Journal of Cardiac Failure - Articles in Press

Prevalence of, Associations With, and Prognostic Value of Tricuspid Annular Plane Systolic Excursion (TAPSE) Among Outatients Referred for the Evaluation of Heart Failure - Corrected Proof

2012-01-27

Abstract: Background: Prevalence, predictors, and prognostic value of right ventricular (RV) function measured by the tricuspid annular plane systolic excursion (TAPSE) in patients with chronic heart failure (CHF) symptoms with a broad range of left ventricular ejection fraction (LVEF) are unknown.Methods and Results: Of 1,547 patients, mean (±SD) age was 71 ± 11 years, 48% were women, median (interquartile range [IQR]) TAPSE was 18.5 (14.0–22.7) mm, mean LVEF was 47 ± 16%, 47% had LVEF ≤45% and 67% were diagnosed with CHF, defined as systolic (S-HF) if LVEF was ≤45% and as heart failure with preserved ejection fraction (HFPEF) if LVEF was >45% and treated with a loop diuretic. During a median (IQR) follow-up of 63 (41–75) months, mortality was 34%. In multivariable analysis, increasing age, N-terminal pro–B-type natriuretic peptide (NT-proBNP), New York Heart Association functional class, right atrial volume index, and transtricuspid pressure gradient; lower TAPSE, diastolic blood pressure, and hemoglobin; and atrial fibrillation (AF) or COPD were associated with an adverse prognosis. Receiver operating characteristic curve analysis identified a TAPSE of 15.9 mm as the best prognostic threshold (P = .0001); 47% of S-HF and 20% of HFPEF had a TAPSE of <15.9 mm. The main associations with a TAPSE <15.9 mm were higher NT-proBNP, presence of atrial fibrillation and presence of LV systolic dysfunction.Conclusions: In patients with CHF, low values for TAPSE are common, especially in those with reduced LVEF. TAPSE, unlike LVEF, was an independent predictor of outcome.

Depression Predicts Repeated Heart Failure Hospitalizations - Corrected Proof

2012-01-27

Abstract: Objective: Management of depression, if it is independently associated with repeated hospitalizations for heart failure (HF), offers promise as a viable and cost-effective strategy to improve health outcomes and reduce health care costs for HF. The objective of this study was to assess the association between depression and the number of HF-related hospitalizations in patients with low-to-moderate systolic or diastolic dysfunction, after controlling for illness severity, socioeconomic factors, physician adherence to evidence-based medications, patient adherence to HF drug therapy, and patient adherence to salt restrictions.Methods and Results: The Heart Failure Adherence and Retention Trial (HART) was a randomized behavioral trial to evaluate whether patient self-management skills coupled with HF education improved patient outcomes. Depression was measured at baseline with the Geriatric Depression Scale (GDS). The number of hospitalizations was analyzed with a negative binomial regression model that included an offset term to account for the differential duration of follow-up for individual subjects. The average unadjusted number of hospitalizations per year was 0.40 in the depressed group (GDS ≥10) and 0.33 in the nondepressed group (GDS <10). Depression was a strong predictor (incident rate ratio 1.45; P = .006) after adjusting for physician adherence to evidence-based medication use, patient adherence to HF drug therapy, patient adherence to salt restriction, illness severity, HF severity (6-minute walk <620 feet), and socioeconomic factors.Conclusions: Depression is a strong psychosocial predictor of repeated hospitalizations for HF. Compared with nondepressed individuals, those with depression were hospitalized for HF 1.45 times more often, even after controlling for physician adherence to evidence-based medications and patient adherence to HF drug therapy and salt restrictions. This finding suggests that clinicians should screen for depression early in the course of HF management.

