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Pawar SG, Saravanan PB, Gulati S, Pati S, Joshi M, Salam A, Khan N. Study the relationship between left atrial (LA) volume and left ventricular (LV) diastolic dysfunction and LV hypertrophy: Correlate LA volume with cardiovascular risk factors. Dis Mon 2024; 70:101675. [PMID: 38262769 DOI: 10.1016/j.disamonth.2024.101675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Heart failure (HF) with normal ejection fraction - the isolated diastolic heart failure, depicts increasing prevalence and health care burden in recent times. Having less mortality rate compared to systolic heart failure but high morbidity, it is evolving as a major cardiac concern. With increasing clinical use of Left atrial volume (LAV) quantitation in clinical settings, LAV has emerged as an important independent predictor of cardiovascular outcome in HF with normal ejection fraction. This article is intended to review the diastolic and systolic heart failure, their association with left atrial volume, in depth study of Left atrial function dynamics with determinants of various functional and structural changes.
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Affiliation(s)
| | | | | | | | - Muskan Joshi
- Tbilisi State Medical University, Tbilisi, Georgia
| | - Ajal Salam
- Government Medical College, Kottayam, Kerala, India
| | - Nida Khan
- Jinnah Sindh Medical University, Karachi, Pakistan
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2
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Vaduganathan M, Patel RB, Michel A, Shah SJ, Senni M, Gheorghiade M, Butler J. Mode of Death in Heart Failure With Preserved Ejection Fraction. J Am Coll Cardiol 2017; 69:556-569. [PMID: 28153111 DOI: 10.1016/j.jacc.2016.10.078] [Citation(s) in RCA: 164] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 10/26/2016] [Indexed: 12/20/2022]
Abstract
Little is known about specific modes of death in patients with heart failure with preserved ejection fraction (HFpEF). Herein, the authors critically appraise the current state of data and offer potential future directions. They conducted a systematic review of 1,608 published HFpEF papers from January 1, 1985, to December 31, 2015, which yielded 8 randomized clinical trials and 24 epidemiological studies with mode-of-death data. Noncardiovascular modes of death represent an important competing risk in HFpEF. Although sudden death accounted for ∼25% to 30% of deaths in trials, its definition is nonspecific; it is unclear what proportion represents arrhythmic deaths. Moving forward, reporting and definitions of modes of death must be standardized and tailored to the HFpEF population. Broad-scale systematic autopsies and long-term rhythm monitoring may clarify the underlying pathology and mechanisms driving mortal events. There is an unmet need for a longitudinal multicenter, global registry of patients with HFpEF to map its natural history.
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Affiliation(s)
- Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Ravi B Patel
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Sanjiv J Shah
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michele Senni
- Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Mihai Gheorghiade
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Javed Butler
- Division of Cardiology, Stony Brook University, Stony Brook, New York.
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Bonsu KO, Owusu IK, Buabeng KO, Reidpath DD, Kadirvelu A. Clinical characteristics and prognosis of patients admitted for heart failure: A 5-year retrospective study of African patients. Int J Cardiol 2017; 238:128-135. [PMID: 28318656 DOI: 10.1016/j.ijcard.2017.03.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 02/28/2017] [Accepted: 03/04/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Mortality associated with heart failure (HF) remains high. There are limited clinical data on mortality among HF patients from African populations. We examined the clinical characteristics, long-term outcomes, and prognostic factors of African HF patients with preserved, mid-range or reduced left ventricular ejection fraction (LVEF). METHODS AND RESULTS We conducted a retrospective longitudinal cohort study of individuals aged ≥18years discharged from first HF admission between January 1, 2009 and December 31, 2013 from the Cardiac Clinic, Directorate of Medicine of the Komfo Anokye Teaching Hospital, Ghana. A total of 1488 patients diagnosed of HF were included in the analysis. Of these, 345 patients (23.2%) had reduced LVEF (LVEF<40%) [HFrEF], 265(17.8%) with mid-range LVEF (40%≥LVEF<50%) [HFmEF] and 878 (59.0%) had preserved LVEF (LVEF≥50%) [HFpEF]. Kaplan-Meier curves and log-rank test demonstrated better prognosis for HFpEF compared to HFrEF and HFmEF patients. An adjusted Cox analysis showed a significantly lower risk of mortality for HFpEF (hazard ratio (HR); 0.74; 95% confidence interval (CI) 0.57-0.94) p=0.015). Multivariate analyses showed that age, higher New York Heart Association (NYHA) functional class, lower LVEF, chronic kidney disease, atrial fibrillation, anemia, diabetes mellitus and absence of statin and aldosterone antagonist treatment were independent predictors of mortality in HF. Although, prognostic factors varied across the three groups, age was a common predictor of mortality in HFpEF and HFmEF. CONCLUSIONS This study identified the clinical characteristics, long-term mortality and prognostic factors of African HF patients with reduced, mid-range and preserved ejection fractions in a clinical setting.
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Affiliation(s)
- Kwadwo Osei Bonsu
- School of Medicine and Health Sciences, Monash University, Jalan Lagoon Selatan, Bandar Sunway, 47500, Selangor DE, Malaysia; Accident and Emergency Directorate, Komfo Anokye Teaching Hospital, P.O. Box 1934, Kumasi, Ghana.
| | - Isaac Kofi Owusu
- Directorate of Medicine, Komfo Anokye Teaching Hospital, P.O. Box 1934, Kumasi, Ghana; Department of Medicine, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Kwame Ohene Buabeng
- Department of Pharmacy Practice, Faculty of Pharmacy and Pharmaceutical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology.
| | - Daniel D Reidpath
- School of Medicine and Health Sciences, Monash University, Jalan Lagoon Selatan, Bandar Sunway, 47500, Selangor DE, Malaysia.
| | - Amudha Kadirvelu
- School of Medicine and Health Sciences, Monash University, Jalan Lagoon Selatan, Bandar Sunway, 47500, Selangor DE, Malaysia.
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Salam AM, Sulaiman K, Al-Zakwani I, Alsheikh-Ali A, Aljaraallah M, Al Faleh H, Elasfar A, Panduranga P, Singh R, Abi Khalil C, Al Suwaidi J. Coronary artery disease prevalence and outcome in patients hospitalized with acute heart failure: an observational report from seven Middle Eastern countries. Hosp Pract (1995) 2016; 44:242-251. [PMID: 27737597 DOI: 10.1080/21548331.2016.1246945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES The purpose of this study was to report prevalence, clinical characteristics, precipitating factors, management and outcome of patients with coronary artery disease (CAD) among patients hospitalized with heart failure (HF) in seven Middle Eastern countries and compare them to non-CAD patients. METHODS Data were derived from Gulf CARE (Gulf aCute heArt failuRe rEgistry), a prospective multicenter study of 5005 consecutive patients hospitalized with acute HF during February-November 2012 in 7 Middle Eastern countries. RESULTS The prevalence of CAD among Acute Heart Failure (AHF) patients was 60.2% and varied significantly among the 7 countries (Qatar 65.7%, UAE 66.6%, Kuwait 68.0%, Oman 65.9%, Saudi Arabia 62.5%, Bahrain 52.7% and Yemen 49.1%) with lower values in the lower income countries. CAD patients were older and more likely to have diabetes, hypertension, dyslipidemia and chronic kidney disease. Moreover, CAD patients were more likely to have history of cerebrovascular and peripheral vascular disease when compared to non-CAD patients. In-hospital mortality rates were comparable although CAD patients had more frequent re-hospitalization and worse long-term outcome. However, CAD was not an independent predictor of poor outcome. CONCLUSION The prevalence of CAD amongst patients with HF in the Middle East is variable and may be related to healthcare sources. Regional and national studies are needed for assessing further the impact of various etiologies of HF and for developing appropriate strategies to combat this global concern.
