Detrimental effects of intense vasodilation in women with acute heart failure: novel insights from a prospective randomized controlled trial

Background

Guidelines recommend evaluating the risk/benefit ratio of novel therapies individually in women and men, as the pathophysiology and the response to treatment may differ according to sex. Among patients with acute heart failure (AHF), a strategy of intensive vasodilation, compared with usual care, overall did provide comparable outcomes. However, sex-specific differences in heart failure pathophysiology and the effect of the strategy in women with AHF remained unclear.

Purpose

To characterize sex-specific differences in heart failure pathophysiology and to evaluate the effect of a strategy that emphasized early intensive and sustained vasodilation in women with AHF.

Methods

In a randomized, open-label blinded-end-point trial patients hospitalized for AHF were enrolled in 10 hospitals in Switzerland, Bulgaria, Germany, Brazil, and Spain. Inclusion criteria were AHF expressed by acute dyspnea and increased plasma concentrations of natriuretic peptides, systolic blood pressure ≥100 mmHg, and a plan for treatment in a general ward. Patients were randomized 1:1 to a strategy of early intensive and sustained vasodilation throughout the hospitalization or usual care. The primary end point was a composite of all-cause mortality or rehospitalization for AHF at 180 days. The subgroup analysis according to sex was predefined.

Results

Among 781 patients who completed the trial, 288 (36.9%) were women. Women were significantly older, had a higher systolic blood pressure at presentation and a more common history of diastolic dysfunction (all ps<0.05), whereas men had a significantly higher body surface area, a more common history of ischemic heart disease and a significant lower left ventricular ejection fraction (all ps<0.05). The primary end point, a composite of all-cause mortality or rehospitalization for AHF at 180 days, occurred in 53 female patients (37.9%) in the intervention group (including 28 deaths [20.0%]) and in 35 female patients (23.6%) in the usual care group (including 22 deaths [14.9%]) (absolute difference for the primary end point, 14.3%; adjusted hazard ratio, 1.62 [95% CI, 1.05–2.50]; P=0.03).

Conclusion

Among women with AHF, a strategy of early intensive and sustained vasodilation, compared with usual care, had a detrimental effect on a composite outcome of all-cause mortality and AHF rehospitalization at 180 days.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): University Hospital Basel

Prognostic value of a disease-specific health-related quality score in acute heart failure

Background

Despite the striking therapeutic progress made in the treatment of heart failure (HF), rehospitalization rate and mortality remain a major and often unpredictable problem. Previous studies have shown the prognostic value of Kansas City Cardiomyopathy Questionnaire (KCCQ), a score assessing disease-specific health-related quality of life in stable chronic HF patients. Recently, a large study including 4898 patients with acute HF (AHF) enrolled in China reported the incremental predictive ability of KCCQ for a composite outcome of death and rehospitalization. However, these findings were not yet confirmed. In order to address this unmet need, the aim of this study was to examine the prognostic value of KCCQ in another AHF cohort.

Purpose

To validate the prognostic value of the KCCQ in AHF.

Methods

Goal-directed AfterLoad Reduction in Acute Congestive Cardiac Decompensation Study (GALACTIC) was a prospective, multicenter (n=10), randomized, interventional controlled trial enrolling adult patients presenting with AHF. KCCQ was assessed shortly after admission. We focused on the prognostic value of the short version KCCQ-12, explored the association with the composite of all-cause mortality and AHF rehospitalization within 30- and 180-day follow-up and compared it to the original score. Patients were grouped into quartiles according their KCCQ: high-risk (0–<25), moderate- to high-risk (25–<50), low- to moderate-risk (50–<75) and low-risk group (75–100). Cumulative incidence of assessed endpoints was displayed in Kaplan-Meier curves. Covariate adjustments were made using Cox regression. Prognostic accuracy over N-terminal pro-B-type natriuretic peptide (NT-proBNP) was evaluated by time-dependent area under the curve.

Results

Among 781 patients, 419 (median age 78, 35% female, 32% new onset of HF) had a complete set of variables to calculate KCCQ. Follow-up was available in all patients up to 180 days. 29 (7%) and 122 (29%) patients died or were rehospitalized for AHF within 30- and 180-days, respectively. Median KCCQ-12 was 37.5 with 25% of patients attaining the high- and 8% the low-risk group. After adjustment, each 10-point decrease in the KCCQ was associated with a 10% increase in 180-day risk regardless of new onset or acute decompensated chronic HF, age, sex, comorbidities, systolic blood pressure, creatinine, NT-proBNP and sodium levels. The prognostic ability for a 30-day risk was not significant. Using the same adjustments, a 10-point decrease in the original KCCQ was significant for a 20% and a 11% increase in risk for the short- and long-term composite outcome. The prognostic accuracy of KCCQ was comparable to NT-proBNP.

Conclusions

Health status, measured by the KCCQ-12 among patients with AHF, is significantly associated with a long-term composite outcome of all-cause mortality and AHF rehospitalization. The original KCCQ overall score is an independent predictor for both, the 30- and 180-day composite outcome.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union, the Swiss National Science Foundation

Prevalence, patient characteristics and outcome of hyponatremia in acute heart failure

Background

Hyponatremia is the most common electrolyte disturbance found in hospitalized patients. Previous studies have shown that low serum sodium levels at presentation are associated with increased mortality and morbidity in patients hospitalized with acute heart failure (AHF). However, given the complicated multifactorial origin of hyponatremia, the role of serum sodium level in risk stratification in patients with AHF is still largely unknown.

