- Email: [email protected]
Hemodynamic Improvement in Acutely Decompensated Diastolic Heart Failure with Nesiritide Infusion
The 9th Annual Scientific Meeting
•
HFSA
S107
064
066
Right Ventricular Tissue Doppler Is Associated with Functional Capacity in Heart Failure Patients Thomas D. Stamos1,2, M. T. Alahdab1, Ibrahim N. Mansour1; 1Cardiology, Cook County Hospital, Chicago, IL; 2Cardiology, University of Illinois at Chicago, Chicago, IL
Sub-Maximal CPX Exercise Evaluation: Ventilation Based Parameters for CHF Risk Stratification Nampalli K. Vijay1, Dean J. MacCarter1, Richard D. Jantz1, Melinda M. Washam1; 1 Cardiology, Aurora Denver Cardiology Associates, Denver, CO
Background: Previous studies have shown a correlation between left ventricular systolic myocardial velocity (Sm) measured by tissue Doppler and left ventricular performance. The current study was designed to evaluate whether right ventricular systolic myocardial velocity is associated with functional capacity in heart failure patients. Methods: We performed echocardiography and 6-minute walk tests in 26 consecutive patients admitted to the hospital with a primary diagnosis of heart failure and left ventricular systolic dysfunction (LVEF ⬍ 45%). Peak right ventricular systolic myocardial velocity (RV Sm) was determined from tissue Doppler samples obtained at the lateral tricuspid annulus. Results: The mean RV Sm was 7.10 cm/ s. Patients with an RV Sm greater than the mean value and less than the mean value where similar in terms of age, sex and LVEF. Patients with an RV Sm greater than the mean value walked significantly further during six-minute walk testing than those with an RV Sm less than the mean value (871.6 vs. 660.6 feet, p ⫽ ⬍ 0.02). Conclusions: RV Sm is associated with functional capacity in heart failure patients. Further study will be required to determine if RV Sm can predict outcomes in this patient population. RV Sm ⬍ 7.1 (cm/s) RV Sm ⬎ 7.1 (cm/s) P Value
Age (yrs)
Male (%)
6-min Walk (ft)
49.5 52.6 ns
73 80 ns
660.6 871.6 ⬍0.02
Introduction: Ventilation efficiency (Veff), the linear slope relationship between minute ventilation (VE) and VCO2 has been reported to be the most powerful independent predictor of CHF patient survival even more so than VO2 max. Veff is determined using maximum treadmill (TM) exercise. However, sub-maximal determination of Veff and other VE based parameters has neither been investigated nor its potential risk prediction assessed. Methods: Seventy four subjects;27 females, mean age 64.2 ⫾ 12.8 were categorized by Weber class A,B,C and D using VO2 values at the anaerobic threshold (AT) with class C and D being HF patients (n ⫽ 25). Class A subjects (n ⫽ 31) had no known CAD while class B (n ⫽ 17) had a previous diagnosis of hypertension and/ or CAD. Pts were either tested using sub-maximal incremental TM exercise or a submaximal, 4 minute, step test with one step “cycle” per 2 seconds utilizing an 8 inch step. All breath by breath gas exchange data were collected and analyzed with a CardiAssess system up to the AT. Veff and O2 uptake efficiency (O2eff), the slope of VO2 to the log of VE were determined by linear regression analysis. Data analysis was performed retrospectively in conjuction with routine clinical visits. Results: CPX Parameter Weber Class A Weber Class B Weber Class C Weber Class D Veff
32.8 ⫾ 5.3
O2 uptake eff
2.06 ⫾ .63
36.8 ⫾ 8.0 p ⬍ .05 1.53 ⫾ .31 p ⬍ .001
41.0 ⫾ 6.5 p ⬍ .0001 1.37 ⫾ .35 p ⬍ .0001
48.6 ⫾ 10.7 p ⬍ .0001 .91 ⫾ .11 p ⬍ .0001
All “p” values above represent the comparison to Weber class A. All patients tested using sub-max TM or Step protocols reached their AT. Ventilation and O2 uptake efficiency in class C and D CHF pts. revealed highly significant decreases, as compared to Weber class A subjects. Both Weber class C and D have been previously shown to have a poor prognosis. Conclusion: Sub-maximal exercise testing with gas exchange is feasible using a simple, short duration Step test. Sub-maximal ventilation based exercise parameters can be used for risk stratification of patients with HF. Step testing offers a more tolerable and safe means of chronic serial testing for physician guidance of optimal HF therapy.
