Download 288 Prognosis in heart failure

288
Prognosis in heart failure
cardiac dysfunction and portend an adverse cardiovascular outcome for patients
with heart failure (HF), but LA function is rarely measured.
Methods: Out-patients referred with suspected heart failure between 2000 and
2010 who underwent cardiac magnetic resonance imaging (CMRI) were included
in this analysis. HF was defined as the presence of relevant symptoms and
signs and evidence of cardiac dysfunction: either a left ventricular ejection fraction (LVEF) <50% or a raised amino-terminal pro-brain natriuretic peptide (NTproBNP) >400 pg/ml (or >125 pg/ml for patients taking loop diuretics). LAEF
was defined as (LA maximum volume-LA minimum volume)/LA maximum volume
and was measured in both 2 and 4 chamber views.
Results: Of 982 patients enrolled, 191 had atrial fibrillation, whilst 127 were considered not to have heart failure. The median (IQR) LAEF was 42 (31-51)% in patients with HF (in sinus rhythm) and 55 (48-61)% in patients with no HF (p<0.001).
Comparing patients with HF in the lowest (23; IQR: 17-28%) and highest quartile
of LAEF (56; IQR: 53-61%), those in the lowest quartile had lower LV and right
ventricular (RV) EF, and increased LV and RV mass, as well as higher plasma
NTproBNP. Overall, Log [LAEF] and log [NTproBNP] were correlated (r=-0.410,
p<0.001). Of patients who had LAEF measured (those in sinus rhythm), 202 died
during a median follow up of 1390 days (IQR: 763-2342). In a multivariable Cox
regression model, LAEF, but not LVEF, was independently associated with an
adverse outcome (HR for 10% change: 0.81 (95% CI: 0.74-0.90), p=0.001). NTproBNP and LAEF competed in the model with each providing similar prognostic
information. During a median follow up of 1282 days (IQR: 701-2197), 101 patients developed atrial fibrillation (AF). Age (HR for 10 year change: 1.62 (95%
CI: 1.23 - 2.14) p<0.001) and LAEF (HR for 10% change: 0.81 (95% CI: 0.660.90), p=0.044) were the only variables that independently predicted incident AF.
Conclusions: In patients referred with suspected heart failure, LAEF identifies
those with a higher risk of AF and an adverse outcome.
P1494 | BEDSIDE
Differential effect of left ventricular ejection fraction on long term
mortality in patients hospitalized with acute heart failure. Data
from the HFSIS 2003 registry
E. Koifman, E. Kopel, D. Medvedovsky, E. Maor, A. Hamdan, I. Goldenberg,
R. Klempfner on behalf of HFSIS. Chaim Sheba Medical Center, Leviev Heart
Center, Tel Hashomer, Israel
Background: Contemporary heart failure (HF) therapies have not resulted in improved outcome among HF patients with preserved left ventricular (LV) function.
We sought to evaluate the differential effect of LV function on long term mortality
following hospitalization for acute HF patients in a real world setting.
Methods: All-cause mortality at 4 years following hospitalization for HF was assessed by LV ejection fraction (LVEF, categorized as preserved [≥50%], mildly[40%-49%], moderately- [30%-39%], and severely-[<30%] reduced) among 1620
patients enrolled in the Heart Failure Survey in Israel.
Results: Among study patients 30% had preserved LVEF, and 20%, 25%, and
25%, had mild, moderate, and severe, reductions in LVEF, respectively. The cumulative mortality rate at 4 years was highest among those with reduced LVEF,
and similar between patients with preserved LV function compared with mild or
moderate reductions on LVEF (Figure). Multivariate analysis showed that patients with severely reduced LVEF had a 20% (p=0.03) increase in 4-year mortality rate compared with preserved LVEF patients, whereas mild or moderate
reduction in LVEF had no impact on mortality rates (HR=0.91 [p=0.33] and
1.02 [p=0.85], respectively). Independent predictors of 4-year mortality among
patients with preserved LVEF included age > 75 (HR=2.15, p<0.001), NYHA
class III-IV vs. I-II (HR=1.54, p<0.001) and glomerular filtration rate ≤ 50 ml/min
(HR=1.82, p<0.001), while systolic blood pressure>140 mmHg had a protective
effect (HR=0.68, p=0.001).