Purpose

To evaluate the prevalence and prognostic value of hyponatremia in patients presenting with AHF to the emergency department (ED).

Methods

Basics in Acute Shortness of Breath EvaLuation (BASEL V) was a prospective, multicenter, diagnostic study recruiting dyspneic patients at the ED. The final diagnosis of AHF was adjudicated by 2 independent physicians. Hyponatremia was defined as a serum sodium level of <135 mmol/l. The prognostic accuracy of hyponatremia in predicting all-cause mortality and a composite outcome of death and heart failure (HF) rehospitalization was quantified using multivariable adjusted Cox regression. Adjustments were made for the following variables: age, sex, history of ischemic heart disease, previous HF, infection as a trigger of AHF, systolic blood pressure, glomerular filtration rate and log-transformed N-terminal pro-B-type natriuretic peptide (NT-proBNP) at presentation. The incremental value of hyponatremia to the MEESSI-Score, a validated AHF risk score, was quantified using area under the curve (AUC) analyses.

Results

Among 1572 patients with AHF, 1499 patients were eligible for the main analysis, of whom 215 (14.3%) had hyponatremia, 1249 (83.3%) normonatremia and 35 (2.3%) hypernatremia at presentation. Of those with hyponatremia, 21 (9.8%) and 54 (25.1%) patients died, 27 (12.6%) and 79 (36.7%) patients experienced the composite outcome within 30 and 180 days, respectively. Multivariable adjusted hazard ratios (aHR) were 0.97 (95%-CI 0.94–1.01) and 0.97 (95%-CI 0.95–0.99) for mortality, 0.97 (95%-CI 0.94–1.00) and 0.98 (95%-CI 0.95–0.99) for the composite outcome within 30 and 180 days, respectively. The risk for mortality and a composite of all-cause mortality and HF rehospitalization within 180 days after presenting to the ED with AHF rose significantly with a lower sodium level at presentation. Each 1-unit decrease in sodium level [mmol/L] was associated with a 3% and 2.7% increase in the hazard rate of mortality (aHR 0.97, p=0.01) and the composite outcome (aHR 0.98, p=0.01), respectively. While in the 30-day analyses after multivariable adjustment sodium had no significant prognostic value. The already excellent predictive ability of the MEESSI-Score for 30-day mortality was not enhanced by sodium level (AUC 0.80 versus 0.80, p=0.834).

Conclusion

Hyponatremia at presentation is associated with a higher risk of 180-day mortality in patients with AHF. However, its role as an independent prognostic marker in risk stratification remains unclear.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science FoundationSchweizerische Herzstiftung

CA 125 in the diagnosis and risk stratification of acute heart failure

Background

Recent evidence confirms the elevation of CA 125 in non-tumor processes such as acute heart failure (AHF). However, the utility of this novel biomarker for diagnosis, prognosis, and therapy guidance in AHF remains unclear.

Purpose

To investigate the potential of CA 125 for diagnosis, prognosis and therapy guidance in unselected AHF patients presenting with acute dyspnea to the emergency department (ED).

Methods

We quantified CA 125 in a blinded fashion among patients presenting with acute dyspnea to the ED in a multicenter diagnostic study. Final diagnosis of AHF including AHF-phenotype was centrally adjudicated by two independent cardiologists. To further characterize CA 125's potential in AHF correlations with established biochemical and imaging markers were assessed. Diagnostic accuracy for AHF was quantified by the area under the receiver operating characteristic curve (AUC). All-cause mortality within 360 days was the prognostic endpoint.

Results

Among 470 patients eligible for this analysis, 268 (57.0%) had adjudicated AHF. CA 125 concentrations at presentation were significantly higher among AHF patients vs. patients with other final diagnoses (45.8 U/ml [interquartile range (IQR), 18.5–110.3] vs. 16.2 U/ml [IQR, 9.6–31.6], p<.001). Patients with worsening heart failure had significant higher CA 125 levels compared to other heart failure phenotypes (p=.018). There was a significant positive correlation of CA 125 and high-sensitivity cardiac troponin T and NTproBNP and a significant negative correlation of CA 125 and left ventricular ejection fraction (correlation coefficients 0.204, 0.220, −0.331, respectively; all ps<.001). CA 125's AUC for AHF was significantly lower compared to NTproBNP's in the overall population (0.72, 95% confidence interval (CI) 0.67–0.76 vs. 0.93, 95% CI 0.90–0.95, p<.001, Figure 1) and in predefined subgroups according to age, gender and renal function. Among 268 AHF patients, 84 (31.3%) died within 360 days of follow-up. CA 125 plasma concentrations above the median indicated increased risk of all-cause mortality (hazard ratio 2.06, 95% CI 1.31–3.24; p=.002, Figure 2). CA 125's prognostic accuracy for 360-days mortality was comparable with NT-proBNP's and high-sensitivity cardiac troponin T's. CA 125 did not independently predict all-cause mortality at 360 days when used in validated multivariable regression models and had no interactions with medical therapies at discharge.

Conclusion

CA 125 may aid physicians in the risk stratification and rapid triage of patients with suspected AHF.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation Figure 1. ROC curve comparisonFigure 2. Kaplan-Meier curve 360 days mortality

Discordance in prognostic ability between physician assessed NYHA classification and self-reported health status in patients with acute heart failure

Background

Especially in patients with acute heart failure (AHF) the NYHA classification remains of uncertain representation of patients' actual health state. Alternatively, patient's subjective well-being, in terms of health-related quality of life (HRQL), showed to have an excellent prognostic ability in out clinic patients with chronic heart failure.