065
067
Hemodynamic Improvement in Acutely Decompensated Diastolic Heart Failure with Nesiritide Infusion Ann T. Tong1, Amber L. Reece1, Mary Vooletich1, Marc A. Rozner1, Daniel J. Lenihan1, Jean-Bernard Durand1; 1Cardiology, UT MD Anderson Cancer Ctr, Houston, TX Background: Heart failure (HF) with preserved LV systolic function, commonly described as diastolic HF (DHF), accounts for up to 40% of HF cases and is associated with significant mortality and morbidity. Unlike systolic HF, for which there is substantial evidenced-based medicine derived from large randomized trials, treatment of DHF is less defined. Nesiritide is the recombinant human B-type natriuretic peptide (BNP) that has been approved for the treatment of acutely decompensated HF. In the VMAC trial, only 12% of patients had normal LVEF; thus experience of using nesiritide in patients with DHF is limited. Furthermore, acute hemodynamic response to nesiritide in patients with DHF is not well characterized. Methods: We prospectively screened all patients at MD Anderson Cancer Center who were admitted with acute decompensated HF with LVEF ⬎45%. Enrolled patients underwent right heart catheterization (RHC) and hemodynamic measurements were obtained prior to and during the first 60 minutes of nesiritide bolus and infusion. Nesiritide was continued for 48 hours. Echo/Doppler studies were performed at time of RHC and discharge. Results: To date, we have screened 23 patients; 7 met our criteria. All patients (age 67 ⫹ 11 yrs, 1 male, 100% had hypertension, 57% CAD, 29% diabetes) were in NYHA IV. Baseline BNP was 813 ⫹ 376 pg/ml and LVEF 56 ⫹ 11%. All patients had Doppler evidence of diastolic dysfunction as well as elevated LV filling pressure. No cardiovascular event was noted during nesiritide infusion. PCWP decreased acutely with infusion (Figure 1; dashed line is averaged data). CVP(16 ⫹ 4mmHg → 10 ⫹ 4mmHg) and cardiac output (5.5 ⫹ 1.6 L/min → 7.3 ⫹ 1.5L/min) both significantly improved, p ⬍ 0.05. Mean NYHA after nesiritide was 2.4⫹0.5. All patients were discharged in stable condition. Followup PA pressure estimated by Doppler significantly decreased, 51.3⫹7.9 → 41.7 ⫹ 14.2 mmHg, p ⫽ 0.03. Conclusion: Nesiritide improves the hemodynamic profile in patients with acute decompensated diastolic HF. In addition, symptoms are improved and no adverse cardiovascular event was noted. These data suggest that nesiritide may have a role in the treatment of diastolic HF.
Obesity in Patients with Heart Failure and a Preserved Ejection Fraction Raja Wajahat1, Inna Titova1, Lyna El Khoury Rumbarger1, Donald L. King1, Mathew S. Maurer1; 1Medicine, Columbia University, New York, NY Background: Obesity is common in patients with heart failure and a preserved ejection fraction (HFPEF) and is associated with alterations in ventricular structure and function that may be due to plasma volume expansion and/or large conduit artery stiffness. We hypothesized that obesity would result in increased large conduit artery stiffness in HFPEF patients. Methods: 67 subjects (37 with HFNEF and 30 healthy controls) underwent freehand 3D echocardiography (3DE). Left ventricular chamber and arterial properties were obtained through a combination of sphygmomanometry with 3DE. Arterial properties were determined by three indicators: the augmentation index (AI%), aortic compliance (Ca) and arterial elastance (Ea). Plasma volume was measured in a subset of HFPEF subjects with I131 tagged albumin. Ventricular volumes were compared using absolute values as well as age, gender and body size normalized volumes. Results: The demographic features of the subjects are shown below. The mean BMI was higher in HFPEF compared with controls. Arterial properties (Ea, AI and Ca) differed in HFPEF compared to controls and were indicative of less stiff arteries in obese subjects than non-obese subjects. LV volumes and plasma volumes were increased in HFPEF and more so in obese than non-obese subjects (3456 ⫾ 990 vs. 2782 ⫾ 359 ml, p ⫽ 0.0479). Conclusion: HFPEF is characterized by increases in large conduit artery stiffness. However, arterial elastance is lower and aortic compliance higher in obese as compared to non-obese HFPEF subjects suggesting that cardiac effects of obesity are not mediated by increased afterload. The increase in LV and plasma volumes in obese subjects suggests that obesity may contribute to the clinical syndrome of HFPEF through alterations in preload volume.