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Affiliation(s)
- Amar M Salam
- a Department of Cardiology , Al-khor Hospital, Hamad Medical Corporation , Doha , Qatar
| | | | - Ibrahim Al-Zakwani
- c Department of Pharmacology & Clinical Pharmacy , Sultan Qaboos University , Muscat , Oman
| | - Alawi Alsheikh-Ali
- d College of Medicine , Mohammed Bin Rashid Medical University , Dubai , United Arab Emirates
| | | | - Husam Al Faleh
- f Department of Cardiology and Cardiovascular Surgery , King Saud University , Riyadh , Saudi Arabia
| | - Abdelfatah Elasfar
- g Department of Cardiology , Prince Salman Hospital , Riyadh , Saudi Arabia
| | | | - Rajvir Singh
- a Department of Cardiology , Al-khor Hospital, Hamad Medical Corporation , Doha , Qatar
| | - Charbel Abi Khalil
- h Department of Genetic Medicine and Department of Medicine , Weill Cornell Medical College in Qatar , Doha , Qatar
| | - Jassim Al Suwaidi
- i Department of Adult Cardiology and Cardiovascular Surgery , Heart Hospital, Hamad Medical Corporation , Doha , Qatar
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5
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Atherton JJ. Chronic heart failure: we are fighting the battle, but are we winning the war? SCIENTIFICA 2012; 2012:279731. [PMID: 24278681 PMCID: PMC3820562 DOI: 10.6064/2012/279731] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 10/31/2012] [Indexed: 05/04/2023]
Abstract
Heart failure represents an end-stage phenotype of a number of cardiovascular diseases and is generally associated with a poor prognosis. A number of organized battles fought over the last two to three decades have resulted in considerable advances in treatment including the use of drugs that interfere with neurohormonal activation and device-based therapies such as implantable cardioverter defibrillators and cardiac resynchronization therapy. Despite this, the prevalence of heart failure continues to rise related to both the aging population and better survival in patients with cardiovascular disease. Registries have identified treatment gaps and variation in the application of evidenced-based practice, including the use of echocardiography and prescribing of disease-modifying drugs. Quality initiatives often coupled with multidisciplinary, heart failure disease management promote self-care and minimize variation in the application of evidenced-based practice leading to better long-term clinical outcomes. However, to address the rising prevalence of heart failure and win the war, we must also turn our attention to disease prevention. A combined approach is required that includes public health measures applied at a population level and screening strategies to identify individuals at high risk of developing heart failure in the future.
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Affiliation(s)
- John J. Atherton
- Cardiology Department, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD 4006, Australia
- School of Medicine, University of Queensland, Brisbane, QLD 4006, Australia
- *John J. Atherton:
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Castillo JC, Anguita MP, Jiménez M. Outcome of heart failure with preserved ejection fraction: a multicentre spanish registry. Curr Cardiol Rev 2011; 5:334-42. [PMID: 21037850 PMCID: PMC2842965 DOI: 10.2174/157340309789317814] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2008] [Revised: 09/30/2008] [Accepted: 10/02/2008] [Indexed: 12/01/2022] Open
Abstract
Background: Studies on clinical features, treatment and prognosis of patients with congestive heart failure (CHF) and preserved left ventricular ejection fraction (LVEF) are few and their results frequently conflicting. Aims: To investigate the characteristics and long term prognosis of patients with CHF and preserved (≥ 45%) LVEF. Methods and Results: We conducted a prospective multicentre study with 4720 patients attended in 62 heart failure clinics from 1999 to 2003 in Spain (BADAPIC registry). LVEF was preserved in 30% patients. Age, female gender, prevalence of atrial fibrillation, hypertension and non-ischaemic cardiopathy were all significantly greater in patients with preserved LVEF. Mean follow-up was 40±12 months. Mortality and other cardiovascular complication rates during follow up were similar in both groups. On multivariate analysis ejection fraction was not an independent predictor for mortality. Survival at one and five years was similar in both groups (79% and 59% for patients with preserved LVEF and 78% and 57% for those with reduced LVEF, respectively). Conclusions: In the BADAPIC registry, a high percentage of heart failure patients had preserved LVEF. Although clinical differences were seen between groups, morbidity and mortality were similar in both groups.
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Abstract
Heart failure (HF) is a major public health issue, with a prevalence of over 5.8 million in the USA, and over 23 million worldwide, and rising. The lifetime risk of developing HF is one in five. Although promising evidence shows that the age-adjusted incidence of HF may have plateaued, HF still carries substantial morbidity and mortality, with 5-year mortality that rival those of many cancers. HF represents a considerable burden to the health-care system, responsible for costs of more than $39 billion annually in the USA alone, and high rates of hospitalizations, readmissions, and outpatient visits. HF is not a single entity, but a clinical syndrome that may have different characteristics depending on age, sex, race or ethnicity, left ventricular ejection fraction (LVEF) status, and HF etiology. Furthermore, pathophysiological differences are observed among patients diagnosed with HF and reduced LVEF compared with HF and preserved LVEF, which are beginning to be better appreciated in epidemiological studies. A number of risk factors, such as ischemic heart disease, hypertension, smoking, obesity, and diabetes, among others, have been identified that both predict the incidence of HF as well as its severity. In this Review, we discuss key features of the epidemiology and risk profile of HF.
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8
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Zareba KM, Shenkman HJ, Bisognano JD. Comparison of acute electrocardiographic presentation in patients with diastolic vs systolic heart failure. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2009; 15:165-9. [PMID: 19627289 DOI: 10.1111/j.1751-7133.2009.00097.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
There are limited data comparing admission electrocardiograms (ECGs) in patients with acute diastolic (DHF) vs systolic heart failure (SHF) and their ability to predict cardiac events (CEs). Admission ECGs were evaluated in 241 acute heart failure patients (88 DHF; 153 SHF). DHF was defined as left ventricular ejection fraction >45%. End points consisted of rehospitalization for CEs or death during a 30-day follow-up. DHF patients had more atrial fibrillation (AF) while SHF patients had faster heart rates and longer QRS and QTc duration. There were 68 CEs: 26 (30%) in DHF and 42 (27%) in SHF patients ( P=.728). Multivariate logistic regression analysis revealed that in DHF patients, CEs were associated with nonischemic heart failure, blood urea nitrogen >28 mg/dL, and AF. In the SHF group, CEs were associated with AF. Admission ECG differs between acute DHF and SHF patients. CE rates are similar in both groups; AF is the only ECG parameter predictive of CEs.
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Naruse H, Ishii J, Kawai T, Hattori K, Ishikawa M, Okumura M, Kan S, Nakano T, Matsui S, Nomura M, Hishida H, Ozaki Y. Cystatin C in acute heart failure without advanced renal impairment. Am J Med 2009; 122:566-73. [PMID: 19393984 DOI: 10.1016/j.amjmed.2008.10.042] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2008] [Revised: 09/08/2008] [Accepted: 10/14/2008] [Indexed: 10/20/2022]
Abstract
BACKGROUND The prognostic value of cystatin C relative to glomerular filtration rate (GFR) estimated by the Modification of Diet in Renal Disease Study (MDRD) equation modified for Japan has not been investigated in acute heart failure patients with normal to moderately impaired renal function. More accurate detection of mild renal impairment might improve the risk stratification of heart failure patients, especially patients with normal to moderately impaired renal function. METHODS Cystatin C and creatinine levels were measured on admission in 328 consecutive patients hospitalized for worsening chronic heart failure with a GFR estimated by MDRD equation modified for Japan >or=30 mL/min/1.73 m(2). RESULTS During a median follow-up period of 915 days, there were 52 (16%) cardiac deaths. In stepwise Cox regression analyses including cystatin C and GFR estimated by MDRD equation modified for Japan (either as continuous variables or as variables categorized into quartiles), cystatin C (P <.0001), but not GFR estimated by MDRD equation modified for Japan, was independently associated with cardiac mortality. Adjusted relative risk according to the quartiles of these markers and Kaplan-Meier analyses revealed that the cystatin C was a better marker to separate low-risk from high-risk patients. Furthermore, receiver-operating characteristic curve analyses of these markers revealed that cystatin C showed a higher precision in predicting cardiac mortality. CONCLUSION Measurements of cystatin C might improve early risk stratification compared with GFR estimated by MDRD equation modified for Japan in acute heart failure patients with normal to moderately impaired renal function.
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Affiliation(s)
- Hiroyuki Naruse
- Department of Internal Medicine, Fujita Health University School of Medicine, Toyoake, Japan
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El-Menyar AA, Galzerano D, Asaad N, Al-Mulla A, Arafa SEO, Al Suwaidi J. Detection of myocardial dysfunction in the presence of normal ejection fraction. J Cardiovasc Med (Hagerstown) 2007; 8:923-33. [PMID: 17906478 DOI: 10.2459/jcm.0b013e328014daf2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Detection of subclinical myocardial involvement is of utmost importance in risk stratification and prognosis; the role of ejection fraction in the detection of subclinical disease may be unhelpful. Our aim was to evaluate the methodology and importance of early detection of myocardial involvement in the presence of normal ejection fraction. Most of the pertinent English and non-English articles published from 1980 to 2006 in Medline, Scopus, and EBSCO Host research databases have been reviewed. Serial assessment of systolic function with different techniques should be avoided, since imaging modalities and ejection fraction measurements are not interchangeable. Additional non-invasive tools still are needed for the identification of subclinical left ventricular dysfunction in certain diseases. The recognition of subclinical involvement will prompt initiation of specific therapy to prevent the development of overt left ventricular dysfunction. This also is needed for determining the best timing for intervention in asymptomatic patients with metabolic and valvular disorders.
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Affiliation(s)
- Ayman A El-Menyar
- Department of Cardiology and Cardiovascular Surgery, Hamad Medical Corporation, Hamad General Hospital, Doha, Qatar.