Objectives

It is unknown whether HRQL instruments can assess a more reliable prognostication in patients hospitalized due to AHF than the NYHA classification.

Methods

Goal Directed Afterload Reduction in Acute Congestive Cardiac Decompensation Study (GALACTIC) was a multicenter, randomized, open-label blinded-end-point trial that emphasized early intensive and sustained vasodilation in adult patients hospitalized due to AHF with NYHA functional class III/IV, however provided neutral findings. HRQL was assessed by the generic EQ-5D-3L which is a 3-leveled 5-item instrument and the disease-specific Kansas City Cardiomyopathy Questionnaire (KCCQ). Unadjusted and adjusted Cox regression models were performed after patients were grouped into low (EQ-5D −0.074<0.25; KCCQ 0<25), moderately low (0.25<0.5; 25<50), moderately high (0.5<0.75; 50<75) and high HRQL (0.75–1.0; 75–100).

Results

781 patients were enrolled in 10 centres in 5 countries over 2 continents among which 536 (69%) patientshad completed theEQ-5D and 419 (54%) the KCCQ shortly after admission. Within 180 days of follow-up69 (13%) and 54 (13%) patients died and 151 (28%) and 122 (29%) died or were rehospitalized due to AHF, respectively. Cumulative incidence as well as HRs in patients grouped according to NYHA (n=536) indicated a comparable or significantly lower risk in patients with NYHA IV: e.g. for the combined outcome HR 1.07 (95% CI 0.777–1.473) and aHR 0.463 (95% CI 0.245–0.875). Whereas HRs in patients grouped according to both, EQ-5D (n=536) and KCCQ (n=419), increased from the group with highest to the group with the lowest HRQL: e.g. aHR for moderately high 1.11 (95% CI 0.718–1.715), for moderately low 1.721 (95% CI 1.102–2.688) and for low EQ-5D index 1.891 (95% CI 1.136–3.149) referenced to high HRQL (EQ-5D index 0.75–1.0).

Conclusions

These findings corroborate and extend previous work suggesting that NYHA classification poorly discriminates AHF patients' prognosis and challenge its' extensive application. HRQL might be a possible alternative to easily assess these patients' heath state.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, the Swiss Heart Foundation A. 180-day mortality; B. composite outcome

Prognostic value of self-reported subjective exercise capacity in patients with acute dyspnea

Background

Quantitative assessment of self-reported exercise capacity as provided by the Duke Activity Status Index (DASI) is a validated measure of exercise capacity in stable ambulatory patients.

Objectives

This study aimedto test whether the quantification of self-reported exercise capacityusing the DASI may aid physicians in the risk stratification of patients presenting with acute dyspnea to the emergency department (ED).

Methods

Basics in Acute Shortness of Breath EvaLuation (BASEL V) was a prospective cohort study recruiting dyspneic patients at the ED. The prognostic value and accuracy of theDASI assessed shortly after presentation were quantified using Cox regression analyses and the Area under the curve (AUC).

Results

Among 1019 patients eligible for this analysis 529 (51.9%) had an adjudicated final diagnosis of acute heart failure, 75 (7.4%) and 297 (29.1%) patients died within 90 and 720 days after presentation. Unadjusted hazard ratios (HR) and multivariable adjusted hazard ratios (aHR) for 90-day and 720-day mortality increased continuously from the fourth (best self-reported exercise capacity) to the first DASI-quartile (worst self-reported exercise capacity). For 720-day mortality in the first quartile theHR was 9.1 (95%-CI 5.5–14.9) (aHR 6.1 [95%-CI 3.7–10.1]), in the second quartile 6.4 (95%-CI 3.9–10.6) (aHR 4.4 [95%-CI 2.6–7.3]), while in the third quartile the HR was 3.2 (95%-CI 1.9–5.5) (aHR 2.4 [95%-CI 1.4–4.0]). The prognostic accuracy of the DASI was moderate-to-high and higher than that of B-type natriuretic peptide (BNP) and NT-proBNP (N-terminal pro-BNP) concentrations, e.g. for 720-day mortality prediction AUC 0.70 versus 0.64, p=0.020; 0.72 versus 0.68, p=0.074.

Conclusions

Quantification of self-reported subjective exercise capacityusing the DASI provides moderate-to-high prognostic accuracy in patients presenting with acute dyspnea to the ED and may aid physicians in further risk stratification.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union, the Swiss National Science Foundation. Duke Activity Status Index

Safety and acute clinical outcomes of atrial fibrillation catheter ablation in octogenarians: a multicentre evaluation with a matched younger cohort

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Sven Knecht and the International Octogenarian AF ablation group

Background

Octogenarians are a fast-growing demographic with a high burden of atrial fibrillation (AF). There are limited data on procedural safety and acute outcomes of catheter ablation (CA) for AF in this group.

Purpose

Investigation of complications & outcomes in octogenarians undergoing CA for AF.

Methods

Data on all octogenarian patients who underwent AF ablation at nine European cardiology centres between 2013 and 2019 were retrospectively analysed and matched with control patients aged <80 years.  The characteristics used for matching were type of AF, type of procedure (de novo or redo), & the year of procedure.

