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Prediction of Congestive Heart Failure as Adverse Outcome of Non-ST-Elevation Myocardial Infarction
The 13th Annual Scientific Meeting CI 5 1.70-5.71, p50.0002) when both were elevated than either alone. Stratification by both N-ANP and ET-1 better discriminated deaths from WHF as opposed to other causes of death (c50.61; 95% CI 5 0.52-0.70, p!0.0001) than either N-ANP or ET1 level alone. Conclusions: Simultaneous profiling using both N-ANP and ET-1 better predicted different modes of death in HF pts than either N-ANP or ET-1 alone; this strategy might be helpful in selecting pts with higher risk for SD or deaths from WHF to whom more intensive treatments can be targeted.
306 New Heart Failure Score Predicts Outcomes in Heart Failure Patients Konstadina Darsaklis, Sophia Farooki, Viviane Nguyen, Nadia Giannetti; Cardiology, McGill University Health Center - Royal Victoria Hospital, Montreal, QC, Canada Introduction: Heart failure patients are at risk of adverse cardiac events. Because heart failure is a heterogenous disease, a comprehensive assessment of these patients, inclusive of history, physical exam, and laboratory investigations, may best predict adverse outcomes. The McGill Heart Failure Score (MHFS) is a comprehensive assessment comprised of 3 sections (table 1). Items in each section are graded on a scale from 0 (no symptoms) to 3 (severe symptoms). All three sections are summed for a total possible maximum score of 48. Hypothesis: We hypothesize that the MHFS can accurately predict adverse outcomes in heart failure patients at 1 year follow-up. Methods: Patients at the Royal Victoria Hospital’s Heart Failure Clinic were recruited into this prospective observational study. Baseline evaluation included MHFS and NYHA assessment. Primary outcomes recorded at follow-up included i) ER visits !24 hours for CHF, ii) hospital admissions for CHF, iii) death and iv) heart transplant. A total MHFS cutoff of 10 was chosen. Outcomes and NYHA classes in patients above and below the cutoff of 10 were compared. Results: Eighty patients with abnormal ejection fractions were recruited. Forty-four patients had a total score !10. Their mean NYHA class was 1.68 6 0.52 and their average EF was 24.5%. Six out of 44 patients had a primary outcome event. The percentages of patients with adverse events were 2.3%, 4.5%, 6.8%, and 0% for outcomes i through iv, respectively. Thirty-six patients had a total score O10. Their mean NYHA class was 2.11 6 0.52 and their average EF was 29.8%. Seventeen patients out of 36 had a primary outcome event. The percentages of patients with adverse events were 2.8%, 25%, 16.7%, and 2.8% for outcomes i through iv, respectively. There were significantly more patients who had adverse events in the cohort with a total score O10 (p!0.001), despite similar NYHA classes. Conclusion: In heart failure patients, a McGill Heart Failure Score O10 predicts a worse cardiac prognosis, within the next year. This may be a more reliable predictor than NYHA classification at initial evaluation. Further validation in a larger sample size is warranted. The McGill Heart Failure Score History
Physician Evaluation
Laboratory
Dyspnea walking 2m on flat surface Dyspnea climbing 1 flight of stairs Dyspnea lying flat Lack of energy Difficulty completing daily tasks
Adjustment of diuretic (last month) Systolic blood pressure
Urea
Leg edema Pulmonary rales Adjustment of diuretics today
Sodium Albumin Bilirubin
HFSA
(n51172)(P50.924). The mean number of inpatient days was 13.6 (SD527.0) in the exercise training group compared to 15.0 (SD531.4) days in usual care (P50.21). Additional measures of medical resource use, including urgent care visits, outpatient visits and procedures, home IV therapy, skilled nursing and rehabilitative care were similar between groups, with the exception of trends indicating that fewer patients in the exercise training group underwent high-cost inpatient procedures including heart transplant and/or placement of a left ventricular assist device (n544 [3.7%] vs. n531 [2.7%], P50.14). Total direct medical costs were estimated at $50,857 (SD581,488) in the exercise training group and $56,177 (SD592,749) in the usual care group (95% CI for difference: $-12,755 to $1547). Direct cost of exercise training was estimated at $1006 (SD5337): $632 for supervised training and $374 for home-based training. Conclusions: Exercise training had little systematic impact on medical resource use overall, but the cost of exercise training may have been offset through a reduction in high-cost procedures.