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11
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Lago RM, Singh PP, Nesto RW. Congestive heart failure and cardiovascular death in patients with prediabetes and type 2 diabetes given thiazolidinediones: a meta-analysis of randomised clinical trials. Lancet 2007; 370:1129-36. [PMID: 17905165 DOI: 10.1016/s0140-6736(07)61514-1] [Citation(s) in RCA: 545] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The overall clinical benefit of thiazolidinediones (TZDs) as a treatment for hyperglycaemia can be difficult to assess because of the risk of congestive heart failure due to TZD-related fluid retention. Since prediabetic and diabetic patients are at high cardiovascular risk, the outcome and natural history of such risks need to be better understood. We aimed to examine the risk of congestive heart failure and of cardiac death in patients given TZDs. METHODS We used a search strategy to identify 3048 studies. 3041 were excluded, and we did a systematic review and meta-analysis of the seven remaining randomised double-blind clinical trials of drug-related congestive heart failure in patients given TZDs (either rosiglitazone or pioglitazone). We calculated pooled random-effects estimates of the risk ratios for development of congestive heart failure in patients given TZDs compared with controls. The main outcome measures were development of congestive heart failure and the risk of cardiovascular death. FINDINGS 360 of 20 191 patients who had either prediabetes or type 2 diabetes had congestive heart failure events (214 with TZDs and 146 with comparators). Results showed no heterogeneity of effects across studies (I2=22.8%; p for interaction=0.26), which indicated a class effect for TZDs. Compared with controls, patients given TZDs had increased risk for development of congestive heart failure across a wide background of cardiac risk (relative risk [RR] 1.72, 95% CI 1.21-2.42, p=0.002). By contrast, the risk of cardiovascular death was not increased with either of the two TZDs (0.93, 0.67-1.29, p=0.68). INTERPRETATION Congestive heart failure in patients given TZDs might not carry the risk that is usually associated with congestive heart failure which is caused by progressive systolic or diastolic dysfunction of the left ventricle. Longer follow-up and better characterisation of such patients is needed to determine the effect of TZDs on overall cardiovascular outcome.
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12
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Witt BJ, Gami AS, Ballman KV, Brown RD, Meverden RA, Jacobsen SJ, Roger VL. The incidence of ischemic stroke in chronic heart failure: a meta-analysis. J Card Fail 2007; 13:489-96. [PMID: 17675064 DOI: 10.1016/j.cardfail.2007.01.009] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2006] [Revised: 01/23/2007] [Accepted: 01/26/2007] [Indexed: 12/25/2022]
Abstract
BACKGROUND There is marked variability in the reported stroke rates among persons with heart failure (HF). We performed a meta-analysis to provide summary estimates of the stroke rate in HF and to explain heterogeneity in the existing literature. We will summarize the ischemic stroke rate at various time points during follow-up among adults with chronic heart failure. METHODS AND RESULTS A systematic review of the electronic literature in Medline and PubMed as well as hand searching of the reference lists of identified articles and of the meeting abstracts for the 1995-2004 American College of Cardiology and American Heart Association scientific sessions was performed to identify qualifying studies. Articles were included if they included a population with chronic HF and reported the number (or percent) of persons with HF who experienced an ischemic stroke during follow-up. Studies were excluded if the study population included > or = 50% of persons with acute (postmyocardial infarction) HF, or if > or = 50% of the study population required artificial support with a ventricular assist device or parenteral inotropic medications. Case reports, case series, and nonoriginal research articles were not included. Determination of study eligibility and data extraction were conducted by 2 independent reviewers using standardized forms. Results are reported as stroke rate per 1000 cases of HF, with 95% Poisson confidence intervals. Pooled estimates of the stroke rate were calculated with fixed and random effects models. Heterogeneity was explored according to a priori specified subgroup analyses. Overall, 26 studies met inclusion criteria. Eighteen of every 1000 persons suffered a stroke during the first year after the diagnosis of HF. The stroke rate increased to a maximum of 47.4 per 1000 at 5 years. Studies with fewer women, those conducted in 1990 or earlier, and cohort studies reported higher stroke rates than studies with more women, those conducted after 1990, and clinical trials. CONCLUSIONS Stroke is an important complication among persons with HF. Variability among reported stroke rates can be explained in part by differences in study design, patient population, and HF standards of care at the time of the study. Despite the heterogeneity in reported stroke rates, this meta-analysis shows that stroke prevention in HF represents an opportunity to prevent morbidity and save many lives in this highly fatal disease.
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Affiliation(s)
- Brandi J Witt
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine and Mayo Foundation, Rochester, Minnesota 55905, USA
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13
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Pirracchio R, Cholley B, De Hert S, Solal AC, Mebazaa A. Diastolic heart failure in anaesthesia and critical care. Br J Anaesth 2007; 98:707-21. [PMID: 17468492 DOI: 10.1093/bja/aem098] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Diastolic heart failure is an underestimated pathology with a high risk of acute decompensation during the perioperative period. This article reviews the epidemiology, risk factors, pathophysiology, and treatment of diastolic heart failure. Although frequently underestimated, diastolic heart failure is a common pathology. Diastolic heart failure involves heart failure with preserved left ventricular (LV) function, and LV diastolic dysfunction may account for acute heart failure occurring in critical care situations. Hypertensive crisis, sepsis, and myocardial ischaemia are frequently associated with acute diastolic heart failure. Symptomatic treatment focuses on the reduction in pulmonary congestion and the improvement in LV filling. Specific treatment is actually lacking, but encouraging data are emerging concerning the use of renin-angiotensin-aldosterone axis blockers, nitric oxide donors, or, very recently, new agents specifically targeting actin-myosin cross-bridges.
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Affiliation(s)
- R Pirracchio
- Department of Anaesthesiology, Lariboisière University Hospital, Paris, France
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14
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De Keulenaer GW, Brutsaert DL. Systolic and diastolic heart failure: Different phenotypes of the same disease? Eur J Heart Fail 2007; 9:136-43. [PMID: 16884955 DOI: 10.1016/j.ejheart.2006.05.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2005] [Revised: 02/20/2006] [Accepted: 05/24/2006] [Indexed: 11/16/2022] Open
Abstract
Traditional pathophysiological concepts of chronic heart failure have largely focused on the haemodynamic consequences of ventricular systolic dysfunction. How these concepts relate to the pathophysiology of diastolic heart failure, i.e., heart failure with a preserved ejection fraction is, however, unclear, causing uncertainty about pathophysiology, diagnosis and management. Recent measurements of regional myocardial systolic function in patients with diastolic heart failure indicate that systolic and diastolic heart failure may be more closely related than previously anticipated. Rather than being considered as separate diseases with a distinct pathophysiology, systolic and diastolic heart failure may be merely different clinical presentations within a phenotypic spectrum of one and the same disease. In this review, we will interpret these new insights in a broader conceptual context of chronic heart failure and design novel paradigms in which systolic and diastolic heart failure jointly progress in a pathophysiological time trajectory of only one disease.
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15
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Frenneaux M, Williams L. Ventricular-arterial and ventricular-ventricular interactions and their relevance to diastolic filling. Prog Cardiovasc Dis 2007; 49:252-62. [PMID: 17185113 DOI: 10.1016/j.pcad.2006.08.004] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Chronic heart failure is a common clinical problem, and, until recently, attention has focused predominantly on those patients with reduced left ventricular (LV) systolic function, as evidenced by a reduced LV ejection fraction. However, nearly half of all patients thought clinically to have heart failure have a "preserved" LV ejection fraction, variously defined as greater than 40% to 45% ("heart failure with normal ejection fraction" syndrome). The interaction of the heart with the systemic vasculature, termed ventricular-arterial coupling, is a key determinant of cardiovascular performance. The capacity of the body to augment cardiac output, regulate systemic blood pressure, and respond appropriately to elevations in heart rate and preload depends on both the properties of the heart and the properties of the vasculature into which the heart ejects blood. Although the marked increase of arterial and cardiac stiffness with aging can maintain ventricular-vascular coupling within a normal range, it does have detrimental effects on hemodynamic stability and cardiac reserve. Patients with heart failure with normal ejection fraction have been shown to have both arterial and ventricular stiffening, resulting in enhanced pressure-load dependence and sensitivity of blood pressure to circulating volume and diuretics. There is also indirect evidence to suggest that on exercise, increased external constraint to LV filling (as a result of diastolic ventricular interaction and pericardial constraint) may contribute to impaired use of the Starling mechanism in this group of patients.
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Affiliation(s)
- Michael Frenneaux
- Department of Cardiovascular Medicine, University of Birmingham, Birmingham, United Kingdom
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16
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Shammas RL, Khan NUA, Nekkanti R, Movahed A. Diastolic heart failure and left ventricular diastolic dysfunction: What we know, and what we don't know! Int J Cardiol 2007; 115:284-92. [PMID: 16904774 DOI: 10.1016/j.ijcard.2006.03.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2005] [Revised: 01/26/2006] [Accepted: 03/11/2006] [Indexed: 10/24/2022]
Abstract
Diastolic heart failure is a common form of congestive heart failure that is responsible for significant morbidity and mortality. In contrast to heart failure caused by systolic left ventricular dysfunction, diastolic heart failure is harder to diagnose and less likely to be accepted as a diagnosis. In addition, treatment strategies are much less defined than those for heart failure caused by systolic dysfunction.