Low Serum Total Cholesterol Level Is a Surrogate Marker, But Not a Risk Factor, for Poor Outcome in Patients Hospitalized With Acute Heart Failure: A Report From the Korean Heart Failure Registry - Corrected Proof

2012-01-27

Abstract: Background: Hypercholesterolemia is a major risk factor for incident coronary artery disease and the prevalence of heart failure (HF). The causal relationship between low total cholesterol (TC) levels and poor clinical outcome in patients with acute HF has not been investigated. This study evaluated the effect of cholesterol levels on the long-term outcome in patients hospitalized due to acute HF.Methods and Results: We analyzed a cohort of 2,797 HF patients who were eligible for analysis in 3,200 patients of the Korean Heart Failure Registry. Patients were stratified into quartiles of TC (Q1 <133, Q2 133–158, Q3 159–190, and Q4 >190 mg/dL). Propensity score matching was performed with the patients in Q1 and Q4. Patients with lower serum TC had lower blood pressure, lower hemoglobin, lower serum sodium, and higher natriuretic peptide levels than patients with higher TC levels. Low TC was associated with increased risks for death and readmission due to HF; the adjusted hazard ratio (HR) of Q1 compared with Q4 was 1.57 (95% confidence interval [CI] 1.30–1.90). However, propensity score matching analysis revealed that low cholesterol itself did not affect outcome (HR 1.12, 95% CI 0.85–1.48).Conclusions: Low TC is strongly associated with mortality and morbidity in patients with HF. However, low TC seemed to be a secondary result of the patient’s state rather than an independent risk factor for poor outcome.

Association Between Prehospital Delay and Subsequent Clinical Course in Patients With/Hospitalized for Heart Failure - Corrected Proof

Peter Johansson, Martje van der Wal, Dirk J. van Veldhuisen, Tiny Jaarsma — 2012-01-27

Abstract: Background: The clinical consequences of prehospital delay in heart failure (HF) patients are unknown. This study explores the relationship between prehospital delay of HF patients and length of hospital stay, plasma values of brain natriuretic peptides (BNP) as well as the association of delay with all-cause mortality, readmission for HF, or all-cause readmissions during short- (60 days) and long-term (18 months) follow-up.Methods: Data from 1023 hospitalized HF patients mean aged 71 years from the Coordinating study evaluating Outcomes of Advising and Counselling in HF study were analyzed.Results: Patients who delayed less than 1 day had significantly shorter stay in hospital (10 days vs. 11 days, P = 0.033). They also had significantly (P = 0.004) lower median plasma values of BNP (377 pg/mL) at discharge compared to patients who delayed >24 hours (492 pg/mL). Delay was not related to all-cause mortality and/or readmissions for HF.Conclusion: Although patients with a prehospital delay less than 1 day were more symptomatic on admission, they had a shorter hospital stay as well as lower plasma values of BNP at discharge. Delay was not associated hospital readmissions or mortality after discharge.

Right Ventricular Longitudinal Strain Correlates Well With Right Ventricular Stroke Work Index in Patients With Advanced Heart Failure Referred for Heart Transplantation - Corrected Proof

2012-01-16

Abstract: Background: Right ventricular (RV) systolic function has a critical role in determining the clinical outcome and success of using left ventricular assist devices (LVADs) in patients with refractory heart failure. Tissue Doppler and M-mode measurements of tricuspid systolic motion (tricuspid S′ and tricuspid annular plane systolic excursion [TAPSE]) are the most currently used methods for the quantification of RV longitudinal function; RV deformation analysis by speckle-tracking echocardiography (STE) has recently allowed the analysis of global RV longitudinal function. Using cardiac catheterization as the reference standard, this study aimed at exploring the correlation between RV longitudinal function by STE and RV stroke work index (RVSWI) in patients referred for cardiac transplantation.Methods and Results: Right-side heart catheterization and transthoracic echo Doppler were simultaneously performed in 41 patients referred for cardiac transplantation evaluation for advanced systolic heart failure. Thermodilution RV stroke volume and invasive pulmonary pressures were used to obtain RVSWI. RV longitudinal strain (RVLS) by STE was assessed averaging all segments in apical 4-chamber view (global RVLS) and by averaging RV free-wall segments (free-wall RVLS). Tricuspid S′ and TAPSE were also calculated. No significant correlations were found for TAPSE or tricuspid S′ with RVSWI (r = 0.14; r = 0.06; respectively). Close negative correlations between global RVLS and free-wall RVLS with the RVSWI were found (r = −0.75; r = −0.82; respectively; both P < .0001). Furthermore, free-wall RVLS demonstrated the highest diagnostic accuracy (area under the receiver operating characteristic (ROC) curve 0.90) and good sensitivity and specificity of 92% and 86%, respectively, to predict depressed RVSWI using a cutoff value of less than −11.8%.Conclusions: In a group of patients referred for heart transplantation, TAPSE and tricuspid S′ did not correlate with invasively obtained RVSWI. RV longitudinal deformation analysis by STE correlated well with RVSWI, providing a better estimation of RV systolic performance.

