Symptoms and signs of heart failure in patients with myocardial infarction: reproducibility and relationship to chest X-ray, radionuclide ventriculography and right heart catheterization

Performance of Cardiovascular Physical Exam Skills by Internal Medicine Residents

OBJECTIVE

Few studies have assessed the ability of internal medicine residents to perform a cardiovascular physical examination using real patients.

METHODS

First year internal medicine interns from two large academic medical centers in Maryland examined the same patient with aortic insufficiency as part of the Assessment of Physical Examination and Communication Skills (APECS). Interns were assessed on five clinical domains: physical exam technique, identifying physical signs, generating a differential diagnosis, clinical judgement, and maintaining patient welfare. Spearman's correlation test was used to describe associations between clinical domains. Preceptor comments were examined to identify common errors in physical exam technique and identifying physical signs.

RESULTS

One-hundred and nine interns examined the same patient with aortic insufficiency across 14 APECS sessions. Only 58 interns (53.2%) correctly identified the presence of a diastolic murmur, and only 52 interns (47.7%) included aortic insufficiency on their differential diagnosis. There was a significant and positive correlation between physical exam technique and identification of the correct physical findings (r=0.42, p<0.001). Both technique (r=0.34, p=0.003) and identifying findings (r=0.42, p<0.001) were significantly associated with generating an appropriate differential diagnosis. Common errors in technique included auscultating over the gown, timing the cardiac cycle with the radial pulse, and failing to palpate for the apical impulse.

CONCLUSIONS

Internal medicine interns had variable skills in performing and interpreting the cardiovascular physical exam. Improving cardiovascular exam skills would likely lead to increased identification of relevant cardiovascular findings, inform clinical decision making and improve overall patient care.

Estimated plasma volume is not a robust indicator of the severity of congestion in patients with heart failure

BACKGROUND

Congestion is the main cause of morbidity and a prime determinant of survival in patients with heart failure (HF). However, the assessment of congestion is subjective and estimation of plasma volume (ePV) has been suggested as a more objective measure of congestion. This study aimed to explore the relationships and interactions between ePV, the severity of congestion and survival using a nationwide registry.

METHODS

Of the 1054 patients with HF enrolled in the registry, 769 had sufficient data to calculate ePV (using the Duarte, Kaplan, and Hakim equations) and relative plasma volume status (rPVS), and these patients were subsequently included in the present analysis. The severity of congestion was assessed using a 6-point congestion score (CS). Patients were divided into three groups according to the degree of congestion.

RESULTS

Out of four equations tested, only ePVDuarte and rPVS were statistically higher in patients with severe congestion as compared to patients with no congestion (p<0.001 for both). Both ePVDuarte (r = 0.197, p<0.001) and rPVS (r = 0.153, p<0.001) showed statistically significant correlations with CS and both had a modest accuracy (70.4% for ePVDuarte and 69.4% for rPVS) to predict a CS ≥3. After a median follow up of 496 days, both ePVDuarte (OR:1.14,95%CI:1.03-1.26, p = 0.01) and rPVS (OR:1.02, 95%CI:1.00-1.03, p = 0.03) were associated with all-cause mortality after adjusting for demographic and clinical variables. However, none of the indices were associated with mortality following the introduction of CS to the models (p>0.05 for both).

CONCLUSIONS

Elevated ePVDuarte and rPVS were indicators of congestion but with a limited robustness, and either parameter could be clinically useful when a comprehensive clinical evaluation of congestion is not feasible.

Are non-invasive estimations of plasma volume an accurate measure of congestion in patients with chronic heart failure?

AIMS

We report associations between different formulae for estimating plasma volume status (PVS) and clinical and ultrasound markers of congestion in patients with chronic heart failure (CHF) enrolled in the Hull Lifelab registry.

METHODS AND RESULTS

Cohort 1 comprised patients with data on signs and symptoms at initial evaluation (n = 3505). Cohort 2 included patients with ultrasound assessment of congestion [lung B-line count, inferior vena cava (IVC) diameter, jugular vein distensibility (JVD) ratio] (N = 341). Two formulae for PVS were used: (a) Hakim (HPVS) and (b) Duarte (DPVS). Results were compared with clinical and ultrasound markers of congestion. Outcomes assessed were mortality and the composite of heart failure (HF) hospitalisation and all-cause mortality. In cohort 1, HPVS was associated with mortality [hazard ratio (HR) per unitary increase = 1.02 (1.01-1.03); P < 0.001]. In cohort 2, HPVS was associated with B-line count (HR) = 1.05 [95% confidence interval (CI) (1.01-1.08); P = 0.02] and DPVS with the composite outcome [HR = 1.26 (1.01-1.58); P = 0.04]. HPVS and DPVS were strongly related to haemoglobin concentration and HPVS to weight. After multivariable analysis, there were no strong or consistent associations between PVS and measures of congestion, severity of symptoms, or outcome. By contrast, log[NTproBNP] was strongly associated with all three.

CONCLUSION

Amongst patients with CHF, HPVS and DPVS are not strongly or consistently associated with clinical or ultrasound evidence of congestion, nor clinical outcomes after multivariable adjustment. They appear only to be surrogates of the variables from which they are calculated with no intrinsic clinical utility.

Theoretical and clinical disease and the biostatistical theory

Although concepts of disease have received much scrutiny, the benefits of distinguishing between theoretical and clinical disease-and what is meant by those terms-may not be as readily apparent. One way of characterizing the distinction between theoretical and clinical conceptions of disease is by relying on Boorse's biostatistical theory (BST) for a conception of theoretical disease. Clinical disease could then be defined as theoretical disease that is diagnosed. Explicating this distinction provides a useful extension of the BST. The benefits of this approach are clearly and non-normatively demarcating disease from non-disease, while allowing for values and purpose to determine what criteria are used in clinical practice to represent a disease's underlying dysfunction. Through discussion of a variety of medical conditions, including polycystic ovary syndrome and type 2 diabetes mellitus, I explore how the relationship between BST-based theoretical and clinical disease could make sense of various features of clinical practice and medical theory. It could do this by lending focus to a nuanced understanding of the pathophysiological defects present in disease and the means by which they are assessed. This could contribute to making sense of revised nosologies and diagnostic criteria.

Iatrogenic Decompensated Heart Failure

Purpose of Review

To provide an overview of the potential iatrogenic causes of acute decompensated heart failure (AHF) and an evidence-based management strategy to address this.

Recent Findings

As the heart failure (HF) population continues to age and become burdened with greater comorbidities and polypharmacy, patients become more susceptible to the iatrogenic precipitants of HF. The following clinical scenarios are familiar to clinicians, but the sequelae to AHF are often unanticipated: HF medications withdrawn during an intercurrent illness and not restarted, cardiotoxic therapy prescribed for cancer without timely and regular monitoring of left ventricular function, excessive intravenous fluids administered for sepsis or postoperatively, a blood transfusion volume not adjusted for body weight, iatrogenic anaemia that goes unnoticed or an inappropriate type of pacemaker implanted in a patient with underlying left ventricular systolic dysfunction.

Summary

Iatrogenic decompensated HF is a phenomenon that is infrequently documented in the literature but increasingly confronted by clinicians of all specialties. It is associated with a high mortality and morbidity rate. By having greater awareness of these triggers, iatrogenic AHF should be one that is prevented rather than managed when it occurs.