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Affiliation(s)
- Rony L Shammas
- Division of Cardiology, TA 378, Pitt County Memorial Hospital, East Carolina University Brody School of Medicine, Greenville, NC 27834, USA.
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de Keulenaer GW, Brutsaert DL. Pathophysiology and Clinical Impact of Diastolic Heart Failure. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Cardiac Hypertrophy. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Delhaye D, Remy-Jardin M, Teisseire A, Hossein-Foucher C, Leroy S, Duhamel A, Remy J. MDCT of Right Ventricular Function: Comparison of Right Ventricular Ejection Fraction Estimation and Equilibrium Radionuclide Ventriculography, Part 1. AJR Am J Roentgenol 2006; 187:1597-604. [PMID: 17114556 DOI: 10.2214/ajr.05.1193] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of this study was to calculate right ventricular ejection fraction by use of ECG-gated MDCT and to compare the results with those of equilibrium radionuclide ventriculography. SUBJECTS AND METHODS Forty-nine consecutively examined patients (30 men, 19 women; mean age, 59 years) with known or suspected right ventricular dysfunction secondary to bronchopulmonary (n = 30) or pulmonary vascular (n = 19) disease underwent ECG-gated 16-MDCT angiography of the heart (rotation time, 0.42 second; 120 kV; 300 mAs; collimation, 12 x 0.75 mm; pitch, 0.2) after CT angiographic examination of the entire thorax according to a standard protocol. Biphasic administration of a 30% contrast agent was systematically performed (phase 1, 90 mL at 3 mL/s; phase 2, 30 mL at 1.5 mL/s); no patient received additional medication. Right ventricular ejection fraction was calculated after two reviewers in consensus determined the reconstruction windows and segmentation of the right ventricular cavity on a series of diastolic and systolic short-axis images. The results were compared with those of equilibrium radionuclide ventriculography. RESULTS At data acquisition, the mean (+/- SD) heart rate of the study group was 82 +/- 13.87 beats per minute (BPM) (range, 51-115 BPM). ECG showed a sinus rhythm in 30 (61%) of the patients and irregular cardiac rhythm in 19 (39%) of the patients. Agreement between the two techniques was estimated by intraclass correlation coefficient (0.77), the method of Bland and Altman (limits of concordance, -14.9 and 13.7), and percentage of variability between two measurements expressed by mean absolute percentage error (12.1%). The estimated effective dose for heart examination was 7.48 mSv with CT and 5 mSv with scintigraphy. The mean effective dose for the chest and heart CT examinations was 11.64 mSv. CONCLUSION Right ventricular ejection fraction can be reliably estimated with 16-MDCT in unselected patients.
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Affiliation(s)
- Damien Delhaye
- Department of Thoracic Imaging, Hospital Calmette, University Center of Lille, Blvd. Jules Leclerc, 59037 Lille, France
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Bhatia RS, Tu JV, Lee DS, Austin PC, Fang J, Haouzi A, Gong Y, Liu PP. Outcome of heart failure with preserved ejection fraction in a population-based study. N Engl J Med 2006; 355:260-9. [PMID: 16855266 DOI: 10.1056/nejmoa051530] [Citation(s) in RCA: 1394] [Impact Index Per Article: 77.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The importance of heart failure with preserved ejection fraction is increasingly recognized. We conducted a study to evaluate the epidemiologic features and outcomes of patients with heart failure with preserved ejection fraction and to compare the findings with those from patients who had heart failure with reduced ejection fraction. METHODS From April 1, 1999, through March 31, 2001, we studied 2802 patients admitted to 103 hospitals in the province of Ontario, Canada, with a discharge diagnosis of heart failure whose ejection fraction had also been assessed. The patients were categorized in three groups: those with an ejection fraction of less than 40 percent (heart failure with reduced ejection fraction), those with an ejection fraction of 40 to 50 percent (heart failure with borderline ejection fraction), and those with an ejection fraction of more than 50 percent (heart failure with preserved ejection fraction). Two groups were studied in detail: those with an ejection fraction of less than 40 percent and those with an ejection fraction of more than 50 percent. The main outcome measures were death within one year and readmission to the hospital for heart failure. RESULTS Thirty-one percent of the patients had an ejection fraction of more than 50 percent. Patients with heart failure with preserved ejection fraction were more likely to be older and female and to have a history of hypertension and atrial fibrillation. The presenting history and clinical examination findings were similar for the two groups. The unadjusted mortality rates for patients with an ejection fraction of more than 50 percent were not significantly different from those for patients with an ejection fraction of less than 40 percent at 30 days (5 percent vs. 7 percent, P=0.08) and at 1 year (22 percent vs. 26 percent, P=0.07); the adjusted one-year mortality rates were also not significantly different in the two groups (hazard ratio, 1.13; 95 percent confidence interval, 0.94 to 1.36; P=0.18). The rates of readmission for heart failure and of in-hospital complications did not differ between the two groups. CONCLUSIONS Among patients presenting with new-onset heart failure, a substantial proportion had an ejection fraction of more than 50 percent. The survival of patients with heart failure with preserved ejection fraction was similar to that of patients with reduced ejection fraction.
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Affiliation(s)
- R Sacha Bhatia
- Heart & Stroke/Richard Lewar Centre of Excellence, University of Toronto, and the Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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Hernández G, Anguita M, Ojeda S, Durán C, Rodríguez A, Ruiz M, Moreno Á, López-Granados A, Castillo JC, Arizón JM, de Lezo JS. Insuficiencia cardiaca con función sistólica conservada. Diferencias pronósticas según la etiología. Rev Esp Cardiol 2006. [DOI: 10.1157/13087056] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Solomon SD, Anavekar N, Skali H, McMurray JJV, Swedberg K, Yusuf S, Granger CB, Michelson EL, Wang D, Pocock S, Pfeffer MA. Influence of ejection fraction on cardiovascular outcomes in a broad spectrum of heart failure patients. Circulation 2005; 112:3738-44. [PMID: 16330684 DOI: 10.1161/circulationaha.105.561423] [Citation(s) in RCA: 571] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Left ventricular function is a principal determinant of cardiovascular risk in patients with heart failure. The growing number of patients with preserved systolic function heart failure underscores the importance of understanding the relationship between ejection fraction and risk. METHODS AND RESULTS We studied 7599 patients with a broad spectrum of symptomatic heart failure enrolled in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) Program. All patients were randomized to candesartan at a target dose of 32 mg once daily or matching placebo and followed up for a median of 38 months. We related left ventricular ejection fraction (LVEF), measured before randomization at the sites, to cardiovascular outcomes and causes of death. Mean LVEF in patients enrolled in CHARM was 38.8+/-14.9% (median LVEF 36%). Patients with lower LVEF tended to have higher baseline New York Heart Association class. The hazard ratio for all-cause mortality increased by 39% for every 10% reduction in ejection fraction below 45% (hazard ratio 1.39, 95% CI 1.32 to 1.46), with adjustment for baseline covariates. All-cause mortality, cardiovascular death, and all components of cardiovascular death declined with increasing ejection fraction until an ejection fraction of 45%, after which the risk of these outcomes remained relatively stable with increasing LVEF. The absolute change in rate per 100 patient-years for each 10% reduction in LVEF was greatest for sudden death and heart failure-related death. The effect of candesartan in reducing cardiovascular outcomes was consistent across LVEF categories. CONCLUSIONS LVEF is a powerful predictor of cardiovascular outcome in heart failure patients across a broad spectrum of ventricular function. Nevertheless, once elevated to a range above 45%, ejection fraction does not further contribute to assessment of cardiovascular risk in heart failure patients.