Differentiation of Cardiac and Noncardiac Dyspnea Using Bioelectrical Impedance Vector Analysis (BIVA) - Corrected Proof

2011-12-26

Abstract: Background: There is no gold standard for the differential diagnosis of acute dyspnea despite the usefulness of N-terminal pro–B-type natriuretic peptide (NT-proBNP) and lung ultrasound. No study has evaluated the contribution of bioelectrical impedance vector analysis (BIVA) in discriminating between cardiac and noncardiac dyspnea. We sought to determine whether a relationship exists between ultrasound detection of lung congestion, NT-proBNP, and BIVA in patients with acute dyspnea.Methods and Results: Eligible patients were between 50 and 95 years, with an estimated glomerular filtration rate of ≥30 mL min−1 1.73 m−2, who presented to an emergency department with dyspnea. Dyspnea was classified by reviewers blinded to BIVA as cardiac or noncardiac based on physical examination, electrocardiogram, chest X-ray, NT-proBNP, and B-lines of lung congestion on ultrasound. Overall, 315 patients were enrolled (median age 77 years, 48% male). An adjudicated diagnosis of cardiac dyspnea was established in 169 (54%). Using BIVA, vector positions below −1 SD of the Z-score of reactance were associated with peripheral congestion (χ2 = 115; P < .001). BIVA measures were reasonably accurate in discriminating cardiac and noncardiac dyspnea (69% sensitivity, 79% specificity, 80% area under the receiver operating characteristic curve).Conclusions: In patients presenting with acute dyspnea, the combination of BIVA and lung ultrasound may provide a rapid noninvasive method to determine the cause of dyspnea.

A Positive 2-Item Patient Health Questionnaire Depression Screen Among Hospitalized Heart Failure Patients Is Associated With Elevated 12-Month Mortality - Corrected Proof

2011-12-26

Abstract: Background: Given the association of depression with poorer cardiac outcomes, an American Heart Association Science Advisory has advocated routine screening of cardiac patients for depression using the 2-item Patient Health Questionnaire (PHQ-2) “at a minimum.” However, the prognostic value of the PHQ-2 among HF patients is unknown.Methods and Results: We screened hospitalized HF patients (ejection fraction [EF] <40%) that staff suspected may be depressed with the PHQ-2, and then determined vital status at up to 12-months follow-up. At baseline, PHQ-2 depression screen–positive patients (PHQ-2+; n = 371), compared with PHQ-2 screen–negative patients (PHQ-2−; n = 100), were younger (65 vs 70 years) and more likely to report New York Heart Association (NYHA) functional class III/IV than class II symptoms (67% vs. 39%) and lower levels of physical and mental health–related quality of life (all P ≤ .002); they were similar in other characteristics (65% male, 26% mean EF). At 12 months, 20% of PHQ-2+ versus 8% of PHQ-2− patients had died (P = .007) and PHQ-2 status remained associated with both all-cause (hazard ratio [HR] 3.1, 95% confidence interval [CI] 1.4–6.7; P = .003) and cardiovascular (HR 2.7, 95% CI 1.1–6.6; P = .03) mortality even after adjustment for age, gender, EF, NYHA functional class, and a variety of other covariates.Conclusions: Among hospitalized HF patients, a positive PHQ-2 depression screen is associated with an elevated 12-month mortality risk.

New Insights into Mechanisms of Action of Carvedilol Treatment in Chronic Heart Failure Patients—A Matter of Time for Contractility - Corrected Proof