Variable Age (years) Gender (% Female) BMI EDV (ml) Normalized EDV (%) SV (ml) Normalized SV (%) LV Mass (grams) EF (%) Augmentation Index (%) Ea (mm Hg/ml) Aortic Compliance (ml/mm Hg)
Normals (n ⫽ 30)
HFPEF (n ⫽ 37)
45 ⫾ 19 37% 26 ⫾ 3 112 ⫾ 24 111 ⫾ 18 61 ⫾ 17 110 ⫾ 16 142 ⫾ 20 57 ⫾ 4 11 ⫾ 13 1.7 ⫾ 0.4 1.5 ⫾ 0.4
71 ⫾ 17* 76%* 30 ⫾ 7 117 ⫾ 30 135 ⫾ 29* 62 ⫾ 15 124 ⫾ 23* 182 ⫾ 53* 53 ⫾ 5* 24 ⫾ 14* 2.2 ⫾ 0.6* 1.0 ⫾ 0.5*
Non-Obese Obese HFPEF HFPEF (n ⫽ 17) (n ⫽ 20) 68 ⫾ 22 82% 25 ⫾ 3 109 ⫾ 26 131 ⫾ 29 56 ⫾ 13 120 ⫾ 23 177 ⫾ 51 52 ⫾ 5 27 ⫾ 9 2.5 ⫾ 0.7 0.8 ⫾ 0.3
73 ⫾ 11 70% 35 ⫾ 6 124 ⫾ 33 138 ⫾ 30 66 ⫾ 16^ 128 ⫾ 23 186 ⫾ 56 54 ⫾ 5 22 ⫾ 17 2.0 ⫾ 0.5^ 1.2 ⫾ 0.5^
*p ⬍ 0.05 for comparison with controls, ^ p ⬍ 0.05 versus non-obese HFNEF
•
HFSA
S107
064
066
Right Ventricular Tissue Doppler Is Associated with Functional Capacity in Heart Failure Patients Thomas D. Stamos1,2, M. T. Alahdab1, Ibrahim N. Mansour1; 1Cardiology, Cook County Hospital, Chicago, IL; 2Cardiology, University of Illinois at Chicago, Chicago, IL
Sub-Maximal CPX Exercise Evaluation: Ventilation Based Parameters for CHF Risk Stratification Nampalli K. Vijay1, Dean J. MacCarter1, Richard D. Jantz1, Melinda M. Washam1; 1 Cardiology, Aurora Denver Cardiology Associates, Denver, CO
Background: Previous studies have shown a correlation between left ventricular systolic myocardial velocity (Sm) measured by tissue Doppler and left ventricular performance. The current study was designed to evaluate whether right ventricular systolic myocardial velocity is associated with functional capacity in heart failure patients. Methods: We performed echocardiography and 6-minute walk tests in 26 consecutive patients admitted to the hospital with a primary diagnosis of heart failure and left ventricular systolic dysfunction (LVEF ⬍ 45%). Peak right ventricular systolic myocardial velocity (RV Sm) was determined from tissue Doppler samples obtained at the lateral tricuspid annulus. Results: The mean RV Sm was 7.10 cm/ s. Patients with an RV Sm greater than the mean value and less than the mean value where similar in terms of age, sex and LVEF. Patients with an RV Sm greater than the mean value walked significantly further during six-minute walk testing than those with an RV Sm less than the mean value (871.6 vs. 660.6 feet, p ⫽ ⬍ 0.02). Conclusions: RV Sm is associated with functional capacity in heart failure patients. Further study will be required to determine if RV Sm can predict outcomes in this patient population. RV Sm ⬍ 7.1 (cm/s) RV Sm ⬎ 7.1 (cm/s) P Value
Age (yrs)
Male (%)
6-min Walk (ft)
49.5 52.6 ns
73 80 ns
660.6 871.6 ⬍0.02
Introduction: Ventilation efficiency (Veff), the linear slope relationship between minute ventilation (VE) and VCO2 has been reported to be the most powerful independent predictor of CHF patient survival even more so than VO2 max. Veff is determined using maximum treadmill (TM) exercise. However, sub-maximal determination of Veff and other VE based parameters has neither been investigated nor its potential risk prediction assessed. Methods: Seventy four subjects;27 females, mean age 64.2 ⫾ 12.8 were categorized by Weber class A,B,C and D using VO2 values at the anaerobic threshold (AT) with class C and D being HF patients (n ⫽ 25). Class A subjects (n ⫽ 31) had no known CAD while class B (n ⫽ 17) had a previous diagnosis of hypertension and/ or CAD. Pts were either tested using sub-maximal incremental TM exercise or a submaximal, 4 minute, step test with one step “cycle” per 2 seconds utilizing an 8 inch step. All breath by breath gas exchange data were collected and analyzed with a CardiAssess system up to the AT. Veff and O2 uptake efficiency (O2eff), the slope of VO2 to the log of VE were determined by linear regression analysis. Data analysis was performed retrospectively in conjuction with routine clinical visits. Results: CPX Parameter Weber Class A Weber Class B Weber Class C Weber Class D Veff