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Affiliation(s)
- Scott D Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02445, USA
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Zaret BL. Barry Lewis Zaret, MD: a conversation with the editor. Interview by William Clifford Roberts. Am J Cardiol 2005; 95:1199-217. [PMID: 15877993 DOI: 10.1016/j.amjcard.2005.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2005] [Accepted: 02/16/2005] [Indexed: 11/24/2022]
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Varela-Roman A, Grigorian L, Barge E, Bassante P, de la Peña MG, Gonzalez-Juanatey JR. Heart failure in patients with preserved and deteriorated left ventricular ejection fraction. Heart 2005; 91:489-94. [PMID: 15772209 PMCID: PMC1768853 DOI: 10.1136/hrt.2003.031922] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To determine clinical and prognostic differences between preserved and deteriorated systolic function (defined as left ventricular (LV) ejection fractions > or = 50% and < 50%, respectively) in patients with heart failure satisfying modified Framingham criteria. PATIENTS AND METHODS Records were studied of 1252 patients with congestive heart failure (CHF) (mean (SD) age 69.4 (11.7) years; 485 women, 767 men) who had been admitted to a cardiology service for CHF in the period 1991-2002 and whose LV systolic function had been echocardiographically evaluated within two weeks of admission. Data were collected on the main clinical findings, supplementary examinations, treatment, and duration of hospitalisation. Whether the patient was alive in the spring of 2003 was evaluated by searching the general archives of the hospital and by telephone survey. RESULTS LV systolic function was preserved in 39.8% of patients. Age, female to male sex ratio, and prevalence of atrial fibrillation, valve disease, and other non-ischaemic, non-dilated cardiopathies were all significantly greater in the group with preserved systolic function. New York Heart Association functional class IV, third heart sound, jugular vein congestion, cardiomegaly, radiological signs of lung oedema, pathological Q waves, left bundle branch block, sinus rhythm, ischaemic cardiopathy, and dilated cardiomyopathy were all significantly more prevalent in the group with deteriorated systolic function, as was treatment with angiotensin converting enzyme inhibitors and most other antihypertensive drugs on discharge from hospital. There was no significant difference in survival between the groups with preserved and deteriorated systolic function (either survival regardless of age at admission or in subgroups aged < 75 and > or = 75 years at admission). In the whole group, survival rates after one, three, and five years were 84.0%, 66.7%, and 50.9%, respectively. CONCLUSION In view of the poor prognosis of patients with CHF with preserved LV systolic function, who are currently treated empirically, it is to be hoped that relevant controlled clinical trials under way will afford information allowing optimisation of their treatment.
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Affiliation(s)
- A Varela-Roman
- Clinical University Hospital, Santiago de Compostela 15706, Spain.
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Abstract
Diastolic dysfunction and the clinical syndrome of diastolic heart failure have become well recognized as contributors to the overall burden of congestive heart failure. This increasing awareness has led to several recent investigations into the impact of diastolic abnormalities on morbidity and mortality. This article reviews the current state of knowledge regarding the prognosis of patient populations with diastolic dysfunction and diastolic heart failure.
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Affiliation(s)
- Kristen M Franklin
- Division of Cardiology, Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01655, USA
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Thomas MD, Fox KF, Coats AJS, Sutton GC. The epidemiological enigma of heart failure with preserved systolic function. Eur J Heart Fail 2004; 6:125-36. [PMID: 14984719 DOI: 10.1016/j.ejheart.2003.11.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2002] [Revised: 09/16/2003] [Accepted: 11/13/2003] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Current epidemiological evidence suggests that the prevalence of preserved systolic function in patients with heart failure varies widely from 13 to 74%. This inconsistency suggests a lack of consensus as to what this condition really is and how it has been characterised for epidemiological studies. AIMS In this review, we summarise and discuss the current understanding of the epidemiology of heart failure with preserved systolic function and the challenges that this raises. METHODS Studies were identified from Medline and Embase Literature Database searches using the subject headings heart failure, diastolic heart failure, epidemiology, incidence, prevalence, diagnosis, prognosis and mortality. RESULTS Sixty-one studies of congestive heart failure with preserved systolic function were reviewed. There is great diversity in the criteria used to determine whether heart failure is present, the patient population, the setting of the study and methods of evaluating left ventricular function. This makes epidemiological studies of prevalence, morbidity and mortality impossible to compare. CONCLUSIONS The diagnosis of this syndrome might be better defined in terms of symptoms, elevated neuro hormones and impaired cardiac workload. This would allow accurate identification of cases so that further research could be conducted to measure outcome and assess therapeutic benefit.
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Affiliation(s)
- Martin D Thomas
- Cardiovascular Medicine, National Heart and Lung Institute, Imperial College, Charing Cross Campus, Fulham Palace Road, London SW3 6LY, UK.
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Affiliation(s)
- Gerard P Aurigemma
- Division of Cardiology, Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01655, USA.
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Elgeti T, Lembcke A, Enzweiler CNH, Breitwieser C, Hamm B, Kivelitz DE. Comparison of Electron Beam Computed Tomography With Magnetic Resonance Imaging in Assessment of Right Ventricular Volumes and Function. J Comput Assist Tomogr 2004; 28:679-85. [PMID: 15480045 DOI: 10.1097/01.rct.0000134197.12043.a6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Intraindividual comparison of right ventricular volumes and function using electron beam computed tomography (EBT) and magnetic resonance imaging (MRI). METHODS Twenty-seven patients with a known cardiac history were referred for evaluation of ventricular function parameters. The following standardized protocols were used: contrast-enhanced multislice mode EBT and gradient echo sequence MRI. Right ventricular end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), and ejection fraction (EF) were calculated using a slice summation method. Interobserver variability was calculated. RESULTS The correlation between the 2 methods was: r = 0.901 for EDV, r = 0.938 for ESV, r = 0.823 for SV, and r = 0.953 for EF. Electron beam computed tomography overestimated EDV and ESV slightly when compared with MRI (P < 0.05). No significant differences (P > 0.05) were found between SV and EF. Mean values determined by EBT and MRI were as follows: 168.6 +/- 62.3 mL and 153.7 +/- 59.1 mL for EDV, 104.7 +/- 60.4 mL and 95.1 +/- 54.8 mL for ESV, 63.2 +/- 19.3 mL and 58.7 +/- 19.8 mL for SV, and 40.2% +/- 14.1% and 40.2% +/- 13.6% for EF, respectively. Interobserver variability ranged between 1.0% and 3.2%. CONCLUSION Electron beam computed tomography shows good agreement with a close correlation and an acceptable interobserver variability for right ventricular volumes and global function, with a small but significant overestimation of EDV and ESV when compared with MRI.
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Affiliation(s)
- Thomas Elgeti
- Department of Radiology, Charité Medical School-Campus Mitte, Berlin, Germany.
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Peyster E, Norman J, Domanski M. Prevalence and predictors of heart failure with preserved systolic function: Community hospital admissions of a racially and gender diverse elderly population. J Card Fail 2004; 10:49-54. [PMID: 14966775 DOI: 10.1016/s1071-9164(03)00579-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The reported prevalence of preserved systolic function (PSF) heart failure (HF) varies widely and has not been well-studied in nonwhite patients. To estimate the prevalence of PSF HF resulting in hospital admission, we studied admissions to a large community hospital serving a racially diverse community. METHODS The charts of 300 consecutive patients > or =65 years old with a primary discharge diagnosis of HF were reviewed. In patients who met the Framingham criteria for HF diagnosis, an assessment of left ventricular function was obtained from review of chart data. Comparison of baseline characteristics and multivariate analysis of potential predictors of PSF HF was undertaken. RESULTS Of the 300 patients, 247 (82%) met the Framingham criteria for diagnosis of HF. Ninety-seven patients (39%) of these had PSF. Twenty (8%) of the diagnosed HF patients had a diagnosis of severe aortic or mitral valvular disease, 9 of whom had preserved systolic functions. Thus 88 (36%) of the HF patients had PSF HF likely resulting from diastolic dysfunction. On multivariate analysis, age, hypertension at presentation, peripheral edema, normal sinus rhythm and a history of coronary artery bypass grafting or coronary angioplasty were significantly associated with PSF HF rather than HF with reduced systolic function. Left bundle branch block or other intraventricular conduction delay was independently associated with reduced systolic function HF. However, because these findings occurred in patients with and without systolic dysfunction, none were pathognomonic of PSF HF. CONCLUSION In this racially diverse, majority nonwhite, cohort of older patients admitted for HF, the Framingham criteria for the diagnosis of HF were met in 82% of the patients. Of these, 39% had PSF HF and 36% had PSF HF in the absence of severe aortic or mitral valve disease, suggesting that diastolic dysfunction was etiologic. Although there was an independent association of PSF HF with a number of clinical characteristics, none of these characteristics was pathognomonic of preserved, versus reduced, systolic function HF.