2011-12-26

Abstract: Background: It is unclear whether improvement in left ventricular (LV) ejection fraction (LVEF) following treatment with a combined α1,β1,β2-blockade can be attributed to improvement in LV contractility, to a reduction in afterload, and/or to improvements in LV remodeling and chamber size. We aimed to examine whether the observed improvement in LVEF following carvedilol treatment is due to changes in intrinsic myocardial contractility beyond changes in LV chamber size or loading conditions.Methods and Results: In 49 consecutive patients with chronic heart failure (HF), LVEF ≤35%, NYHA functional class II–IV, on angiotensin-converting enzyme inhibitors but not on ß-blockers, LV contractile performance and remodeling were assessed by comprehensive echocardiography at baseline and after 3 and 6 months of treatment with carvedilol. Carvedilol treatment resulted in significant improvements in LVEF, shortening fraction, and velocity of circumferential shortening (VCFc). There were no significant changes in the mean arterial blood pressure or systemic vascular resistance index; but LV end-systolic wall stress (LVESS), effective arterial elastance, ventriculoarterial coupling, and LV end-diastolic and end-systolic dimensions and volumes were significantly reduced. Estimated end-systolic elastance, VCFc-to-LVESS ratio, and pulsatile arterial compliance significantly improved after 6 months of treatment with carvedilol. The slope of the VCFc relationship to LVESS worsened from 0 to 3 months, but significantly improved from 3 to 6 months.Conclusions: Despite an initial transient negative inotropic effect from 0 to 3 months, carvedilol treatment was associated with a positive inotropic effect with significant improvement in load-independent indexes of myocardial contractility beyond what can be attributed to changes in LV chamber size and load after 3 months. There were no changes in systemic vascular resistance with carvedilol treatment; however, improvement in pulsatile arterial compliance and ventriculoarterial coupling suggested enhanced cardiac mechanoenergetic performance along with improved systemic arterial compliance.

Serum Glutathione S-Transferase P1 1 in Prediction of Cardiac Function - Corrected Proof

2011-12-22

Abstract: Background: Glutathione S-transferase P1 1 (GSTP1) belongs to the multigene isozyme family involved in cellular response to oxidative stress and apoptosis. Our initial retrospective proteomic analysis suggested that GSTP1 is associated with heart failure (HF). Although pro–B-type natriuretic peptide (proBNP) serves currently as a surrogate diagnostic and prognostic parameter in HF patients, its specificity remains uncertain. We hypothesized that GSTP1 might be a useful serum marker in the monitoring of HF patients.Methods and Results: Serum GSTP1 and proBNP were prospectively measured in 193 patients subdivided based on their ejection fraction (EF) either in equal-sized quintiles or predefined EF groups >52%, 43%–52%, 33%–42%, 23%–32% and ≤22%. At a cutoff of ≥231 ng/mL, GSTP1 identified HF patients with EF ≤22% with 81% sensitivity and 83% specificity, and at a cutoff of ≥655 pg/mL, proBNP identified the same patient group with 84% sensitivity and 22% specificity. GSTP1 at a ≥126 ng/mL cutoff identified EF ≤42% with 90% sensitivity and 95% specificity, or proBNP at a ≥396 pg/mL cutoff had 97% sensitivity and 20% specificity. In regression analyses, GSTP1, but not proBNP, discriminated between EF ≤42% and EF >42% in HF patients.Conclusions: These results suggest that GSTP1 is strongly associated with HF and could serve as a sensitive and specific marker to predict the ventricular function in HF patients.

Beta-Blockers and Weight Change in Patients With Chronic Heart Failure - Corrected Proof

Ben W.J. Boxall, Andrew L. Clark — 2011-12-05

Abstract: Background: There is an inverse association between body mass and mortality in patients with chronic heart failure (CHF). Beta-blockers have been associated with weight gain. We wanted to examine the relation between beta-blocker use and weight in a population of patients with CHF.Methods and Results: We weighed 276 patients presenting with CHF (mean age 71.3 ± 9.5 years, 72.8% male). None were taking a beta-blocker at presentation, but all had started by 4 months’ follow-up. The patients were reweighed after 1 year. There was an increase in weight (0.9 ± 7.0 kg; P = .03) and body mass index (0.2 ± 2.4 kg/m2; P = .02). Patients in New York Heart Association (NYHA) functional class III or IV had no significant weight change, whereas those in class I or II had an increase of 1.62 kg (P < .0001). In patients who had no peripheral edema at baseline or 1 year, there was a greater increase in weight (1.3 ± 6.9 kg; P = .01).Conclusions: Beta-blocker use and intensification of heart failure treatment is associated with weight gain in CHF. The increase is greater in those who are nonedematous and tends to occur in patients with NYHA functional class I and II symptoms.