Prevalence, pattern and clinical relevance of ultrasound indices of congestion in outpatients with heart failure

AIMS

Even if treatment controls symptoms, patients with heart failure may still be congested. We aimed at assessing the prevalence and clinical relevance of congestion in outpatients with chronic heart failure.

METHODS AND RESULTS

We recorded clinical and ultrasound [lung B-lines; inferior vena cava (IVC) diameter; internal jugular vein diameter before and after a Valsalva manoeuvre (JVD ratio)] features of congestion in heart failure patients during a routine check-up. Of 342 patients who attended, predominantly in New York Heart Association class I or II (n = 257; 75%), 242 (71%) had at least one feature of congestion, either clinical (n = 139; 41%) or by ultrasound (n = 199; 58%). Amongst patients (n = 203, 59%) clinically free of congestion, 31 (15%) had ≥ 14 B-lines, 57 (29%) had a dilated IVC (> 2.0 cm), 38 (20%) had an abnormal JVD ratio (< 4), 87 (43%) had at least one of these, and 27 (13%) had two or more. During a median follow-up of 234 (interquartile range 136-351) days, 60 patients (18%) died or were hospitalized for heart failure. In univariable analysis, each clinical and ultrasound measure of congestion was associated with increased risk but, in multivariable models, only higher N-terminal pro-B-type natriuretic peptide and IVC, and lower JVD ratio, were associated with the composite outcome.

CONCLUSIONS

Many patients with chronic heart failure with few symptoms have objective evidence of congestion and this is associated with an adverse prognosis. Whether using these measures of congestion to guide management improves outcomes requires investigation.

Imaging technologies for cardiac fiber and heart failure: a review

There has been an increasing interest in studying cardiac fibers in order to improve the current knowledge regarding the mechanical and physiological properties of the heart during heart failure (HF), particularly early HF. Having a thorough understanding of the changes in cardiac fiber orientation may provide new insight into the mechanisms behind the progression of left ventricular (LV) remodeling and HF. We conducted a systematic review on various technologies for imaging cardiac fibers and its link to HF. This review covers literature reports from 1900 to 2017. PubMed and Google Scholar databases were searched using the keywords "cardiac fiber" and "heart failure" or "myofiber" and "heart failure." This review highlights imaging methodologies, including magnetic resonance diffusion tensor imaging (MR-DTI), ultrasound, and other imaging technologies as well as their potential applications in basic and translational research on the development and progression of HF. MR-DTI and ultrasound have been most useful and significant in evaluating cardiac fibers and HF. New imaging technologies that have the ability to measure cardiac fiber orientations and identify structural and functional information of the heart will advance basic research and clinical diagnoses of HF.

Fluid Management in Patients with Chronic Heart Failure

Congestion, or fluid overload, is a classic clinical feature of patients presenting with heart failure patients, and its presence is associated with adverse outcome. However, congestion is not always clinically evident, and more objective measures of congestion than simple clinical examination may be helpful. Although diuretics are the mainstay of treatment for congestion, no randomised trials have shown the effects of diuretics on mortality in chronic heart failure patients. Furthermore, appropriate titration of diuretics in this population is unclear. Research is required to determine whether a robust method of detecting - and then treating - subclinical congestion improves outcomes.

Nosology, ontology and promiscuous realism

Medics may consider worrying about their metaphysics and ontology to be a waste of time. I will argue here that this is not the case. Promiscuous realism is a metaphysical position which holds that multiple, equally valid, classification schemes should be applied to objects (such as patients) to capture different aspects of their complex and heterogeneous nature. As medics at the bedside may need to capture different aspects of their patients' problems, they may need to use multiple classification schemes (multiple nosologies), and thus consider adopting a different metaphysics to the one commonly in use.

Development and initial validation of a simple clinical decision tool to predict the presence of heart failure in primary care: the MICE (Male, Infarction, Crepitations, Edema) rule

AIMS

Diagnosis of heart failure in primary care is often inaccurate, and access to and use of echocardiography is suboptimal. This study aimed to develop and provisionally validate a clinical prediction rule to optimize referral for echocardiography of people identified in primary care with suspected heart failure.

METHODS AND RESULTS

A systematic review identified studies of diagnosis of heart failure set in primary care. The individual patient data for five of these studies were obtained. Logistic regression models to predict heart failure were developed on one of the data sets and validated on the others using area under the receiver operating characteristic curve (AUROC), and goodness-of-fit calibration plots. A model based upon four simple clinical features (Male, history of myocardial Infarction, Crepitations, Edema: MICE) and natriuretic peptide had good validity when applied to other data sets, with AUROCs between 0.84 and 0.93, and reasonable calibration. The rule performed well across the data sets, with sensitivity between 81% and 96% and specificity between 57% and 74%.

CONCLUSIONS

A simple clinical rule based upon gender, history of myocardial infarction, presence of ankle oedema, and presence of basal lung crepitations can discriminate between people with suspected heart failure who should be referred straight for echocardiography and people for whom referral should depend upon the result of a natriuretic peptide test. Prospective validation and an implementation evaluation of the rule is now warranted.

Ultrasound pleural effusion sign as a useful marker for identifying heart failure worsening in established heart failure patients during follow-up

Clinical significance of UltraSound Pleural Effusion (US-PLE) and test characteristics of this sign for identifying worsening heart failure (HF) during follow-up of HF patients are unclear. Clinical records of 83 established HF patients were examined. The diagnosis of worsening HF was classified as "highly certain,""probable,""uncertain," or "no" based on the combination of the changes in symptoms/signs and B-type natriuretic peptide (BNP). Routine test included searching for the US-PLE sign. During a follow-up of 652±456 days, 1826 visits were evaluated. Among the 83 study patients, 78 had at least one of the following: worsening symptom(s), HF-related sign(s), and/or elevated BNP levels (≥3-fold increase) at one or more clinic visits. The US-PLE sign was present at 83 visits of 49 study patients. Its appearance was associated with the presence of HF-related symptom(s)/sign(s) and BNP elevation (odds ratio, 53-177, P<.0001 each). The test characteristics of the US-PLE sign for diagnosis of high possibility of worsening HF status fulfilling the "highly certain" or "probable" criteria were: sensitivity (76.6%), specificity (98.6%), positive predictive value (71.1%), and negative predictive value (99.0%). The US-PLE sign has high diagnostic accuracy for identifying worsening HF, including asymptomatic events, in HF patients during follow-up.

Can new pulmonary gas exchange parameters contribute to evaluation of pulmonary congestion in left-sided heart failure?

BACKGROUND

Assessment of pulmonary congestion in left-sided heart failure is necessary for guiding anticongestive therapy. Clinical examination and chest x-ray are semiquantitative methods with poor diagnostic accuracy and reproducibility.

OBJECTIVES

To establish reference values, describe reproducibility, and investigate the diagnostic and monitoring properties in relation to pulmonary congestion of new pulmonary gas exchange parameters describing ventilation/perfusion mismatch (variable fraction of ventilation [fA2] or the drop in oxygen pressure from the mixed alveolar air of the two ventilated compartments to the nonshunted end-capillary blood [DeltaPO(2)]) and pulmonary shunt.