Results

216 octogenarians (81.9 ± 1.9 years; 52.8% females) underwent an AF ablation procedure, and were matched with 216 patients aged <80 years (62.4 ± 9.5 years, 34.7% females), p <0.001 for both. The proportion of paroxysmal and persistent AF was 43.5% & 56.5% respectively in both groups, and 79.3% of the procedures were de novo. RF ablation made up 75.4% & 75.9% (p = 0.90) procedures in octogenarians and controls respectively.  17 complications occurred in 14 (7.9%) octogenarian patients and 11 in 11 (5.1%) patients in the younger matched cohort (p = 0.07). There were 4.2% & 1.9% major complications (p= 0.17) and 3.7% & 3.2% minor complications (p= 0.77) in the octogenarian & younger cohorts respectively. Complications in octogenarians consisted of groin complications (n = 6), pneumonia (n = 3), pericardial effusion (n = 2), phrenic nerve injury (n = 2), pulmonary oedema (n = 1), gastroparesis (n = 1), stroke (n = 1). Acute procedural success rates were 99.1% & 99.5% (p = 0.62) The complication rates were similar for RF; 6.0% vs 5.4% (p = 0.79) and Cryoballoon; 14.0% vs 4.1% (p = 0.09) in both octogenarians and younger cohort respectively.

Conclusion

In spite of significantly higher overall risk profile of octogenarians undergoing AF ablation, there is no difference in acute procedural success and complication rates as compared to younger patients Catheter ablation of AF in octogenerians Octogenarians n = 216 Matched Controls (aged < 80yrs) n = 216 P value Age (yrs), mean (SD)s 81.9 (1.9) 62.4(9.5) < 0.0001 Females, (%) 52.8 34.7 0.0002 CHA2DS2-VASc, mean (SD) 3.6 (1.2) 1.4 (1.3) < 0.0001 Mean LA size, mm 42.8 ± 8.3mm 45.8 ± 16.2 0.062 Impaired LV function, (%) 23.7 17.9 0.206 IHD, (%) 20.7 5.9 < 0.0001 Procedural time (mins), mean (sd) 150.6 (69.7) 148.9 (64.4) 0.914 All complications, n (%) 17 (7.9) 11 (5.1) 0.073

Ablation Index-guided 50W ablation for left atrial posterior wall isolation compared with lower powers: feasibility and lesion level analysis

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Groupe de Rythmologie de la Société Française de Rythmologie

Background 

Posterior Wall Isolation (PWI) is increasingly performed for Atrial Fibrillation (AF). The use of Ablation Index (AI)-guided 50W ablation for PWI has not been described, nor the interplay between ablation parameters at this power when compared to lower powers. 

Methods 

40 consecutive AF patients (26 males, 65.5 ± 10.0 years. 95% non-paroxysmal AF) underwent PWI following pulmonary vein isolation. A roof line and floor line were created with point-by-point ablation, targeting a contact force (CF) of 10-30g, AI 550-600 on the roof and 400-450 on the floor, and inter-tag distance of <6mm. 35-40W powers were used for the first 20 patients, and 50W used for the next 20. Generator impedance was monitored in real time for each lesion. Ablation inside the box was delivered in case of failure of first pass isolation (FPI). All VisiTags (n = 959) were analyzed retrospectively. 

Results 

PWI was successful in 19(95%) of the 35-40W group and in all 20 patients in the 50W group, with FPI seen in 8(40%) and 10(50%) respectively, p = 0.53. The mean CF and number of RF applications on the roof. floor and inside the box were similar between the two groups. Ablation time per lesion (10.4 [8.8-12.5]sec) and total ablation time per patient (3.84[3.34-4.66] min) were shorter in the 50W group as compared to 35-40W (13.0 [11.6-16.2] sec and 5.86 [4.23-7.73] min respectively), p < 0.005. The mean AI and Impedance Drop were larger in the 50W group (Table). There was no steam pop observed in any of the 959 radiofrequency applications. 

Conclusion 

Ablation Index guided 50W ablation has a very high success rate for posterior wall isolation with shorter ablation times and higher impedance drop compared to conventional powers. Steam pops may be avoidable by targeting CF < 30g, and by monitoring impedance in real-time. 50W Group(N = 458) 35-40W Group(N = 501) p-value Number of lesions (s, IQR)Roof lineFloor lineAdditional ablation inside box 21.5 [19.5-26.3]7.0 [5.8-9.0]13.0 [10.8-14.3]6.0 [6.0-6.8] 24.0 [20.8-29.5]8.0 [6.0-10.0]12.5 [10.8-14.0]5.5 [2.8-9.0] 0.330.180.850.59 Ablation Time per lesion (s, IQR)Roof lineFloor lineAdditional ablation inside box 10.4 [8.8-12.5]13.0 [10.9-16.0]9.9 [8.7-11.4]8.1 [6.9-9.0] 13.0 [11.6-16.2]14.5 [12.4-19.0]12.7 [11.4-15.9]11.8 [10.6-14.0] <0.005<0.005<0.005<0.005 Total RF Time (min, IQR)Roof lineFloor lineAdditional ablation inside box 3.84 [3.34-4.66]1.54 [1.15-1.90]2.06 [1.68-2.54]0.79 [0.65-1.07] 5.86 [4.23-7.73]1.98 [1.62-2.59]2.78 [2.28-3.25]1.07 [0.59-1.42] < 0.0050.0190.0090.50 Impedance Drop (ohms, IQR)Roof lineFloor lineAdditional ablation inside box 7.4 [5.2-10.3]8.7 [6.1-11.3]6.9 [5.0-10.1]7.1 [5.4-9.8] 6.9 [4.8-9.7]7.5 [5.1-10.0]6.0 [4.2-8.3]8.3 [5.8-10.9] 0.0070.04< 0.0050.17 Contact Force (g, IQR)Roof lineFloor lineAdditional ablation inside box 21.1 [14.5-30.3]23.9 [17.8-32.7]19.2 [13.2-25.3]25.5 [18.5-36.9] 21.2 [14.9-28.1]24.3 [17.2-30.3]19.0 [14.1-25.0]23.1 [16.9-31.7] 0.560.450.870.21 Ablation Index (IQR)Roof lineFloor lineAdditional ablation inside box 471 [441-519]560 [509-571]453 [436-475]461 [430-488] 461 [434-493]502 [466-541]446 [426-464]455 [434-478] < 0.005< 0.005< 0.0050.59 Lesion level analysis for Posterior Wall Isolation