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Affiliation(s)
- Eliot Peyster
- The Clinical Trials Group, Division of Heart and Vascular Diseases, National Heart, Lung, and Blood Institute/NIH, Two Rockledge Center, 6701 Rockledge Drive, MSC 7936, Bethesda, MD 20892, USA
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Phillip B, Pastor D, Bellows W, Leung JM. The Prevalence of Preoperative Diastolic Filling Abnormalities in Geriatric Surgical Patients. Anesth Analg 2003; 97:1214-1221. [PMID: 14570626 DOI: 10.1213/01.ane.0000083527.45070.f2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Preoperative assessment of heart function has typically focused on evaluating left ventricular ejection fraction (LVEF). Recent evidence suggests that diastolic heart failure is common and may cause substantial morbidity and mortality. We designed this study to examine the prevalence and potential clinical correlates of diastolic filling abnormalities as measured by echocardiography in geriatric surgical patients. Patients >=65 yr of age undergoing coronary artery surgery without concomitant valvular surgery or those with one or more risk factors for cardiovascular disease undergoing noncardiac surgery were prospectively studied. Preoperative precordial echocardiography was performed for patients undergoing noncardiac surgery, and intraoperative transesophageal echocardiography was performed for those undergoing cardiac surgery. LVEF and diastolic filling properties including E/A ratio and deceleration time were measured. Overall, 251 patients were enrolled. The mean age was 72 +/- 7 yr. Multiple linear regression analyses showed that patients with a history of myocardial infarction P = 0.021), angina pectoris (beta = -6.09, 95% CI: -9.66, -2.52; P = 0.01), and valvular heart disease (beta = -5.05, 95% CI: -9.56, -0.55; P = 0.028) had lower LVEF than those without such conditions. Of the patients with normal LVEF, 61.5% had diastolic filling abnormalities. Diastolic filling indices including E/A ratio (beta = -1.11, 95% CI -6.02, 3.78; P = 0.65) and deceleration times (beta = -3.42, 95% CI -31.28, 24.45; P = 0.81) contributed no additional predictive value for LVEF. No clinical predictors could be identified to predict diastolic filling abnormalities. For patients undergoing noncardiac surgery, analysis of variance demonstrates that the clinical assessment of LVEF using history and physical examination data was able to grossly discriminate the different levels of LVEF as compared with echocardiography (P = 0.0004). However, under-estimation of LVEF occurred more frequently than over-estimation. Although physicians' clinical assessment of systolic ejection fraction was generally accurate, geriatric patients with normal LVEF often had isolated diastolic filling abnormalities that could not be predicted by clinical factors. These results suggest that evaluation of LV systolic function alone is not discriminatory in comprehensively characterizing LV function in geriatric surgical patients. IMPLICATIONS Although physicians' clinical assessment of systolic ejection fraction was generally accurate, geriatric patients with normal left ventricular (LV) ejection fraction often had isolated diastolic filling abnormalities that could not be predicted by clinical factors. These results suggest that evaluation of LV systolic function alone is not discriminatory in comprehensively characterizing LV function in geriatric surgical patients.
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Affiliation(s)
- Bridget Phillip
- From the Department of Anesthesia and Perioperative Care, University of California, San Francisco and Department of Cardiovascular Anesthesia, Kaiser Permanente Medical Center, San Francisco, California
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Curtis JP, Sokol SI, Wang Y, Rathore SS, Ko DT, Jadbabaie F, Portnay EL, Marshalko SJ, Radford MJ, Krumholz HM. The association of left ventricular ejection fraction, mortality, and cause of death in stable outpatients with heart failure. J Am Coll Cardiol 2003; 42:736-42. [PMID: 12932612 DOI: 10.1016/s0735-1097(03)00789-7] [Citation(s) in RCA: 374] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The aim of this study was to assess the prognostic importance of left ventricular ejection fraction (LVEF) in stable outpatients with heart failure (HF). BACKGROUND Although LVEF is an accepted prognostic indicator of prognosis in HF patients, the relationship of LVEF and mortality across the full spectrum of LVEF is incompletely understood. METHODS We examined the association of LVEF and outcomes among 7,788 stable HF patients enrolled in the Digitalis Investigation Group trial. RESULTS During mean follow-up of 37 months, mortality was substantial in all LVEF groups (range, LVEF <or= 15%, 51.7%, LVEF > 55%, 23.5%). Among patients with LVEF <or= 45%, mortality decreased in a near linear fashion across successively higher LVEF groups (LVEF < 15%, 51.7%; LVEF 36% to 45%, 25.6%; p < 0.0001). This association was present after multivariable adjustment, although the magnitude of this associated risk was reduced (LVEF <or= 15%: hazard ratio [HR] 1.77, 95% confidence interval [CI] 1.48 to 2.11; LVEF 16% to 25%: HR 1.44, 95% CI 1.28 to 1.61; LVEF 26% to 35%: HR 1.10, 95% CI 0.98 to 1.28; LVEF 36% to 45%: referent). In contrast, mortality rates were comparable among patients with LVEF > 45% both before (LVEF 46% to 55%: 23.3%; LVEF > 55%: 23.5%; p = 0.25), and after multivariable adjustment (LVEF 46% to 55%: HR 0.92, 95% CI 0.77 to 1.10; LVEF > 55%: HR 0.88, 95% CI 0.71 to 1.09; LVEF 36% to 45%: referent). Patients with lower LVEF were at increased absolute risk of death due to arrhythmia and worsening HF, but these were leading causes of death in all LVEF groups. CONCLUSIONS Among HF patients in sinus rhythm, higher LVEFs were associated with a linear decrease in mortality up to an LVEF of 45%. However, increases above 45% were not associated with further reductions in mortality.
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Affiliation(s)
- Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut 06520-8025, USA
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Kerzner R, Gage BF, Freedland KE, Rich MW. Predictors of mortality in younger and older patients with heart failure and preserved or reduced left ventricular ejection fraction. Am Heart J 2003; 146:286-90. [PMID: 12891197 DOI: 10.1016/s0002-8703(03)00151-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although half of elderly patients with heart failure have preserved left ventricular ejection fraction (LVEF), little is known about predictors of mortality in this group. METHODS We reviewed the charts of 400 patients hospitalized at an academic medical center in 1999 with a principal discharge diagnosis of heart failure. Patients were divided into 4 groups on the basis of age > or =75 or <75 years and the presence of preserved or reduced LVEF. Vital status was ascertained as of October 2001. RESULTS A total of 373 patients (mean age 69.1 years, 56.0% female, 47.5% nonwhite) underwent echocardiography to assess LVEF. Of these, 216 patients were <75 years of age (81 with preserved LVEF [group 1, 21.7%] and 135 with reduced LVEF [group 2, 36.2%]), and 157 were > or =75 years of age (81 with preserved LVEF [group 3, 21.7%] and 76 with reduced LVEF [group 4, 19.6%]). After a mean follow-up of 25 months, independent predictors of mortality among the 4 groups differed substantially: group 1, male sex, prescription of a calcium-channel blocker, and diuretic dose at discharge; group 2, blood urea nitrogen (BUN), lower hemoglobin level, and not being prescribed a beta-blocker at discharge; group 3, BUN; and group 4, older age, history of myocardial infarction, severity of reduced LVEF, and diuretic dose. CONCLUSION In patients with heart failure, predictors of mortality vary by age and by the presence of preserved or reduced LVEF. Traditional predictors of mortality in patients with reduced LVEF may not apply to elderly patients with preserved LVEF.
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Affiliation(s)
- Roger Kerzner
- Department of Medicine, Washington University School of Medicine, St Louis, Mo 63110, USA
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Ansari M, Alexander M, Tutar A, Massie BM. Incident cases of heart failure in a community cohort: importance and outcomes of patients with preserved systolic function. Am Heart J 2003; 146:115-20. [PMID: 12851618 DOI: 10.1016/s0002-8703(03)00123-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The clinical presentation and outcomes of patients with heart failure and preserved systolic function have not been well characterized in the outpatient setting. METHODS This was a retrospective cohort study of 403 patients with new-onset heart failure in a large regional health maintenance organization between July 1996 and December 1996. The clinical characteristics and treatment of patients with preserved ejection fractions (PrEF; >45%) were compared with those of patients with with reduced left ventricular function (Low EF) after excluding patients with terminal comorbidities. The main outcome measure was the combination of death, cardiovascular (CV) hospitalization, or both, which was assessed for as long as 24 months (mean, 22 months) with proportional hazards models. RESULTS Sixty-five patients (16%) did not have an assessment of left ventricular (LV) function. Of the remaining 338 patients, 191(57%) had an EF <45% (Low EF group) and 147 (44%) had preserved LV function (PrEF group). Patients with PrEF tended to be older, more frequently women, have less coronary disease and myocardial infarction, and have more atrial fibrillation and other comorbid conditions. They had higher systolic blood pressures and pulse pressures and slower heart rates than the patients with reduced LV function on initial presentation. Overall, mortality and CV hospitalization rates were similar in the 2 groups; however, on multivariate analysis, which took into account baseline differences between groups, low EF was a significant independent predictor of the combined end point (hazard ratio, 1.9; 95% CI, 1.3-2.9). CONCLUSIONS Patients with preserved LV function constitute a significant portion of incident outpatient patients with heart failure and carry a better prognosis than patients with reduced LV function.