32.8 ⫾ 5.3
O2 uptake eff
2.06 ⫾ .63
36.8 ⫾ 8.0 p ⬍ .05 1.53 ⫾ .31 p ⬍ .001
41.0 ⫾ 6.5 p ⬍ .0001 1.37 ⫾ .35 p ⬍ .0001
48.6 ⫾ 10.7 p ⬍ .0001 .91 ⫾ .11 p ⬍ .0001
All “p” values above represent the comparison to Weber class A. All patients tested using sub-max TM or Step protocols reached their AT. Ventilation and O2 uptake efficiency in class C and D CHF pts. revealed highly significant decreases, as compared to Weber class A subjects. Both Weber class C and D have been previously shown to have a poor prognosis. Conclusion: Sub-maximal exercise testing with gas exchange is feasible using a simple, short duration Step test. Sub-maximal ventilation based exercise parameters can be used for risk stratification of patients with HF. Step testing offers a more tolerable and safe means of chronic serial testing for physician guidance of optimal HF therapy.
065
067
Hemodynamic Improvement in Acutely Decompensated Diastolic Heart Failure with Nesiritide Infusion Ann T. Tong1, Amber L. Reece1, Mary Vooletich1, Marc A. Rozner1, Daniel J. Lenihan1, Jean-Bernard Durand1; 1Cardiology, UT MD Anderson Cancer Ctr, Houston, TX Background: Heart failure (HF) with preserved LV systolic function, commonly described as diastolic HF (DHF), accounts for up to 40% of HF cases and is associated with significant mortality and morbidity. Unlike systolic HF, for which there is substantial evidenced-based medicine derived from large randomized trials, treatment of DHF is less defined. Nesiritide is the recombinant human B-type natriuretic peptide (BNP) that has been approved for the treatment of acutely decompensated HF. In the VMAC trial, only 12% of patients had normal LVEF; thus experience of using nesiritide in patients with DHF is limited. Furthermore, acute hemodynamic response to nesiritide in patients with DHF is not well characterized. Methods: We prospectively screened all patients at MD Anderson Cancer Center who were admitted with acute decompensated HF with LVEF ⬎45%. Enrolled patients underwent right heart catheterization (RHC) and hemodynamic measurements were obtained prior to and during the first 60 minutes of nesiritide bolus and infusion. Nesiritide was continued for 48 hours. Echo/Doppler studies were performed at time of RHC and discharge. Results: To date, we have screened 23 patients; 7 met our criteria. All patients (age 67 ⫹ 11 yrs, 1 male, 100% had hypertension, 57% CAD, 29% diabetes) were in NYHA IV. Baseline BNP was 813 ⫹ 376 pg/ml and LVEF 56 ⫹ 11%. All patients had Doppler evidence of diastolic dysfunction as well as elevated LV filling pressure. No cardiovascular event was noted during nesiritide infusion. PCWP decreased acutely with infusion (Figure 1; dashed line is averaged data). CVP(16 ⫹ 4mmHg → 10 ⫹ 4mmHg) and cardiac output (5.5 ⫹ 1.6 L/min → 7.3 ⫹ 1.5L/min) both significantly improved, p ⬍ 0.05. Mean NYHA after nesiritide was 2.4⫹0.5. All patients were discharged in stable condition. Followup PA pressure estimated by Doppler significantly decreased, 51.3⫹7.9 → 41.7 ⫹ 14.2 mmHg, p ⫽ 0.03. Conclusion: Nesiritide improves the hemodynamic profile in patients with acute decompensated diastolic HF. In addition, symptoms are improved and no adverse cardiovascular event was noted. These data suggest that nesiritide may have a role in the treatment of diastolic HF.