METHODS

Sixty healthy volunteers and 69 patients requiring an acute chest x-ray in a cardiac care unit were included. The gas exchange parameters were estimated by analyzing standard bedside respiratory and circulatory measurements obtained during short-term exposure to different levels of inspired oxygen. Nine patients were classified as having pulmonary congestion using a reference diagnosis and were followed during 30 days of anticongestive therapy. Diagnostic and monitoring properties were compared with chest x-ray, N-terminal probrain natriuretic peptide (NT-proBNP), spirometry values, arterial oxygen tension, alveolar-arterial oxygen difference and venous admixture.

RESULTS

The 95% reference intervals for healthy subjects were narrow (ie, fA2 [0.75 to 0.90], DeltaPO(2) [0.0 kPa to 0.5 kPa] and pulmonary shunt [0.0% to 8.2%]). Reproducibility was relatively good with small within subject coefficients of variation (ie, fA2 [0.05], DeltaPO(2) [0.4 kPa] and pulmonary shunt [2.0%]). fA2, DeltaPO(2) and NT-proBNP had significantly better diagnostic properties, with high sensitivities (100%) but low specificities (30% to 40%). During successful anticongestive therapy, fA2, DeltaPO(2), NT-proBNP and spirometry values showed significant improvements.

CONCLUSIONS

The gas exchange parameter for ventilation/perfusion mismatch but not pulmonary shunt can have a possible role in rejecting the diagnosis of pulmonary congestion and in monitoring anticongestive therapy.

Heart murmur and N-terminal pro-brain natriuretic peptide as predictors of death in 2977 consecutive hospitalized patients

BACKGROUND

Little is known about the prognostic importance of murmur in unselected patients. It is difficult to distinguish between innocent and significant murmurs. N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and BNP have recently been shown to be useful in small series of patients with valvular heart disease. We wanted to test whether murmur predicts mortality in unselected patients admitted to the hospital and whether NT-pro-BNP is capable of distinguishing between innocent and significant murmurs.

METHODS

Consecutive patients (n = 2977) older than 40 years admitted to a local hospital were studied. Auscultation, echocardiography were performed and levels of natriuretic peptides were measured.

RESULTS

A total of 21.8% of the 2977 patients had a murmur. After adjusting for sex and age there was a significant difference in the one-year mortality of patients with and without murmur (OR = 1.57, 95% CI = 1.27-1.94). NT-pro-BNP gave additional prognostic information for both patients with and without murmurs. Presence of a murmur was an independent predictor of 1-year mortality (OR = 1.36, 95% CI = 1.03-1.80) in a multivariate analysis. In patients with a murmur but normal NT-pro-BNP, discovery of valvular heart disease by echocardiography yielded no additional prognostic information.

CONCLUSIONS

Detection of a cardiac murmur during routine medical examination of hospitalized patients is associated with increased risk of death within a year. A blood test for NT-pro-BNP gives significant additional prognostic information of a murmur and could obviate the need for echocardiography in selected patients with a murmur and normal NT-pro-BNP for whom surgery is not feasible.

Age-related pulmonary crackles (rales) in asymptomatic cardiovascular patients

PURPOSE

The presence of age-related pulmonary crackles (rales) might interfere with a physician's clinical management of patients with suspected heart failure. We examined the characteristics of pulmonary crackles among patients with stage A cardiovascular disease (American College of Cardiology/American Heart Association heart failure staging criteria), stratiffed by decade, because little is known about these issues in such patients at high risk for congestive heart failure who have no structural heart disease or acute heart failure symptoms.

METHODS

After exclusion of comorbid pulmonary and other critical diseases, 274 participants, in whom the heart was structurally (based on Doppler echocardiography) and functionally (B-type natriuretic peptide <80 pg/mL) normal and the lung (X-ray evaluation) was normal, were eligible for the analysis.

RESULTS

There was a significant difference in the prevalence of crackles among patients in the low (45-64 years; n = 97; 11%; 95% CI, 5%-18%), medium (65-79 years; n = 121; 34%; 95% CI, 27%-40%), and high (80-95 years; n = 56; 70%; 95% CI, 58%-82%) age-groups (P <.001). The risk for audible crackles increased approximately threefold every 10 years after 45 years of age. During a mean follow-up of 11 +/- 2.3 months (n = 255), the short-term (< or =3 months) reproducibility of crackles was 87%. The occurrence of cardiopulmonary disease during follow-up included cardiovascular disease in 5 patients and pulmonary disease in 6.

CONCLUSIONS

Recognition of age-related pulmonary crackles (rales) is important because such clinically unimportant crackles are so common among elderly patients that, without knowledge of this phenomenon, their existence might interfere with the physician's management of cardiopulmonary patients.

Chronic intermittent hypoxia causes hepatitis in a mouse model of diet-induced fatty liver

Obstructive sleep apnea (OSA) causes chronic intermittent hypoxia (CIH) during sleep. OSA is associated with nonalcoholic steatohepatitis (NASH) in obese individuals and may contribute to progression of nonalcoholic fatty liver disease from steatosis to NASH. The purpose of this study was to examine whether CIH induces inflammatory changes in the liver in mice with diet-induced hepatic steatosis. C57BL/6J mice (n = 8) on a high-fat, high-cholesterol diet were exposed to CIH for 6 mo and were compared with mice on the same diet exposed to intermittent air (control; n = 8). CIH caused liver injury with an increase in serum ALT (461 +/- 58 U/l vs. 103 +/- 16 U/l in the control group; P < 0.01) and AST (637 +/- 37 U/l vs. 175 +/- 13 U/l in the control group; P < 0.001), whereas alkaline phosphatase and total bilirubin levels were unchanged. Histology revealed hepatic steatosis in both groups, with mild accentuation of fat staining in the zone 3 hepatocytes in mice exposed to CIH. Animals exposed to CIH exhibited lobular inflammation and fibrosis in the liver, which were not evident in control mice. CIH caused significant increases in lipid peroxidation in serum and liver tissue; significant increases in hepatic levels of myeloperoxidase and proinflammatory cytokines IL-1beta, IL-6, and CXC chemokine MIP-2; a trend toward an increase in TNF-alpha; and an increase in alpha1(I)-collagen mRNA. We conclude that CIH induces lipid peroxidation and inflammation in the livers of mice on a high-fat, high-cholesterol diet.

Radial Artery Pulse Pressure Variation Correlates With Brachial Artery Peak Velocity Variation in Ventilated Subjects When Measured by Internal Medicine Residents Using Hand-Carried Ultrasound Devices

BACKGROUND

Rapid prediction of the effect of volume expansion is crucial in unstable patients receiving mechanical ventilation. Both radial artery pulse pressure variation (DeltaPP) and change of aortic blood flow peak velocity are accurate predictors but may be impractical point-of-care tools.

PURPOSES

We sought to determine whether respiratory changes in the brachial artery blood flow velocity (DeltaVpeak-BA) as measured by internal medicine residents using a hand-carried ultrasound (HCU) device could provide an accurate corollary to DeltaPP in patients receiving mechanical ventilation.

METHODS

Thirty patients passively receiving volume-control ventilation with preexisting radial artery catheters were enrolled. The brachial artery Doppler signal was recorded and analyzed by blinded internal medicine residents using a HCU device. Simultaneous radial artery pulse wave and central venous pressure recordings (when available) were analyzed by a blinded critical care physician.