Prognostic value of health-related quality of life in patients with acute dyspnea

Background

Previous studies have shown the prognostic value of health-related quality of life (HRQL) in stable and ambulatory chronic heart failure patients. However, it is unknown whether HRQL can predict all-cause mortality in patients presenting to the emergency department (ED) after acute onset of symptoms. In order to address this unmet need, the aim of this study was to assess the prognostic value of HRQL in patients with acute dyspnea caused by acute heart failure (AHF) and other dyspnea aetiologies for 360-day mortality.

Purpose

To assess prognostic value of HRQL using the generic EQ-5D and visual analogue scale (EQ VAS) in patients with acute dyspnea.

Methods

Basics in Acute Shortness of Breath EvaLuation (BASEL V) is a prospective, multicenter, diagnostic study enrolling adult patients presenting with acute dyspnea to the ED. For this analysis, only patients with a complete set of variables necessary for calculation of EQ-5D (range 0–10; with higher score indicating worse HRQL) and EQ VAS (range 0–100; with 100 being the best imaginable health state) at baseline were included. The endpoint was the prognostic value of EQ-5D and EQ VAS at 360 days of follow-up regarding all-cause death. Prognostic accuracy was calculated using c-statistics. In a cox regression analysis EQ-5D was treated as both, a continuous and categorical variable. Adjustments were made for clinically relevant covariates (age, sex, orthopnoea, edema, level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) at presentation, history of coronary artery disease and chronic obstructive pulmonary disease, diuretics, β-blockers and ACE-inhibitors at discharge).

Results

Among 2605 patients enrolled, 1141 (43,8%) had a complete set of variables allowing the calculation of EQ-5D and EQ VAS. Of these patients 594 (52.1%) had an adjudicated final diagnosis of AHF. 211 (18.5%) patients died within 360 days of follow-up. Median EQ-5D was 3 (interquartile range (IQR) 1.5–5) and median EQ VAS was 50 (IQR 40–70). The prognostic accuracy for 360-day mortality was 0.65 (95% confidence interval ((CI) 0.61–0.69) and 0.58 (95% CI 0.54–0.62) for EQ-5D and EQ VAS, respectively (p=0.002). After combining EQ-5D and EQ VAS in a logistic regression model c-statistics regarding all-cause mortality within 360 days did not improve. The prognostic accuracy of EQ-5D was comparable to that of NT-proBNP (c-statistics 0.69, p=0.385). In an adjusted cox regression analysis the hazard ratio for patients with EQ-5D >4 was 2.2 (95% CI 1.7–2.9; p<0.001).

Conclusions

In patients presenting with acute dyspnea HRQL is a strong prognostic instrument. Independently of the aetiology of the dyspnea the prognostic value of the generic EQ-5D for 360-day mortality is comparable to NT-proBNP. Patients with an EQ-5D >4 are at significantly higher risk for mortality within 360 days.

Figure 1. Prognostic value of HRQL

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, Swiss Heart Foundation

Direct comparison of BNP and NT-proBNP for mortality prediction in patients with acute dyspnea

Background

It is unclear whether BNP or NT-proBNP, their admission or discharge measurement or percentage change during hospitalization are preferable for mortality prediction in patients with acute dyspnea.

Purpose

To directly compare BNP and NT-proBNP regarding their potential in mortality prediction in patients with acute dyspnea and in patients with dyspnea due to AHF.

Methods

In a prospective multicenter diagnostic study the presence of AHF was centrally adjudicated by two independent cardiologists among patients presenting with acute dyspnea. The levels of BNP and NT-proBNP were measured at presentation and discharge. Patients were stratified according to their natriuretic peptide response (responders vs. non-responders: natriuretic peptide decrease ≥25% vs. <25% before discharge). Prognostic accuracy for 720-day mortality was quantified using the area under the receiver-operating-characteristic curve (AUC). Cox proportional hazard models were constructed to identify significant predictors for 720-day mortality.

Results

Among 1156 patients presenting with acute dyspnea, 353 (30.5%) died within 720 days of follow-up. Prognostic accuracy for death at 720 days was significantly higher for discharge compared to admission measurements for BNP (AUC 0.750 vs. 0.711, p<0.001) and NT-proBNP (AUC 0.769 vs. 0.720, p<0.001). When directly comparing discharge measurements, NT-proBNP levels exhibited a significantly higher accuracy (p=0.013). 632 (54.6%) and 600 (51.9%) patients were BNP and NT-proBNP non-responders, respectively. Among BNP and NT-proBNP non-responders 202 (32%) and 207 (34.5%) patients died within 720 days of follow-up. After adjusting for common covariates NTproBNP response was the strongest predictor for 720-day mortality in a Cox regression model (Hazard ratio for NT-proBNP non-responders: 2.096 (95% CI 1.550–2.835), p<0.001). Results were confirmed in a sensitivity analysis of 687 (59.4%) patients with adjudicated AHF.