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Affiliation(s)
- Maria Ansari
- Cardiology Division, San Francisco VAMC, CA 94121, USA
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Ahmed A, Allman RM. Sex-related difference in long-term mortality in elderly heart failure patients with preserved left ventricular systolic function. J Gerontol A Biol Sci Med Sci 2003; 58:671-2; author reply 672. [PMID: 12865493 DOI: 10.1093/gerona/58.7.m671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ojeda S, Anguita M, Muñoz JF, Rodríguez MT, Mesa D, Franco M, Ureña I, Vallés F. Características clínicas y pronóstico a medio plazo de la insuficiencia cardíaca con función sistólica conservada. ¿Es diferente de la insuficiencia cardíaca sistólica? Rev Esp Cardiol 2003; 56:1050-6. [PMID: 14622535 DOI: 10.1016/s0300-8932(03)77014-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the prevalence, clinical profile and medium-term prognosis in patients with heart failure and preserved systolic ventricular function compared to those with systolic dysfunction. PATIENTS AND METHOD 153 patients were included, 62 with preserved systolic ventricular function (left ventricular ejection fraction > or = 45%) and 91 with impaired systolic ventricular function (left ventricular ejection fraction < 45%). The mean follow-up period was 25 10 months. RESULTS Mean age was similar (66 10 vs. 65 10; p = 0.54). There was a higher proportion of women among patients with preserved systolic function (53% vs. 28%; p < 0.01). Ischemic and idiopathic cardiomyopathy were the most common causes of heart failure in patients with systolic dysfunction, whereas valvular disease and hypertensive cardiopathy were the most common in patients with preserved systolic function. Angiotensin-converting enzyme inhibitors and beta-blockers were more often prescribed in patients with impaired systolic ventricular function (86% vs. 52%; p < 0.01 and 33% vs. 11%; p < 0.01, respectively). There were no differences between the groups in terms of mortality rate (37% vs. 29%), readmission rate for other causes (29% vs. 23%), readmission rate for heart failure (45% vs. 45%), cumulative survival (51% vs. 62%) and the likelihood of not being readmitted for heart failure (50% vs. 52%). In the multivariate analysis, left ventricular ejection fraction was not a predictor of death or readmission because of heart failure. CONCLUSIONS In a large proportion of patients with heart failure, systolic ventricular function is preserved. Despite the clinical differences between patients with preserved and impaired systolic ventricular function, the medium-term prognosis was similar in both groups.
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Affiliation(s)
- Soledad Ojeda
- Servicio de Cardiología. Hospital Universitario Reina Sofía. Córdoba. España.
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Varela-Roman A, Gonzalez-Juanatey JR, Basante P, Trillo R, Garcia-Seara J, Martinez-Sande JL, Gude F. Clinical characteristics and prognosis of hospitalised inpatients with heart failure and preserved or reduced left ventricular ejection fraction. Heart 2002; 88:249-54. [PMID: 12181216 PMCID: PMC1767326 DOI: 10.1136/heart.88.3.249] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine the clinical and prognostic differences between patients with heart failure who had preserved or deteriorated systolic function, defined as a left ventricular ejection fraction of > 50% or < 50%, respectively, within two weeks of admission to hospital. METHODS The records of 229 patients with congestive heart failure were studied. There were 95 women and 134 men, mean (SD) age 66.7 (11.7) years, who had been admitted to a cardiology department for congestive heart failure in the period 1991 to 1994, and whose left ventricular systolic function had been evaluated echocardiographically within two weeks of admission. Data were collected on the main clinical findings, supplementary investigations, treatment, and duration of hospital admission. Follow up information was obtained in the spring of 1998 by searching the general archives of the hospital and by a telephone survey. RESULTS Left ventricular systolic function was preserved in 29% of the patients. The preserved and deteriorated groups differed significantly in the sex ratio (more women in the preserved group) and in the presence of a third heart sound, cardiomegaly, alveolar oedema, ischaemic cardiomyopathy, and treatment with angiotensin converting enzyme (ACE) inhibitors (all more in the deteriorated group). There were no significant differences in age, New York Heart Association functional class, rhythm disturbances, left ventricular hypertrophy, treatment with drugs other than ACE inhibitors, or survival. In the group as a whole, the survival rates after three months, one year, and five years were 92.6%, 80%, and 48.4%, respectively. CONCLUSIONS In view of the unexpectedly poor prognosis of patients with congestive heart failure and preserved left ventricular systolic function, controlled clinical trials should be carried out to optimise their treatment.
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Affiliation(s)
- A Varela-Roman
- Department of Cardiology, Hospital Clinico Universitario de Santiago, Faculty of Medicine, Santiago de Compostela, Spain
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Hellermann JP, Jacobsen SJ, Gersh BJ, Rodeheffer RJ, Reeder GS, Roger VL. Heart failure after myocardial infarction: a review. Am J Med 2002; 113:324-30. [PMID: 12361819 DOI: 10.1016/s0002-9343(02)01185-3] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The effects of survival after myocardial infarction on the prevalence of chronic heart failure have not been well characterized. We reviewed studies of the incidence, mortality, and predictors of heart failure after myocardial infarction, and suggest directions for further research. METHODS AND RESULTS We conducted a review of the literature from 1978 to 2000. Of 33 identified articles, 18 (55%) included heart failure as a primary endpoint. The mean in-hospital incidence of heart failure after myocardial infarction differed significantly by study design; it was highest in population-based studies and lowest in clinical trials (37% vs. 18%, P <0.01). Only 10 studies reported the incidence of subsequent heart failure. One-year mortality ranged from 16% to 39% and showed no improvement with time. Patients with in-hospital heart failure after myocardial infarction had a two- to sixfold greater in-hospital mortality and up to a fivefold increased 1-year mortality compared with patients without heart failure. The most consistent risk factors for the development of heart failure after myocardial infarction were advanced age, female sex, diabetes, and an increased heart rate at the time of admission. CONCLUSIONS The reported incidence of, and mortality from, heart failure after myocardial infarction varies by study design. Additional research on the etiology and prognosis of late heart failure after myocardial infarction is needed.
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Affiliation(s)
- Jens P Hellermann
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Ahmed A, Roseman JM, Duxbury AS, Allman RM, DeLong JF. Correlates and outcomes of preserved left ventricular systolic function among older adults hospitalized with heart failure. Am Heart J 2002; 144:365-72. [PMID: 12177658 DOI: 10.1067/mhj.2002.124058] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Heart failure (HF) in older adults is often associated with preserved left ventricular systolic function (LVSF). The objective of this retrospective follow-up study was to determine the correlates and outcomes of preserved LVSF among older adults hospitalized with HF. METHODS We studied older Medicare beneficiaries hospitalized with HF (n = 1091) who had documented LVSF evaluation (n = 438). LVSF was defined as preserved if left ventricular ejection fraction was > or =40%. The Fisher exact test and the Student t test were used to compare baseline characteristics between patients with preserved versus those with impaired LVSF. Multivariate logistic regression analysis was used to determine the correlates of preserved LVSF. Cox proportional hazards analyses were used to determine the associations between LVSF and both 4-year mortality rates and 6-month readmission rates and the associations between angiotensin-converting enzyme (ACE) inhibitor use and 4-year mortality rates, separately, in patients with preserved and impaired LVSF. RESULTS Of the 438 patients, 200 (46%) had preserved LVSF. Women were more likely to have preserved LVSF (odds ratio [OR] = 2.44, 95% CI 1.57-3.81) than men. Preserved LVSF was associated with lower 4-year mortality rates (adjusted hazards ratio [HR] = 0.67, 95% CI 0.52-0.86) but not with 6-month readmission rates (adjusted HR = 0.66, 95% CI 0.41-1.09). The use of ACE inhibitors was associated with lower 4-year mortality rates in patients with impaired LVSF (adjusted HR = 0.61, 95% CI 0.43-0.86) but not in those with preserved LVSF (HR = 0.96, 95% CI 0.65-1.42). CONCLUSIONS Among older adults hospitalized with HF, preserved LVSF was common among women and was associated with significantly higher morbidity and mortality rates, which were unaffected by treatment with ACE inhibitors.
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Affiliation(s)
- Ali Ahmed
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Ala, USA.
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Martínez-Sellés M, García Robles JA, Prieto L, Frades E, Muñoz R, Díaz Castro O, Almendral J. [Hospitalized congestive heart failure patients with preserved versus abnormal left ventricular systolic function]. Rev Esp Cardiol 2002; 55:579-86. [PMID: 12113716 DOI: 10.1016/s0300-8932(02)76665-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To compare the clinical characteristics of hospitalized patients with congestive heart failure and left ventricular dysfunction versus normal systolic function. METHODS Clinical records of all admissions with a heart failure diagnostic code over a one-year period were reviewed retrospectively. Of 1,953 admissions, 595 were excluded because they did not fulfill diagnostic criteria. RESULTS A total of 1,069 patients had 1,358 admissions with confirmed heart failure (1.27 admissions/patient). Of them, 706 patients (66%) had an echocardiographic study and 381 (54%) had ventricular dysfunction. Ventricular dysfunction was associated with previous myocardial infarction (OR = 5.8), left bundle-branch block (OR = 5.0), male sex (OR = 2.0), and smoking (OR = 1.8). Meanwhile, a negative association existed with age (OR = 0.97), previous valve surgery (OR = 0.46) and atrial fibrillation (OR = 0.49). Patients with ventricular dysfunction had more hospitalizations in the cardiology department and received more vasodilators, aspirin, and nitrates on discharge. The prescription of angiotensin converting enzyme inhibitors prescription to patients with ventricular dysfunction increased with the severity of ventricular dysfunction and was more frequent in patients admitted to the cardiology department. Systolic dysfunction increased hospital mortality (OR = 2.9). CONCLUSIONS Patients admitted with heart failure and systolic dysfunction had a different clinical profile than patients with a normal ejection fraction. Seven clinical variables predicted the presence of systolic dysfunction. Patients with ventricular dysfunction had more hospital mortality and were prescribed vasodilators, aspirin, and nitrates more often on discharge.