RESULTS

A Doppler signal was obtained in all 30 subjects. The DeltaVpeak-BA correlated well with DeltaPP (r = 0.84) with excellent agreement (weighted kappa, 0.82) and limited intraobserver variability (2.8 +/- 2.8%) [mean +/- SD]. A DeltaVpeak-BA cutoff of 16% was highly predictive of DeltaPP > or = 13% (sensitivity, 91%; specificity, 95%). A poor correlation existed between the CVP and both DeltaVpeak-BA (r = - 0.21) and DeltaPP (r = - 0.16).

CONCLUSIONS

The HCU Doppler assessment of the DeltaVpeak-BA as performed by internal medicine residents is a rapid, noninvasive bedside correlate to DeltaPP, and a DeltaVpeak-BA cutoff of 16% may prove useful as a point-of-care tool for the prediction of volume responsiveness in patients receiving mechanical ventilation.

Chronic intermittent hypoxia predisposes to liver injury

Obstructive sleep apnea (OSA) is characterized by chronic intermittent hypoxia (CIH). OSA is associated with nonalcoholic steatohepatitis (NASH) in obese subjects. The aim of this study was to investigate the effects of CIH on the liver in the absence of obesity. Lean C57BL/6J mice (n = 15) on a regular chow diet were exposed to CIH for 12 weeks and compared with pair-fed mice exposed to intermittent air (IA, n = 15). CIH caused liver injury with an increase in serum ALT (224 +/- 39 U/l versus 118 +/- 22 U/l in the IA group, P < 0.05), whereas AST and alkaline phosphatase were unchanged. CIH also induced hyperglycemia, a decrease in fasting serum insulin levels, and mild elevation of fasting serum total cholesterol and triglycerides (TG). Liver TG content was unchanged, whereas cholesterol content was decreased. Histology showed swelling of hepatocytes, no evidence of hepatic steatosis, and marked accumulation of glycogen in hepatocytes. CIH led to lipid peroxidation of liver tissue with a malondialdehyde (MDA)/free fatty acids (FFA) ratio of 0.54 +/- 0.07 mmol/mol versus 0.30 +/- 0.01 mmol/mol in control animals (P < 0.01), and increased levels of active nuclear factor kappaB (NF-kappaB) in the nuclear fraction of hepatocytes, suggesting that CIH induced oxidative stress in the liver. Finally, CIH greatly exacerbated acetaminophen-induced liver toxicity, causing fulminant hepatocellular injury.

CONCLUSION

In the absence of obesity, CIH leads to mild liver injury via oxidative stress and excessive glycogen accumulation in hepatocytes and sensitizes the liver to a second insult, whereas NASH does not develop.

Self-assessed symptoms in chronic heart failure - Important information for clinical management

AIM

To compare the patients' self-assessment of the severity of their symptoms with a physicians assessment and to evaluate the ability of self-assessed symptoms and ejection fraction (EF) to predict long-term survival in heart failure patients.

METHOD

Patients (n=332) evaluated symptoms using a self-administered functional classification scale (Specific Activity Scale, SAS), which is equivalent to the NYHA scale. EF and NYHA functional class was also recorded. All patients were followed over a 3-year period.

RESULTS

Approximately 50% of patients classified themselves into SAS class I. In contrast, the cardiologists classified only 9% of the patients as NYHA class I. In patients with severe left ventricular dysfunction (EF<or=0.35) SAS score (HR 1.48, 95% CI [1.03-2.12] p=0.03) and ACE inhibitor treatment (0.23 [0.11-0.51], p=0.0003) independently predicted 3-year mortality in a multivariable analysis. EF was not predictive of mortality in the low EF group. Only age predicted long-term outcome in patients with preserved systolic function.

CONCLUSION

Patients' self-assessed symptoms and NYHA classification are not coherent. Left ventricular EF is of less importance in comparison with symptoms in chronic heart failure. Patients reporting less severe symptoms had a favourable 3-year prognosis, regardless of EF.

Are Elderly Patients with Suspected HF Misdiagnosed?

BACKGROUND

Few studies are published on heart failure patients in primary health care, in elderly in advanced age.

OBJECTIVE

The purpose of this study was to examine the accuracy of the diagnosis of heart failure in all men and women with focus on age and gender.

METHODS

The patients were recruited from one selected primary health care in the city of Skellefteå, Sweden. The general practitioners included all patients who had symptoms and signs indicating heart failure. The patients were then referred for an echocardiographic examination and a final cardiology consultation.

RESULTS

The general practitioners identified 121 women and 49 men with suspected heart failure of whom 39% (51 women and 16 men) were above 80 years. Women were significantly older than men (mean age 78 and 75 years, respectively, p = 0.03). The main symptom was dyspnoea (80%). Confirmed heart failure was verified in 45% of the patients and was significantly more common in men than women (p = 0.02). Of all men and women above 80 years, 75% and 22%, respectively (p = 0.01) had a verified systolic heart failure, while there were no significant gender differences in patients younger than 80. In a multivariate regression analysis taking gender, age, smoking, atrial fibrillation, hypertension, angina, myocardial infarction and diabetes into account, myocardial infarction (OR = 4.3, CL = 1.8-10.6) hypertension (OR = 3.4, CI = 1.6-6.9) atrial fibrillation (OR = 2.8, CL = 1.0-7.9) remained significantly predictive of a confirmed diagnosis of heart failure.

CONCLUSION

This study showed the difficulty of diagnosing heart failure accurately based only on clinical symptoms, especially in women above 80 years.

Effect of teaching and type of stethoscope on cardiac auscultatory performance

BACKGROUND

Auscultation of the heart is a routine procedure. It is not known whether auscultatory skills can be improved by teaching or with the use of an advanced stethoscope.

METHODS

This study was a randomized trial with a 2 x 2 factorial design. Seventy-two house officers were randomized to a simple or an advanced stethoscope and to a 4-hour course in auscultation or no course. The doctors auscultated 20 patients' hearts and categorized findings as normal or as one or more of 5 categories of heart diseases. Patients were selected such that 16 had a known heart disease as well as a corresponding murmur and 4 had no heart disease or murmur. Auscultatory performance was assessed as concordance with echocardiographic findings and interobserver variation.

RESULTS

Doctors using the advanced stethoscope diagnosed 35% of the patients correctly, as compared with doctors using the simple stethoscope who did 33% of the patients (P = .27). Similarly, 34% of the patients were diagnosed correctly by doctors who had received teaching as compared with 33% of those who were by doctors who had received no teaching (P = .41). The kappa values were higher for doctors who had received teaching for aortic stenosis (0.43 vs 0.28, P = .004) and ventricular septum defect (0.07 vs 0.01, P = .003). There was no difference between groups for any other single murmur or for the detection of murmurs as such.

CONCLUSION

Heart auscultation findings were in poor accordance with echocardiographic findings and had high interobserver variation. Neither outcome improved to any important extent with the subjects' use of an advanced stethoscope or attending of a course in heart auscultation.

Clinical deterioration in established heart failure: what is the value of BNP and weight gain in aiding diagnosis?

BACKGROUND

Weight gain and increase in B-Type Natriuretic Peptide have been advocated as means of aiding diagnosis of heart failure. However, there are few data to support the use of these criteria in diagnosing clinical deterioration in patients with established disease.