P1493 | BEDSIDE
Prognostic impact of subclinical microalbuminuria in patients with
chronic heart failure
M. Miura 1 , Y. Sakata 1 , S. Miyata 1 , K. Nochioka 1 , T. Takada 1 , S. Tadaki 1 ,
J. Takahashi 1 , N. Shiba 2 , H. Shimokawa 1 on behalf of The CHART-2 Study.
1 Tohoku University Graduate School of Medicine, Department of Cardiovascular
Medicine, Sendai, Japan; 2 International University of Health and Welfare
Hospital, Nasushiobara, Japan
Purpose: According to the latest classification of chronic kidney disease
(CKD), microalbuminuria, defined as urinary albumin to creatinine ratio (UACR)
≥30mg/g, is a risk factor even in patients with preserved glomerular filtration rate
(GFR). However, it remains to be clarified whether this classification could be
applied for the risk stratification of chronic heart failure (CHF) patients.
Methods: From the Chronic Heart Failure Analysis and Registry, we enrolled
2,039 consecutive symptomatic CHF patients who were not on hemodialysis
(mean age 67.4 years, 68.9% male). To determine the discriminating values of
UACR and GFR to stratify the risk for the composite of all-cause death, acute
myocardial infarction, HF admission and stroke, we performed the classification
and regression tree (CART) analysis.
Results: There were 506 composite events (24.8%) during the median followup of 2.7 years. The CART analysis identified the discriminating values as 10.2
and 27.4mg/g for UACR, and 34.3 and 56.3ml/min/1.73m2 for GFR, respectively.
With these values, we divided the subjects into 4 groups according to the risk
of composite events of <15%, 15-25%, 25-35% and >35%, with a hazard ratio
for composite events of 1.00 (reference), 1.92, 2.94, and 3.34, respectively (all P
<0.01) (Figure). Importantly, risk categorization was influenced by the presence
of subclinical albuminuria (UACR: 10.2-27.4mg/g) in patients with mildly reduced
or preserved GFR (Groups 1-3), whereas patients with the highest event rate
(Group 4) were solely characterized by GFR<34.3 ml/min/1.73m2 regardless of
UACR values.
Conclusions: These results indicate that in patients with CHF and mildly reduced
or preserved GFR, even subclinical albuminuria is significantly associated with
poor prognosis.
Cumulative Survival by LVEF Class
Conclusion: Heart failure patients with preserved LVEF experience similar longterm mortality rates as patients with mild or moderate reductions in LV function.
Specific clinical and laboratory characteristics identified increased risk for longterm mortality in this population.
P1495 | BEDSIDE
Clinical and echocardiographic predictors of super-responders to
CRT and its related longterm follow-up
C. Andreoli 1 , E. Carluccio 1 , P. Biagioli 1 , S. D’Addario 1 , G. Zingarini 2 ,
R. Lauciello 1 , C. Zuchi 1 , G. Alunni 1 , C. Cavallini 2 , G. Ambrosio 2 . 1 Division of
Cardiology, University of Perugia, Perugia, Italy; 2 Perugia Hospital, Department
of Cardiology, Perugia, Italy
Background: Individual response to cardiac resynchronization therapy (CRT)
varies significantly, with some patients showing an impressive improvement of
left ventricular (LV) function and marked reverse remodeling, nearly enough to
normalize contractile function. These patients were defined as super-responders
(SR). Few data exist on predictors of SR to CRT and its associated improvement
in long-term prognosis.
Methods: We studied 132 patients who underwent CRT, and had a completed
baseline and 6-8 months echocardiographic follow-up. SR were defined by the top
quartile of end-systolic volume index (ESVI) reduction at follow-up. Best-subset
regression analysis identified predictors of SR. Kaplan-Meier survival analysis
and Cox proportional hazards regression were performed to investigate associations of response category with development of decompensated heart failure
(HF) or all-cause death in the long-term follow-up.
Results: We had 35 SR. All of them showed an ESVI reduction >-40% (mean
ESVI reduction - 21±25%). Six variables emerged as independent predictors
of SR to CRT: absence of diabetes (odds ratio [OR]: 0.08; p=0.002), absence
of anemia (OR: 0.11; p=0.016), deceleration time of early mitral velocity >150
ms (OR: 3.73; p=0.037), QRS duration >150 ms (OR: 9.99; p=0.006), radial
dyssynchrony >130 ms (OR: 16.3; p=0.001), longitudinal intraventricular dyssynchorny at TDI >65 ms (OR: 5.32; p=0.016). Probability of events (per 100 pa-