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Chatterjee K. Primary diastolic heart failure. THE AMERICAN JOURNAL OF GERIATRIC CARDIOLOGY 2002; 11:178-87; quiz 188-9. [PMID: 11986532 DOI: 10.1111/j.1076-7460.2002.00051.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Diastolic heart failure is defined clinically when signs and symptoms of heart failure are present in the presence of preserved left ventricular systolic function (ejection fraction >45%). The incidence and prevalence of primary diastolic heart failure increases with age and it may be as high as 50% in the elderly. Age, female gender, hypertension, coronary artery disease, diabetes, and increased body mass index are risk factors for diastolic heart failure. Hemodynamic consequences such as increased pulmonary venous pressure, post-capillary pulmonary hypertension, and secondary right heart failure as well as decreased cardiac output are similar to those of systolic left ventricular failure, although the nature of primary left ventricular dysfunction is different. Diagnosis of primary diastolic heart failure depends on the presence of preserved left ventricular ejection fraction. Assessment of diastolic dysfunction is preferable but not mandatory. It is to be noted that increased levels of B-type natriuretic peptide does not distinguish between diastolic and systolic heart failure. Echocardiographic studies are recommended to exclude hypertrophic cardiomyopathy, infiltrative heart disease, primary valvular heart disease, and constrictive pericarditis. Myocardial stress imaging is frequently required to exclude ischemic heart disease. The prognosis of diastolic heart failure is variable; it is related to age, severity of heart failure, and associated comorbid diseases such as coronary artery disease. The prognosis of severe diastolic heart failure is similar to that of systolic heart failure. However, cautious use of diuretics and/or nitrates may cause hypotension and low output state. Heart rate control is essential to improving ventricular filling. Pharmacologic agents such as angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and calcium channel blockers are used in selected patients to decrease left ventricular hypertrophy. To decrease myocardial fibrosis, aldosterone antagonists have a potential therapeutic role. However, prospective controlled studies will be required to establish their efficacy in primary diastolic heart failure.
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Affiliation(s)
- Kanu Chatterjee
- Chatterjee Center for Cardiac Research, University of California, San Francisco, CA 94143, USA.
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41
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Mehra MR, Uber PA, Potluri S, Ventura HO. Is heart failure with preserved systolic function an overlooked enigma? Curr Cardiol Rep 2002; 4:187-93. [PMID: 11960586 DOI: 10.1007/s11886-002-0049-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Heart failure with preserved systolic function, or diastolic heart failure, represents the neglected other half of the pandemic of heart failure. Unlike previously held beliefs, diastolic heart failure carries with it the same connotation of morbidity and mortality as systolic heart failure, particularly in the elderly. Due to lack of standards in application of the diagnosis of diastolic heart failure, studies are difficult to interpret due to heterogeneity in the clinical criteria applied to the patient enrollment. It is imperative that preventive efforts be implemented in high-risk groups, and screening measures with newer biomarkers be considered for identifying underlying structural heart disease in order to employ preventive therapy early in the course of illness. No evidence-based therapeutic strategy to reduce morbidity and mortality has been established, even after the diagnosis of diastolic heart failure is manifest. Current therapy targets lusitropic abnormalities in the realm of impaired relaxation, abnormal diastolic compliance, avoidance of tachycardia, and restoration of atrial booster pump function. Outcomes-based placebo-controlled clinical trials are currently underway to define appropriate therapeutic strategies in diastolic heart failure.
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Affiliation(s)
- Mandeep R Mehra
- The Ochsner Cardiomyopathy and Heart Transplantation Center, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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Zile MR, Brutsaert DL. New concepts in diastolic dysfunction and diastolic heart failure: Part I: diagnosis, prognosis, and measurements of diastolic function. Circulation 2002; 105:1387-93. [PMID: 11901053 DOI: 10.1161/hc1102.105289] [Citation(s) in RCA: 727] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Michael R Zile
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, The Gazes Cardiac Research Institute and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC 29425, USA.
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Choudhury L, Gheorghiade M, Bonow RO. Coronary artery disease in patients with heart failure and preserved systolic function. Am J Cardiol 2002; 89:719-22. [PMID: 11897215 DOI: 10.1016/s0002-9149(01)02345-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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44
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Abstract
Diastolic dysfunction in patients with hypertension may present as asymptomatic findings on noninvasive testing, or as fulminant pulmonary edema, despite normal left ventricular systolic function. Up to 40% of hypertensive patients presenting with clinical signs of congestive heart failure have normal systolic left ventricular function. In this article we review the pathophysiologic factors affecting diastolic function in individuals with diastolic function, current and emerging tools for measuring diastolic function, and current concepts regarding the treatment of patients with diastolic congestive heart failure.
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Affiliation(s)
- R A Phillips
- Department of Medicine, Lenox Hill Hospital, 100 East 77th Street, New York, NY 10021, USA.
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45
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Francis DP, Davies LC, Coats AJS. Diagnostic exercise physiology in chronic heart failure. BRITISH HEART JOURNAL 2001. [DOI: 10.1136/hrt.86.1.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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46
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Abstract
The most frequent hospital diagnosis-related group is congestive heart failure (CHF). CHF increases dramatically with age, making it an important problem in our aging population. CHF is caused by a primary abnormality in diastolic function (diastolic heart failure [DHF]) in 50% of patients with CHF who are > 70 years of age. Mortality rates in patients with DHF are comparable to those of patients with systolic heart failure, approaching 50% over 5 years. Successful therapy of DHF requires making a correct diagnosis, identifying the underlying cause, and applying specific and individualized treatment.
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Affiliation(s)
- M R Zile
- Cardiology Section of the Department of Medicine, Gazes Cardiac Research Institute, Charleston, South Carolina, USA
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47
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Abstract
Almost half of the patients affected with congestive heart failure (CHF) in the United States are women. However, past studies have included predominantly men and generalized results to women. Many women with CHF are older, have hypertension, and have higher ejection fractions. Survival differences have been reported previously with conflicting results. Although treatment for left ventricular dysfunction is somewhat standardized, treatment for diastolic dysfunction is less defined. Clinical trials for this group of patients, many of whom are women, have not been performed. In comparison with men, women have several cardiovascular differences as well as differences in electrical properties. In addition, response to medical (pharmacologic) therapy may differ in men and women.Finally, functional status has been shown to be compromised in both men and women with CHF; however, some studies have shown women to experience more exercise intolerance. This may be because more women than men have diastolic dysfunction. Few women have been included in exercise trials. Future trials must address women with CHF, many of whom are older and have normal (or near normal) left ventricular function or diastolic dysfunction.
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48
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Roul G, Bareiss P. [Prognostic factors of chronic heart insufficiency]. Ann Cardiol Angeiol (Paris) 2001; 50:21-9. [PMID: 12555388 DOI: 10.1016/s0003-3928(01)80005-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- G Roul
- Service de cardiologie, hôpitaux universitaires de Strasbourg, avenue Molière, 67098 Strasbourg, France.
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49
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Setaro JF. The hypertensive heart: new observations and evolving therapeutic imperatives. J Clin Hypertens (Greenwich) 2001; 3:14-5. [PMID: 11416676 PMCID: PMC8099211 DOI: 10.1111/j.1524-6175.2001.00825.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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50
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Abstract
Although it is now widely recognized that isolated diastolic dysfunction can lead to the classic signs and symptoms of congestive heart failure (CHF), this disease process is poorly understood and remains of great interest and concern to cardiovascular disease specialists, as well as to primary care physicians. Recent epidemiologic data have suggested that diastolic heart failure is predominantly a disease of the elderly, the fastest growing segment of our population. Diagnosis is often difficult in this subgroup of patients due to the presence of confounding comorbidities. However, early identification in community-based practices and timely intervention is important due to the significant disability and death that results from this progressive disease process. The poor prognosis of CHF patients with systolic dysfunction is shared by those with isolated diastolic heart failure and preserved systolic function. Further studies of the prevalence, clinical characteristics, and natural history of patients with diastolic dysfunction are needed. This review focuses on the emerging data regarding the prevalence and natural history of diastolic heart failure in the community.
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Affiliation(s)
- C Y Hart
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street, Southwest, Rochester, MN 55905, USA.
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