AIMS

This prospective study examines the sensitivity and specificity of absolute and relative changes in BNP and weight in determining the early onset of clinical deterioration in patients with established heart failure.

METHODS

All patients who presented to the outpatient clinic with completed self-reported daily weight books, baseline BNP measurement, outpatient BNP measurement and assessment by a cardiologist blinded to BNP and weight were included. Each patient was determined as clinically stable (CS) or in clinical deterioration (CD). Receiver operating characteristic (ROC) curves and sensitivity and specificity calculations for various absolute and relative BNP and weight changes were carried out.

RESULTS

Weight and BNP changes were examined in 34 CS presentations (mean age 69.5+/-16.1 years) and 43 CD presentations (mean age 70.0+/-10.6 years). ROC analysis demonstrated that neither weight nor BNP changes in absolute or relative values predicted clinical deterioration in this study population adequately (AUC values ranging from 0.64 to 0.66).

CONCLUSIONS

These data demonstrate that increase in body weight and BNP in isolation are not sensitive in assessing clinical deterioration in established heart failure. These observations may need to be emphasized in patient education and to physicians involved in assessment of heart failure patients.

Symptoms in patients with heart failure are prognostic predictors: insights from COMET

BACKGROUND

Although functional status, as assessed by the New York Heart Association classification, is known to be a powerful prognostic marker in chronic heart failure (CHF), the significance of individual symptoms such as breathlessness and fatigue are unknown.

OBJECTIVE

To assess the relative importance of self-reported severity of symptoms as predictors of outcomes in CHF.

METHODS AND RESULTS

All 3029 patients randomized in the Carvedilol or Metoprolol European Trial (ie, COMET) study were included in the analysis. Mean follow-up was 58 months. Symptoms were assessed by 5-point scales. In a univariate analysis, worse scores for breathlessness, orthopnea and fatigue were all significantly related to increased mortality (all P < .0001) and development of worsening heart failure. In a multivariate Cox regression analysis including 16 baseline covariates, only the symptom of breathlessness remained significantly related to mortality (risk ratio [RR] 1.14 per unit: 95% CI 1.04-1.26; P = .01). Fatigue, but not breathlessness, remained a significant predictor for developing worsening heart failure (RR 1.09 per unit; 95% CI 1.02-1.18; P = .02).

CONCLUSIONS

Fatigue and breathlessness, common symptoms in CHF, have important and independent long-term prognostic implications. Accordingly, symptoms need to be effectively evaluated not only because symptom alleviation is a target for treatment, but also because they guide prognosis in patients with CHF.

Exploring symptoms in chronic heart failure

Symptoms in patients with chronic heart failure (CHF) are the cry for help, reflecting not only the physical aspects of the disease but the impact on lifestyle, anxiety, depression and expectations of the patient. Studies consistently show a difference in patients' self-assessed functional classification compared to investigator reported NYHA classification. Moreover, patient self-assessed symptoms have recently been shown to independently predict hospitalisation and mortality over 5 years. Recognition of symptoms and appreciation of their importance justifies the use of a structured assessment in order to provide optimal medical care for patients with CHF. A model of how to structure symptom assessment equally with signs is presented in this paper.

Diagnostic and Prognostic Performance of N-Terminal ProBNP in Primary Care Patients With Suspected Heart Failure

BACKGROUND

The value of N-terminal pro-brain natriuretic peptide (NT-proBNP) in terms of diagnosis and prognosis in congestive heart failure (CHF) and left ventricular systolic dysfunction (LVSD) has been demonstrated previously in various populations, but data on primary care patients are sparse. The aim of this study was to evaluate the diagnostic and prognostic performance of NT-proBNP in primary care patients with suspected CHF.

METHODS AND RESULTS

Three hundred sixty-seven consecutive patients (mean age, 68.8 years; range, 39.0-84.0 years) who had been referred by their general practitioner for echocardiographic evaluation because of suspected CHF. In all patients, NT-proBNP was measured at baseline and left ventricular ejection fraction (LVEF) was estimated with echocardiography. LVSD (LVEF < or =0.40) was found in 9% of the patients. NT-proBNP was significantly higher in patients with LVSD (P < .0001). With predefined cut off values for NT-proBNP (125 pg/mL), the sensitivity, specificity, positive predictive value, and negative predictive value for the detection of LVSD were 0.97, 0.46, 0.15 and 0.99, respectively. Area under the receiver operating characteristic curve was 0.87. The application of an age-differentiated cut-off value for NT-proBNP (125 pg/mL for <75 years old and 450 pg/mL for > or =75 years old) did not increase diagnostic performance. Patients were followed for a median of 778 days; 8% of the patients died during the follow-up period. The mortality rate was higher in patients with NT-proBNP of >125 pg/mL than in patients with normal values (P < .002, log rank), and the difference persisted after controlling for age, gender, and LVEF (hazard ratio per unit increase in log NT-proBNP, 2.2; range, 1.2-4.1; P = .015).

CONCLUSION

In primary care patients who were referred for echocardiography because of suspected CHF, NT-proBNP values <125 pg/mL effectively rule out LVSD. Furthermore low NT-proBNP values are associated with a lower risk of death, independently of age, gender, and LVEF.

B-type natriuretic peptide measurement in heart failure

Serum testing for the hormone B-type natriuretic peptide (BNP) may have clinical utility in congestive heart failure (CHF). This hormone is secreted predominantly by the left ventricular myocardium in patients with CHF. Measurement of serum BNP may improve diagnosis of CHF and may also help guide therapy in patients with CHF. The literature regarding the clinical utility of BNP measurement in CHF is reviewed.

Ultrasound stethoscopy

Miniaturization and digital techniques have resulted in the development of high-resolution, battery-powered personal ultrasound devices with excellent grey-scale and color blood flow imaging capabilities. These devices are appropriately called "ultrasound stethoscopes" and are practical to use. They extend our physical perception during a clinical examination by "seeing the invisible pathology" and allow the user to address specific clinical problems anywhere at the point-of-care. Murmurs and abnormal precordial movements can be directly related to cardiac structural, functional, and flow abnormalities. A cardiac abnormality (pericardial effusion, dilated heart, valvular disease, mass lesion) is rapidly confirmed during the clinical examination and often a specific diagnosis is made. The device can effectively assist in the initial evaluation and rapid diagnosis of potentially life-threatening conditions or in situations where quick decision-making is essential. Overall, they strengthen our clinical diagnostic accuracy and also add quantitative information. The ultrasound stethoscope allows rapid screening for left ventricular dysfunction and occult aortic abdominal aneurysm and left ventricular hypertrophy in patients with hypertension. Training may become an important issue and should focus on criteria of normalcy and identifying specific and major cardiac disorders. There is no doubt, however, that these devices will revolutionize the physical cardiac examination and diagnosis.

Importance of chronic obstructive pulmonary disease for prognosis and diagnosis of congestive heart failure in patients with acute myocardial infarction

AIMS

To evaluate the importance of chronic obstructive pulmonary disease for prognosis and diagnosis of congestive heart failure in patients with acute myocardial infarction.