Conclusion

Percentage change of NT-proBNP during hospitalization seems to be the strongest predictor for long-term mortality in patients with acute dyspnea in general and in those with dyspnea due to AHF in particular.

ROC curve for direct comparison

Funding Acknowledgement

Type of funding source: None

Effect of comprehensive vasodilation vs usual care on mortality and heart failure rehospitalization in women with acute heart failure

Background

Guidelines recommend evaluating the risk/benefit ratio of novel therapies individually in women and men, as the pathophysiology and the response to treatment may differ between women and men. Among patients with acute heart failure (AHF), a strategy of intensive vasodilation, compared with usual care, overall did provide comparable outcomes.

Purpose

To evaluate the effect of a strategy that emphasized early intensive and sustained vasodilation in women with AHF.

Methods

In a randomized, open-label blinded-end-point trial patients hospitalized for AHF were enrolled in 10 hospitals in Switzerland, Bulgaria, Germany, Brazil, and Spain. Inclusion criteria were AHF expressed by acute dyspnea and increased plasma concentrations of natriuretic peptides, systolic blood pressure ≥100mmHg, and a plan for treatment in a general ward. Patients were randomized 1:1 to a strategy of early intensive and sustained vasodilation throughout the hospitalization or usual care. The primary end point was a composite of all-cause mortality or rehospitalization for AHF at 180 days.

Results

Among 788 patients randomized, 781 completed the trial and were eligible for the primary end point analysis. Of these 288 (36.9%) were women. The primary end point, a composite of all-cause mortality or rehospitalization for AHF at 180 days, occurred in 53 female patients (37.9%) in the intervention group (including 28 deaths [20.0%]) and in 34 female patients (23.0%) in the usual care group (including 22 deaths [14.9%]) (absolute difference for the primary end point, 14.9%; adjusted hazard ratio, 1.67 [95% CI: 1.08–2.59]; P=0.02). Clinically significant adverse events with early intensive and sustained vasodilation vs usual care included hypotension (8% vs 2%).

Conclusion

Among women with AHF, a strategy of early intensive and sustained vasodilation, compared with usual care, had a detrimental effect on a composite outcome of all-cause mortality and AHF rehospitalization at 180 days.

Cox Proportional Hazard Curve

Funding Acknowledgement

Type of funding source: None

Quantifying inflammation using interleukin-6 for improved phenotyping and risk stratification in acute heart failure

Background

Acute heart failure (AHF) is the most common cause of hospital admission and continues to have unacceptable high rates of mortality and morbidity. In contrast to acute myocardial infarction, the pathophysiology of AHF is incompletely understood and risk-prediction is poorly defined.

Aim

We aimed to quantify systemic inflammation to assess its possible role in the pathophysiology and risk stratification of patients with AHF.

Methods

Using a novel Interleukin-6 immunoassay with unprecedented sensitivity (limit of detection 0.01ng/l) we quantified systemic inflammation in unselected patients presenting with acute dyspnea to the emergency department in a multicenter study. Plasma concentrations of NT-proBNP (open label) and Interleukin-6 (blinded) were measured at presentation and at discharge. The final diagnosis of AHF and the AHF phenotype were adjudicated by two independent cardiologists. 1-year mortality was the prognostic endpoint.

Results

Among 2042 patients, 1026 (50.2%) had an adjudicated diagnosis of AHF. Interleukin-6 concentrations were significantly higher in AHF patients compared to patients with other causes of dyspnoea (11.2 [6.1–26.5] ng/l vs 9.0 [3.2–32.3] ng/l, p<0.0005). Among patients with AHF Interleukin-6 concentrations were elevated (>4.45ng/l) in 83.7% of them. Among the different AHF phenotypes, Interleukin-6 concentrations were highest in patients with cardiogenic shock (25.7 [14.0–164.2] ng/l) and lowest in patients with hypertensive HF (9.3 [4.8–21.6] ng/l, p=0.001). Inflammation as quantified by Interleukin-6 was a strong predictor of 1-year mortality both in AHF as well as in other causes of acute dyspnea (Figure). During in-hospital treatment Interleukin-6 concentrations significantly decreased in AHF patients. However, changes in the extend of systemic inflammation (delta Interleukin-6) were poorly correlated with changes in hemodynamic stress as quantified by NT-proBNP (delta NT-proBNP, Φc=0.11, p=0.004).

Conclusions

An unexpectedly high percentage of patients with AHF have subclinical systemic inflammation that can be quantified by Interleukin-6, which seems to contribute to the AHF phenotype and to the risk of death.

Kaplan Meier curves for mortality

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Swiss National Science Foundation, Swiss Heart Foundation, European Union, Stiftung für kardiovaskuläre Forschung Basel, University of Basel, University Hospital Basel

P2617Activity of the adrenomedullin system to personalize post-discharge treatment in acute heart failure

Objectives

Activity of the adrenomedullin system was quantified by using bioactive-adrenomedullin (bio-ADM), the biologically active moiety, and midregional proadrenomedullin (MR-proADM), a prohormone fragment, to 1) identify acute heart failure (AHF) phenotypes with disproportional benefit or harm from specific treatments at hospital discharge, 2) predict mortality, and 3) compare the prognostic utility of both biomarkers.