Obesity in Patients with Heart Failure and a Preserved Ejection Fraction Raja Wajahat1, Inna Titova1, Lyna El Khoury Rumbarger1, Donald L. King1, Mathew S. Maurer1; 1Medicine, Columbia University, New York, NY Background: Obesity is common in patients with heart failure and a preserved ejection fraction (HFPEF) and is associated with alterations in ventricular structure and function that may be due to plasma volume expansion and/or large conduit artery stiffness. We hypothesized that obesity would result in increased large conduit artery stiffness in HFPEF patients. Methods: 67 subjects (37 with HFNEF and 30 healthy controls) underwent freehand 3D echocardiography (3DE). Left ventricular chamber and arterial properties were obtained through a combination of sphygmomanometry with 3DE. Arterial properties were determined by three indicators: the augmentation index (AI%), aortic compliance (Ca) and arterial elastance (Ea). Plasma volume was measured in a subset of HFPEF subjects with I131 tagged albumin. Ventricular volumes were compared using absolute values as well as age, gender and body size normalized volumes. Results: The demographic features of the subjects are shown below. The mean BMI was higher in HFPEF compared with controls. Arterial properties (Ea, AI and Ca) differed in HFPEF compared to controls and were indicative of less stiff arteries in obese subjects than non-obese subjects. LV volumes and plasma volumes were increased in HFPEF and more so in obese than non-obese subjects (3456 ⫾ 990 vs. 2782 ⫾ 359 ml, p ⫽ 0.0479). Conclusion: HFPEF is characterized by increases in large conduit artery stiffness. However, arterial elastance is lower and aortic compliance higher in obese as compared to non-obese HFPEF subjects suggesting that cardiac effects of obesity are not mediated by increased afterload. The increase in LV and plasma volumes in obese subjects suggests that obesity may contribute to the clinical syndrome of HFPEF through alterations in preload volume.
Variable Age (years) Gender (% Female) BMI EDV (ml) Normalized EDV (%) SV (ml) Normalized SV (%) LV Mass (grams) EF (%) Augmentation Index (%) Ea (mm Hg/ml) Aortic Compliance (ml/mm Hg)
Normals (n ⫽ 30)
HFPEF (n ⫽ 37)
45 ⫾ 19 37% 26 ⫾ 3 112 ⫾ 24 111 ⫾ 18 61 ⫾ 17 110 ⫾ 16 142 ⫾ 20 57 ⫾ 4 11 ⫾ 13 1.7 ⫾ 0.4 1.5 ⫾ 0.4
71 ⫾ 17* 76%* 30 ⫾ 7 117 ⫾ 30 135 ⫾ 29* 62 ⫾ 15 124 ⫾ 23* 182 ⫾ 53* 53 ⫾ 5* 24 ⫾ 14* 2.2 ⫾ 0.6* 1.0 ⫾ 0.5*
Non-Obese Obese HFPEF HFPEF (n ⫽ 17) (n ⫽ 20) 68 ⫾ 22 82% 25 ⫾ 3 109 ⫾ 26 131 ⫾ 29 56 ⫾ 13 120 ⫾ 23 177 ⫾ 51 52 ⫾ 5 27 ⫾ 9 2.5 ⫾ 0.7 0.8 ⫾ 0.3
73 ⫾ 11 70% 35 ⫾ 6 124 ⫾ 33 138 ⫾ 30 66 ⫾ 16^ 128 ⫾ 23 186 ⫾ 56 54 ⫾ 5 22 ⫾ 17 2.0 ⫾ 0.5^ 1.2 ⫾ 0.5^
*p ⬍ 0.05 for comparison with controls, ^ p ⬍ 0.05 versus non-obese HFNEF