METHOD AND RESULTS

Prospective registration of 6669 consecutive patients admitted with infarction and screened for a randomised controlled trial. A history of COPD was present in 765 (11.5%) patients. Thirty-day and 5-year survival in patients with chronic obstructive pulmonary disease was 86.3 and 42.9%. In patients without pulmonary disease the figures were 87.7 and 57.5%, respectively, giving a relative risk of 1.49 (1.35-1.65). In multivariate analysis the relative risk was 1.15 (1.04-1.28). The prevalence of congestive heart failure was 65.9% in patients with chronic obstructive pulmonary disease and 52.0% in patients without. This difference was most distinct in patients with normal or only slightly decreased left ventricular systolic function. In patients without congestive heart failure, chronic obstructive pulmonary disease was of prognostic importance [RR=1.44 (1.17-1.78)], but not in patients with congestive heart failure [RR=1.09 (0.96-1.23)].

CONCLUSION

Chronic obstructive pulmonary disease is a predictor of long-term mortality in patients with acute myocardial infarction without congestive heart failure, but is also a confounding factor for the diagnosis of congestive heart failure.

Hand carried echocardiography in the critical care setting

Miniaturized echocardiography units known as hand carried ultrasound (HCU) now exist with features similar to those used for standard echocardiography. The small size and low cost of these units may lead to increased availability of echocardiography to be performed by all physicians taking care of critically ill patients. Use of HCU by critical care physicians may allow for improved bedside diagnosis with improved accuracy over physical examination. Studies comparing HCU with standard echocardiography in the critical care setting have reported that HCU is limited by decreased image quality and that it may miss important diagnoses even when used by experienced sonographers and echocardiographers. Despite its limitations, however, HCU can often answer important clinical questions in the critically ill. This review explores the current literature on the use of HCU in the critical care setting, discusses the limitations of HCU, and examines the costs of implementing this new technology.

Third heart sound and elevated jugular venous pressure as markers of the subsequent development of heart failure in patients with asymptomatic left ventricular dysfunction

PURPOSE

To determine the independent prognostic value of a third heart sound (S(3)) and elevated jugular venous pressure in patients with asymptomatic left ventricular dysfunction.

METHODS

We performed a post hoc analysis of 4102 participants from the Studies of Left Ventricular Dysfunction (SOLVD) prevention trial. In that trial, participants with asymptomatic or minimally symptomatic left ventricular dysfunction (New York Association class I or II, left ventricular ejection fraction < or =0.35, no treatment for heart failure) were allocated randomly to enalapril or placebo and followed for a mean (+/- SD) of 34 +/- 14 months. The presence of an S(3) and elevated jugular venous pressure was ascertained by physical examination at study enrollment. We used multivariate proportional hazards models to determine whether these physical examination findings were associated with the development of heart failure, a prespecified endpoint of the SOLVD prevention trial.

RESULTS

At baseline, 209 subjects (5.1%) had an S(3) and 70 (1.7%) had elevated jugular venous pressure. Heart failure developed in 1044 subjects (25.5%). After adjusting for other markers of disease severity, an S(3) was associated with an increased risk of heart failure (relative risk [RR] = 1.38; 95% confidence interval [CI]: 1.09 to 1.73; P = 0.007) and the composite endpoint of death or development of heart failure (RR = 1.34; 95% CI: 1.09 to 1.64; P = 0.005). Elevated jugular venous pressure was also associated with these outcomes in multivariate models.

CONCLUSION

The physical examination provides prognostic information among patients with asymptomatic or minimally symptomatic left ventricular dysfunction.

Palpation of the upper thoracic spine: an observer reliability study

OBJECTIVE

To assess the intraobserver reliability (in terms of hour-to-hour and day-to-day reliability) and the interobserver reliability with 3 palpation procedures for the detection of spinal biomechanic dysfunction in the upper 8 segments of the thoracic spine.

DESIGN

A repeated-measures design was used in all substudies.

SETTING

Department of Nuclear Medicine, Odense University Hospital, Denmark.

PARTICIPANTS

Two chiropractors examined 29 patients and 27 subjects in the interobserver part and 1 chiropractor examined 14 patients and 15 subjects in the intraobserver studies.

INTERVENTION

Three types of palpation were performed: Sitting motion palpation and prone motion palpation for biomechanic dysfunction and paraspinal palpation for tenderness. Each dimension was rated as "absent" or "present" for each segment. All examinations were performed according to a standard written procedure.

RESULTS

Using an "expanded" definition of agreement that accepts small inaccuracies (+/-1 segment) in the numbering of spinal segments, we found--based on the pooled data from the thoracic spine--kappa values of 0.59 to 0.77 for the hour-to-hour and the day-to-day intraobserver reliability with all 3 palpation procedures. Kappa coefficients were 0.24 and 0.22 for the interobserver reliability with prone and sitting motion palpation and 0.67 and 0.70, respectively, with paraspinal palpation for tenderness.

CONCLUSION

With expanded agreement we found good hour-to-hour and day-to-day intraobserver reliability with all 3 palpation procedures and good interobserver reliability for paraspinal tenderness. The interobserver reliability was unacceptably poor with prone and sitting motion palpation.

Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure

BACKGROUND

The independent prognostic value of elevated jugular venous pressure or a third heart sound in patients with heart failure is not well established.

METHODS

We performed a retrospective analysis of the Studies of Left Ventricular Dysfunction treatment trial, in which 2569 patients with symptomatic heart failure or a history of it were randomly assigned to receive enalapril or placebo. The mean (+/-SD) follow-up was 32+/-15 months. The presence of elevated jugular venous pressure or a third heart sound was ascertained by physical examination on entry into the trial. The risks of hospitalization for heart failure and progression of heart failure as defined by death from pump failure and the composite end point of death or hospitalization for heart failure were compared in patients with these findings on physical examination and patients without these findings.

RESULTS

Data on 2479 patients were complete and analyzed. In multivariate analyses that were adjusted for other markers of the severity of heart failure, elevated jugular venous pressure was associated with an increased risk of hospitalization for heart failure (relative risk, 1.32; 95 percent confidence interval, 1.08 to 1.62; P<0.01), death or hospitalization for heart failure (relative risk, 1.30; 95 percent confidence interval, 1.11 to 1.53; P<0.005), and death from pump failure (relative risk, 1.37; 95 percent confidence interval, 1.07 to 1.75; P<0.05). The presence of a third heart sound was associated with similarly increased risks of these outcomes.

CONCLUSIONS

In patients with heart failure, elevated jugular venous pressure and a third heart sound are each independently associated with adverse outcomes, including progression of heart failure. Clinical assessment for these findings is currently feasible and clinically meaningful.

The role of thoracic ultrasonography for evaluation of patients with decompensated chronic heart failure

OBJECTIVES

This study examined the usefulness of thoracic ultrasonography for evaluation of fluid accumulation in patients with decompensated chronic heart failure (CHF) in comparison with physical signs, upright posteroanterior chest X-ray and echocardiography.

BACKGROUND

Decompensated CHF is frequently accompanied by pleural effusion, suggesting that pleural effusion is a useful marker for confirming the diagnosis of the uncontrolled stage of CHF. Thoracic ultrasonography seems to be adequate for this purpose.