Methods

This prospective multicentre study using central adjudication of AHF measured bio-ADM in all patients and MR-proADM in a predefined subgroup in a blinded fashion on admission. Both biomarkers were measured at discharge as well. Interaction with specific treatments at hospital discharge and the biomarkers' prognostic utility during 365 days' follow-up were assessed.

Results

Among 1,886 patients with adjudicated AHF, 514 patients (27.3%) died during the 365 days' follow-up. Patients with bio-ADM plasma concentrations above the median were at a much higher risk of death (HR 1.87, 95% CI 1.57–2.24; p<0.001). After adjusting for age, creatinine plasma concentrations, and medical treatment at discharge, those patients derived disproportional benefit if treated with diuretics and/or angiotensin-converting-enzyme inhibitors/angiotensin receptor blocker (interaction p-values <0.05). These findings were confirmed only for the diuretics treatment when quantifying the adrenomedullin system using MR-proADM plasma concentrations (n=764). For predicting mortality, both biomarkers performed well and MR-proADM had a higher predictive accuracy as compared to bio-ADM (p<0.001).

Table 1. Interaction p-values in multivariate models using a cox proportional hazard analysis for predicting all-cause mortality at 365 days including age, bio-ADM or MR-proADM, creatinine at discharge, and medication at discharge Diuretics ACE inhibitors or ARB Beta blockers Aldosterone antagonists lg bio-ADM*, ng/l <0.001 0.011 0.760 0.175 lg bio-ADM†, ng/l <0.001 0.020 0.807 0.396 lg MR-proADM*, nmol/l 0.031 0.095 0.169 0.441 lg MR-proADM†, nmol/l 0.001 0.126 0.741 0.272 *At admission; †at discharge. ACE: Angiotensin-converting-enzyme; ARBs: Angiotensin receptor blocker; bio-ADM: bioactive adrenomedullin; MR-proADM: midregional proadrenomedullin.

Figure 1

Conclusion

Quantifying the activity of the adrenomedullin system helps to personalize post-discharge treatment and risk-prediction in AHF.

Acknowledgement/Funding

Swiss National Science Foundation, Swiss Heart Foundation, University of Base, Sphingotec

P792Cardiac myosin-binding protein C for the diagnosis and long-term prognosis of acute heart failure

Background

Cardiac myosin-binding protein C (cMyC) is a novel biomarker quantifying cardiac injury. Its utility for the diagnosis, prognosis, and therapy guidance in acute heart failure (AHF) is unclear.

Methods

In a prospective diagnostic multicentre study, unselected patients presenting with acute dyspnoea to the emergency department were enrolled. cMyC, high-sensitive cardiac troponin T (hs-cTnT), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) plasma concentrations were measured. Two independent cardiologists/internists centrally adjudicated the final diagnosis using all individual patient's information. Co-primary outcome measures were cMyC's: diagnostic safety and efficacy; prognostic accuracy.

Results

Among 1,330 recruited patients, 247 from an AHF substudy were not included in the diagnostic analysis. Accordingly, 548 patients (51%) in this analysis had an adjudicated diagnosis of AHF. For the rapid rule-out of AHF, the cMyC cut-off concentration at 16 ng/L achieved a sensitivity of 95% (95% CI, 93–97%), a negative predictive value of 88% (95% CI, 84–92%), and allowed to rule-out 21% of the patients. Correspondingly, cMyC's efficacy and safety in the triage of AHF were slightly lower than NT-proBNP's. Of the 790 AHF patients in the prognostic analysis, 222 (28%) died during the 360 days' follow-up. Patients with cMyC plasma concentrations above the median had significantly shorter mean time to death (274 versus 320 days, p=0.001). Compared to hs-cTnT and discharge NT-proBNP, cMyC showed non-inferior prognostic accuracy. No significant interactions between cMyC and cardiac medical therapies at discharge in predicting 360 days survival were present.

Conclusion

cMyC performs well in the rapid triage and prognosis of AHF.

Acknowledgement/Funding

European Union, Swiss National Science Foundation, Swiss Heart Foundation, Cardiovascular Research Foundation Basel, University Hospital of Basel

P1653Admission high-sensitivity troponin T and NT-proBNP for outcome prediction in acute heart failure

Background

High-sensitivity troponin T (hs-TnT) reflects the severity of ongoing myocardial damage and holds independent prognostic significance in chronic heart failure (HF). In acute HF (AHF), its additive prognostic value over natriuretic peptides is unclear.

Methods

Individual data of 1571 AHF patients with admission hs-TnT were collected from 3 cohorts.

Results

Patients were aged 78±10 years, and 51% were men. Median hs-TnT and N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP) concentrations were 43 ng/L (interquartile interval 26–69) and 5660 (2693–12466), respectively. Patients experiencing in-hospital death (n=187, 13%) had significantly higher hs-TnT and NT-proBNP on admission (both p<0.001). The risk of in-hospital death increased by 45% per each doubling of hs-TnT (HR 1.45, 95% confidence interval - CI 1.31–1.59, p<0.001), and by 32% per each doubling of NT-proBNP (HR 1.32, 95% CI 1.17–1.50, p<0.001). Patients with hs-TnT ≥43 ng/L and NT-proBNP ≥5660 ng/L had a 2.7-fold higher risk of in-hospital death (relative risk - RR 2.7, 95% CI 1.7–4.5). Among the 1262 patients discharged, 1024 deaths occurred over a median 11-month follow-up (4–22). In a model including NT-proBNP, hs-TnT ≥43 ng/L was a strong, independent predictor of all-cause death at 6, 12 and 24 months, and the composite of cardiovascular death or HF hospitalization at 6 and 24 months. hs-TnT ≥43 ng/L also improved risk reclassification.

