusted standard therapy, and death due to CHF. The relative risk for progressive CHF with captopril therapy was 0.34 (95% confidence interval = 0.17-0.68; p = 0.01). A total of 52 prerandomization variables were tested to determine their contribution to disease progression. Logistic regression analysis revealed 5 independent risk factors for progressive CHF: NYHA class, left ventricular end-systolic diameter, need for diuretic, age, and cardiothoracic ratio. The presence of greater than 2 of these risk factors increased the odds ratio for progression to 8.13 (p less than 0.001) compared with the presence of 0-2 risk factors. However, the effectiveness of captopril in preventing progression was higher within the subgroup of patients who had less severe CHF: the odds ratio was 0.12 (95% confidence interval = 0.03-0.45; p less than 0.01) for patients in NYHA class I or II on captopril and was 0.83 for those in class III. We conclude that the severity of CHF, as represented by the above-defined risk factors, is directly related to the likelihood for the development of progressive heart failure. However, the less severe the heart failure, the more effective the treatment with captopril will be in preventing disease progression. Thus, ACE inhibition has considerable potential for improving the prognosis of patients with mild heart failure.