METHODS

Patients with uncontrolled CHF and an interpretable physical examination, chest X-ray, ultrasonogram for the heart and thorax and thoracic X-ray computed tomographic (CT) scan were enrolled in the study (n = 60). Patients free from thoracic and cardiovascular diseases served as a control (n = 22). Thoracic CT scan was used as the gold standard for the presence or absence of pleural effusion. Variables used to predict body fluid accumulation included the following: pulmonary rales, jugular venous distension or peripheral edema, roentgenographic evidence of pulmonary edema or pleural fluid, pericardial or pleural effusion on ultrasonographic study.

RESULTS

The reported incidence of pleural effusion detected by thoracic ultrasonography was high (91%). The incidence of physical signs and roentgenographic signs of body fluid accumulation, however, was modest (56%) to low (33%). The best clinical variable for identifying patients with decompensated CHF was the detection of pleural fluid by thoracic ultrasonography (91% predictive accuracy). This variable also had high interobserver agreement (95% overall agreement, kappa = 0.70). There was only 41% to 65% predictive accuracy of other clinical variables, with 72% to 95% agreement (kappa = 0.400-0.848).

CONCLUSIONS

Thoracic ultrasonography is a simple, sensitive and accurate method for the evaluation of body fluid accumulation in patients with decompensated CHF. This technique can be used to assist in making the diagnosis of decompensated CHF if other causes of pleural effusion have been clinically ruled out.

Clinical predictors of heart failure in patients with first acute myocardial infarction

BACKGROUND

The occurrence of heart failure associated with an acute myocardial infarction has a strong adverse effect on long-term morbidity and mortality. The prediction and prevention of heart failure could influence these adverse events.

METHODS AND RESULTS

We studied 483 consecutive patients who had their first acute myocardial infarction and who were admitted within 24 hours of the onset of symptoms. Heart failure was defined as the presence of pulmonary rales or an S3 gallop, or the presence of alveolar or interstitial edema by radiograph. Baseline demographic data, determination of peak creatine phosphokinase level, echocardiographic left ventricular ejection fraction, blood pressure, and pulse were obtained. Heart failure occurred in 41.6% (201 of 483) of the patients. We observed a bimodal occurrence of heart failure with an early occurrence at admission in 4% (20 of 483) followed by a second increase beginning after the fourth day of admission in 39% of the remaining patients (181 of 463). Predictors of early heart failure were older age, diabetes mellitus, or previous cardiac symptoms, whereas the predictors of heart failure after the fourth day included the same demographic predictors in addition to a history of hypertension, male sex, increased peak creatine phosphokinase level and heart rate, and decrease in left ventricular ejection fraction. In-hospital death occurred in 5.3% compared with 1.4% (P =.012) in patients who did and did not have heart failure, respectively. The occurrence of heart failure during hospital admission also adversely affected the 18-month follow-up, with 14.9% deaths in the patients with heart failure and 6.4% in those without heart failure (P =.002).

CONCLUSION

Heart failure is frequently associated with acute myocardial infarction and occurs with a bimodal distribution and is associated with increased risk of death during hospitalization and during 18 months of follow-up. Predictors of early heart failure include previous medical conditions and age. The second peak occurrence can be predicted by similar characteristics in addition to increased peak creatine phosphokinase level, decreased left ventricular ejection fraction, and increased heart rate.

Clinical assessment of indication for ACE-inhibitor treatment early after acute myocardial infarction

An investigation was conducted to assess whether an algorithm based on simple clinical information would suffice to classify patients with acute myocardial infarction, with respect to indication for angiotensin-converting-enzyme inhibitor treatment. One hundred consecutive patients with myocardial infarction were prospectively studied. Based on clinical, radiological, electrocardiographic and biochemical information, the patients were classified as having (a) significantly depressed left ventricular function (ejection fraction < or = 40%) justifying treatment with angiotensin-converting-enzyme inhibitors (ACEI), (b) preserved ventricular function (ejection fraction > 40%) making ACEI unnecessary, or (c) indeterminate ventricular function, requiring further examination. Using a blinded design, ejection fraction was determined by echocardiography and radionuclide ventriculography. A clinical assumption of reduced left ventricular function had a predictive value of an echocardiographically determined ejection fraction < or = 40% of 83% (n = 23). Clinical criteria of good ventricular function had a predictive value of ejection fraction > 40% of 96% (n = 24). In these two groups clinical misclassification occurred in five patients with ejection fraction within the range of 39-45%. Left ventricular function was found to be clinically indeterminate in 53 of the 100 patients. Ejection fraction values assessed by radionuclide ventriculography (n = 44) were on average 9.3%-points lower than echocardiographic values. The indication for ACEI can apparently be determined on the basis of readily available clinical information in approximately 50% of patients with acute myocardial infarction.

Development and validation of a clinical history form for the diagnosis of congestive heart failure

Our aim was to develop and validate a new diagnostic tool for congestive heart failure (CHF) based only on clinical examination, medical history and current drug use. In the developmental phase, we enrolled 520 consecutive patients with heart disease of different etiology; the diagnosis of CHF was made by means of Smith's clinical and radiological criteria, and the Boston criteria, with a substantial interscale agreement (kappa = 0.89). The initial version of our Form included 37 items on clinical examination, medical history and drug use information. After an item reduction process, the final version of the Clinical History Form (CH Form) included 15 items, each with a score 1 to 4. The CH Form score showed a progressive, significant increase as NYHA Class increased. With a cut-off of 4 points, sensitivity was 88.6% and specificity 86.8% against Smith's criteria for diagnosis of CHF. Substantial interrater agreement was observed for all the 15 items (kappa > 0.6) on a subsample of 250 patients. In the validation phase, we studied an independent sample of 72 patients with heart disease. The CH Form was significantly correlated with left ventricular ejection fraction (r = 0.42; p < 0.0005) and peak oxygen consumption (r = 0.69; p < 0.0001). In the 64 (89%) patients who underwent non-emergent right-heart catheterization, the CH Form score was significantly correlated with pulmonary capillary wedge pressure (r = 0.84; p < 0.0001). The CH Form may represent a useful instrument for the diagnosis of CHF.

Left ventricular atrioventricular plane displacement: an echocardiographic technique for rapid assessment of prognosis in heart failure

OBJECTIVE

To assess the prognostic value of atrioventricular plane displacement in heart failure patients.

DESIGN

Patients were followed prospectively for one year after atrioventricular plane displacement determination.

SETTING

Malmö University Hospital, with a primary catchment area of 250,000 inhabitants.

PATIENTS

181 patients with a clinical diagnosis of heart failure; age 75.7 (SD 5.2) years, duration of heart failure 2.7 (5.7) years; 100 men, 81 women.

MAIN OUTCOME MEASURES

Mortality in relation to atrioventricular plane displacement.

RESULTS

Total mortality was 22.7% (41/181), and was highly significantly (P = 0.001) related to atrioventricular plane displacement. Mortality within prospectively defined categories of displacement was: > or = 10.0 mm, 0% (0/19); 8.2 to 9.9 mm, 10.3% (3/29); 6.4 to 8.1 mm, 19.4% (12/62); and < 6.4 mm, 36.6% (26/71). The groups were similar in age, sex, angiotensin converting enzyme inhibitor and beta blocker treatment, and cause and duration of heart failure.

CONCLUSIONS

Mortality in heart failure is strongly related to atrioventricular plane displacement.