Conclusions

The risk of in-hospital death is almost 3 folds higher with admission hs-TnT ≥43 ng/L and NT-proBNP ≥5660 ng/L, and hs-TnT ≥43 ng/L holds strong independent prognostic significance for post-discharge outcome.

P3532Quantifying hemodynamic cardiac stress and cardiomyocyte injury in hypertensive and normotensive acute heart failure

Background

Better characterization of the different pathophysiological mechanisms involved in normotensive and hypertensive acute heart failure (AHF) might help to develop novel individualized treatment strategies.

Methods

The extent of hemodynamic cardiac stress and cardiomyocyte injury was quantified by measuring B-type natriuretic peptide (BNP) as well as high-sensitive cardiac troponin T (hs-cTnT) in 1,152 unselected patients presenting with AHF to the emergency department (derivation cohort). Systolic blood pressure (SBP) of 90 - 140 mmHg at presentation was used to define normotensive AHF. Findings regarding hemodynamic cardiac stress and cardiomyocyte injury were validated in a second independent AHF cohort (validation cohort; n=324).

Results

In the derivation cohort 667 (58%) patients had hypertensive AHF. Hemodynamic cardiac stress, as quantified by BNP levels, was significantly higher in normotensive AHF as compared to hypertensive AHF (1,105 pg/mL versus 827 pg/mL, p<0.001). In addition, the extent of cardiomyocyte injury, as quantified by hs-cTnT, was significantly higher in normotensive AHF as compared to hypertensive AHF (41 ng/L versus 33 ng/L, p<0.001). These findings were confirmed in the validation cohort.

Table 1. Cardiac stress and myocardial necrosis as quantified by BNP and hs-cTnT plasma concentrations Overall Hypertensive AHF Normotensive AHF p-value BNP in pg/ml, median (IQR) 974 (536–1,712) 827 (448–1,419) 1,105 (611–1,956) <0.001 hs-cTnT in ng/L, median (IQR) 37 (22–67) 33 (19–59) 41 (24–71) <0.001 BNP = B-type natriuretic peptide; hs-cTnT = high-sensitivity cardiac Troponin T; IQR = inter-quartile range.

Figure 1

Conclusion

Biomarker profiling revealed that the extent of hemodynamic stress and cardiomyocyte injury is different in patients with normotensive and hypertensive AHF. This characterization could help to understand AHF phenotypes better, which in turn may lead to more specific management in future, thus improving the dismal prognosis in these patients.

Acknowledgement/Funding

European Union, Swiss National Science Foundation, Swiss Heart Foundation, Cardiovascular Research Foundation Basel, University of Basel

P1656Incremental value of interleukin-6 and C-reactive protein to the MEESSI acute heart failure risk score

Background

The MEESSI-acute heart failure (AHF) risk score has high accuracy in the prediction of 30-day mortality in patients presenting with AHF and may be considered the current gold standard for this indication.

Purpose

As the original MEESSI model does not include measurements of inflammatory biomarkers, the impact of interleukin-6 or C-reactive protein (CRP) on the model's goodness of fit is unknown.

Methods

In a prospective multicenter diagnostic study the presence of AHF was centrally adjudicated by two independent cardiologists among patients presenting with acute dyspnea to the ED. The MEESSI-AHF risk score was calculated using a recalibrated model containing 12 independent risk factors. The incremental value of interleukin-6 and CRP was examined by the use of logistic regression analysis and enter method variable selection with an entry criterion of p<0.05. Goodness of fit tests were performed to measure the updated model's discrimination and calibration.

Results

In 1247 patients with adjudicated AHF, the MEESSI-AHF risk score was calculated. Of these, 1113 patients (89.3%) had available measurements of interleukin-6 and CRP. In the logistic regression analysis both biomarkers had a highly significant impact on the MEESSI model (p<0.001, respectively). Compared to the original MEESSI-Model (c-statistic, 0.79 (95% CI, 0.75–0.83)) the addition of interleukin-6 (c-statistic, 0.81 (95% CI, 0.77–0.85)) or CRP (c-statistic, 0.83 (95% CI, 0.79–0.86)) significantly improved the model's discrimination (p=0.022 and p=0.011, respectively). When assessing the cumulative mortality, the gradient in 30-day mortality over six predefined risk groups was increased by addition of interleukin-6 or CRP. 30-day mortality rates in the lowest and highest risk groups of the original model were 0.4% and 32.5% compared to 0% and 34.9% in the model updated with interleukin-6 and 0.6% and 37.6% in the model updated with CRP. All compared models showed good overall calibration (Hosmer-Lemeshow p=0.302 (original model), p=0.136 (model updated by interleukin-6) and p=0.902 (model updated by CRP)).

Discrimination original_updated

Conclusion

There is significant incremental value of interleukin-6 and CRP to the MEESSI score as indicated by the improved goodness of fit compared to the original model.

Acknowledgement/Funding

European Union, the Swiss National Science Foundation, the Swiss Heart Foundation, the Cardiovascular Research Foundation Basel,