Clinical characteristics and long-term outcome of patients in whom congestive heart failure develops after thrombolytic therapy for acute myocardial infarction: development of a predictive model

Ischemic heart disease is the most common cause of congestive heart failure, which often begins after acute myocardial infarction. To better delineate the clinical characteristics and outcomes of patients in whom congestive heart failure develops after acute myocardial infarction in the thrombolytic era, we prospectively evaluated patients enrolled in six of the TAMI trials. The study cohort comprised 1619 consecutive patients who had at least 1 mm of ST-segment elevation in two contiguous electrocardiographic leads within 6 hours of the onset of acute myocardial infarction and who received intravenous thrombolytic therapy. We prospectively collected clinical characteristics, baseline demographics, acute and 1-week angiographic variables, and in-hospital and 1-year outcome data. We performed stepwise multivariable regression analysis to determine the noninvasive and invasive predictors of the development of in-hospital congestive heart failure. Congestive heart failure developed in 301 patients in the hospital (19% of 1521 patients admitted were not in heart failure). These patients were likely to be older and female, have diabetes mellitus and previous myocardial infarction, and have an anterior wall myocardial infarction. On acute angiography, they had lower ejection fractions and a higher incidence of multivessel disease. Patency at 90 minutes was lower in the patients with congestive heart failure, and acute mitral regurgitation occurred in 1.6% versus 0.21% of patients without congestive heart failure. Patients with congestive heart failure had higher mortality, more in-hospital complications, and longer hospitalizations. At 1-year follow up, 21% of the patients in whom congestive heart failure developed had died versus 5% in the group without congestive heart failure. Predictors of new congestive heart failure included increased age, anterior wall myocardial infarction, lower pulse pressure and systolic blood pressure, diabetes mellitus, and the presence of rales on admission. The acute angiographic variables of reduced ejection fraction, increased number of diseased vessels, and attempted percutaneous intervention improved the concordance of the predictive model by 6%. Congestive heart failure remains a common clinical problem after acute myocardial infarction and is associated with a twofold increase in in-hospital morbidity and a fourfold increase in in-hospital and 1-year mortality. The development of congestive heart failure in the hospital can be predicted from noninvasive and invasive baseline characteristics. We present a simple table to predict congestive heart failure from baseline characteristics and invasive information.

The utility of clinical, electrocardiographic, and roentgenographic variables in the prediction of left ventricular function

To determine the clinical value of simple, widely available variables in estimating left ventricular (LV) function, we performed an analysis on 14,507 patients presenting with chest pain who were enrolled in the Coronary Artery Surgery Study registry. Of these patients, 4,034 had a normal electrocardiogram, and of these, 91.8% had an LV ejection fraction (EF) > 0.50, 7.6% had an EF of 0.36 to 0.50, and only 0.6% had an EF < or = 0.35. The presence of T-wave abnormalities (with normal QRS), left bundle branch block, electrocardiographic evidence of LV hypertrophy or myocardial infarction, cardiomegaly on chest roentgenogram, basilar rales, or third heart sound significantly decreased the likelihood of normal LVEF. Based on these clinical variables, a logistic regression model with a sensitivity of 68% and a specificity of 74% for identifying subjects with normal EF was developed. It was concluded that in patients with chest pain, consideration of such readily available clinical data provides useful information and may decrease the need for more expensive imaging methods.

Improving the accuracy of severity indexes: exceptions to the rules

This study explores the difference between additive and non-additive indexes in measuring the severity of myocardial infarction. It shows, as an example, the fallacy of adding severity scores in a straightforward manner. An additive severity index was constructed from the judgments of seven experts. The experts also identified several exceptions to the additive index. The study used the exceptions to modify the additive index and produce a non-additive severity index. The non-additive severity index explained 36% more of the variance in the severity judgments made by five physicians and two nurses on 50 hypothetical cases than the additive index did. In addition, the non-additive index was 3% more accurate in predicting in-hospital mortality of 7,500 patients with myocardial infarction. When the study reduced the noise in the data by ignoring 1,200 rare cases in which stable estimates of mortality rate were unavailable, the prediction of the non-additive index was 13% more accurate than that of the additive index. Statistical tests showed that the differences between the additive and the non-additive indexes were significant at an alpha level below 1%. The practical implications of non-additive severity indexes are discussed. Researchers and physicians who assess the severity of myocardial infarction should systematically explore exceptions that may improve the accuracy of prediction of an additive index.

Evaluation and management of patients with both peripheral vascular and coronary artery disease

The prevalence of serious angiographic coronary artery disease ranges from 37% to 78% in patients undergoing operation for peripheral vascular disease. Clinical studies have demonstrated that cardiac outcome after peripheral vascular surgery is not adequately predicted by the standard criteria of history, physical findings and rest electrocardiogram. An adequate exercise work load, left ventricular function and thallium redistribution have proved important in perioperative risk stratification. The choice of a perioperative functional cardiac test depends on patient-related factors and the nature of the peripheral vascular operation. Although procedures involving aortic cross-clamping exert a greater hemodynamic stress than do carotid endarterectomy and femoral popliteal surgery, late cardiac morbidity and mortality are significant in all patients with atherosclerotic disease. The decision to proceed with preoperative coronary angiography and myocardial revascularization should be based primarily on indications independent of the peripheral vascular procedure. However, peripheral vascular surgery may influence the timing of myocardial revascularization. Patients with high risk or unstable coronary artery disease may benefit from preoperative coronary revascularization, although this hypothesis remains unproved. In all patients, careful monitoring during and after operation is essential. All patients with peripheral vascular disease should be considered to be at lifelong risk for fatal and nonfatal cardiac events and should undergo appropriate clinical and laboratory evaluation and be treated accordingly.

Early estimation of risk by echocardiographic determination of wall motion index in an unselected population with acute myocardial infarction

In a prospective series of 201 consecutive patients with creatine kinase-MB--documented acute myocardial infarction (AMI), postadmittance and predischarge echocardiographic wall motion indexes (WMI) were determined (median 45 hours vs 14 days after AMI). No significant change of left ventricular systolic performance was found between postadmittance and predischarge examinations in 179 survivors (WMI 1.3 +/- 0.4 vs 1.4 +/- 0.4, p greater than 0.05). Hospital mortality was 11% (22 of 201), cumulated 2-month mortality 15% (31 of 201) and cumulated 1-year mortality 26% (52 of 201). Mortality increased rapidly with decreasing left ventricular function as determined by WMI. When early WMI was less than 1.0, 1-year mortality was 51% (28 of 55) versus 8% (7 of 83) when WMI was greater than 1.3 (p less than 0.0001). Ventricular fibrillation (n = 24) and cardiogenic shock (n = 27) carried a much better prognosis when WMI showed good left ventricular function. When WMI was less than 1.0, 1-year mortality was 83% (10 of 12) versus 93% (13 of 14) in ventricular fibrillation and cardiogenic shock, respectively, whereas it was 0% (0 of 4) versus 33% (2 of 6) when WMI was greater than 1.3. In 15% of patients major discrepancies between early Killip class and WMI were noted. WMI showed much smaller fluctuations during the hospital course of AMI than did Killip class and appeared to be a more stable prognostic marker. Large-scale, early risk stratification by echocardiography has now become available and appears to facilitate a rational, individualized discharge policy in the coronary care unit and to provide an improved basis for randomization of patients in controlled studies aimed at tailoring new treatment in AMI.