308 Predictors of Mortality in African Americans Hospitalized with Systolic Heart Failure Jareer Farah1, Hammam D. Zmily1, Sandip Zalawadiya1, Omaima Ali1, Suleiman Daifallah1, Jalal K. Ghali2; 1Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, MI; 2Cardiology, Detroit Medical Center, Detroit, MI Introduction: Predictors of mortality in systolic heart failure (HF) have not been well characterized in African Americans. Methods: We studied 312 patients hospitalized with systolic HF in urban hospital between Jan and May-2007. Mortality was the primary outcome. We analyzed variables like clinical characteristics, co-morbidities, and laboratory findings. Multi-variate logistic regression analysis was constructed which included all statistically significant variables (p-value # 0.05). Results: The mean age was 61.7 6 16.7. Males were 56.7%. Sixty eight patients (21.8%) died. They were older (70.5 6 16.9 vs 59.3 6 15.9, p50.000), female gender (51.5% vs 41.0%, p50.123), had lower BMI (28.0 6 8.1 vs 30.6 6 8.9, p50.027), lower admission SBP (139.5 6 34.5 vs150.7 6 33.6, p50.016), and admission DBP (80.1 6 18.1 vs 91.4 6 23.1, p50.000). They were more likely to have PVD (16.2% vs 6.6% p50.013), ischemic HF (54.4% vs 37.7%, p50.013), wall motion abnormalities on echocardiogram (47.1% vs 30.7%, p50.012), lower serum calcium on discharge (8.4 6 0.9 vs 8.7 6 0.6 , p5 0.003), to have serum bicarbonate level of O28meq/dl on discharge (48.5% vs 34.0%, p50.029), GFR !60 on discharge (55.9% vs 41.8%, p50.039), had higher MCV on admission (88.7 6 9.9 vs 87.4 6 7.4, p50.233), higher MCV on discharge (89.1 6 9.4 vs 87.6 6 7.2, p50.163) and higher RDW on admission (16.6 6 2.1 vs 15.9 6 2.0, p50.011) and on discharge (16.9 6 2.5 vs 15.7 6 1.9, p50.000). They were less likely to have new onset HF (5.9% vs 16.0%, p50.025), or be discharged on ACEI (52.9% vs 67.2%, p50.030). Multivariate logistic regression analysis for mortality is shown below.
Creatinine
Recent EF
307 Cost of Exercise Training and Its Impact on Medical Resource Use and Costs: Results of HF-ACTION Shelby D. Reed1, David J. Whellan2, Yanhong Li1, Joelle Y. Friedman1, Ileana L. Pina3, Sharon J. Settles1, Linda Davidson-Ray1, Johanna Johnson1, Lawton S. Cooper4, Christopher M. O’Connor1, Kevin A. Schulman1; 1Duke Clinical Research Institute, Durham, NC; 2Thomas Jefferson University, Philadelphia, PA; 3 Case Western Reserve University School of Medicine, Cleveland, OH; 4National Heart Lung and Blood Institute, Bethesda, MD Introduction: HF-ACTION demonstrated modest clinical benefits with exercise training in heart failure patients. Hypothesis: Exercise training reduces medical resource use and direct medical costs. Methods: Between April 2003 and February 2007, HF-ACTION randomized 2331 patients with NYHA Class II-IV heart failure with reduced ejection fraction to usual care plus exercise training, consisting of 36 supervised sessions followed by home-based training, versus usual care alone. Throughout the trial, extensive data on medical resource use and hospital bills were collected to estimate direct medical costs. Intervention-related costs were estimated using patient-level data from the trial, administrative records, and published unit costs. Costs were reported in 2008 US dollars. Counts of hospitalizations and inpatient days were compared using negative binomial regression models. Confidence intervals for cost differences were derived using nonparametric bootstrapping. Results: Mean follow-up was 2.5 years in both groups. There were 2297 hospitalizations in the exercise training group (n51159) and 2332 in the usual care group
S93
Variable Age Presence of diastolic dysfunction Wall motion abnormality Discharge RDW Discharge MCV Discharge serum sodium bicarbonate Discharge Calcium
Odds Ratio
P value
1.04 0.44 1.97 1.36 1.04 2.06 0.65
0.000 0.043 0.033 0.000 0.025 0.022 0.044
Confidence Interval 1.02-1.06 0.20-0.97 1.06-3.68 1.17-1.59 1.01-1.09 1.11-3.83 0.43-0.99
Conclusion: Novel predictors of mortality in African Americans were identified including higher discharge MCV, RDW, serum sodium bicarbonate and lower serum calcium levels. Additional studies are needed to define the role of these factors.
309 Prediction of Congestive Heart Failure as Adverse Outcome of Non-STElevation Myocardial Infarction Lukasz R. Kiljanek, Pramil Cheriyath; Department of Medicine, PinnacleHealth Systems, Harrisburg Hospital, Harrisburg, PA Background: Non ST segment elevation myocardial infarction (NSTEMI) as the initial presentation of coronary artery disease (CAD) often leads to development of congestive heart failure (CHF). The incidence of CHF after NSTEMI is about 4.9 %. Our objective is to create prediction model for developing CHF as an adverse outcome of NSTEMI using Random Forest tool. Methods: The database was collected 20022004 for the CRUSADE registry (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes). Mean age of patients was 61.8 years. Females were 41%, 83% were Caucasians, 30% had diabetes and 22% of the patients had signs of CHF at initial presentation. To analyze the dataset, we used the Random Forest (RF) machine learning algorithm. Results: Mean AUC for the model was 0.95 with sensitivity of 86 %, specificity of 91%, and positive predictive value of 60%
S94 Journal of Cardiac Failure Vol. 15 No. 6S Suppl. 2009 and negative predictive value of 98%. As suspected, variable indicating presence of signs of CHF on initial presentation was the strongest predictor. To further validate our model, we repeated all analyses without the ‘‘signs of CHF on initial presentation’’ as a predictor. Mean AUC for this model was 0.77 with sensitivity of 29% and specificity of 91%, positive predictive value of 33% and negative predictive value of 89%. Discussion: Congestive Heart Failure as an adverse outcome of NSTEMI can be well predicted with Random Forest method even when number of cases and variables used for training is limited. Our results are in agreement with earlier suggested predictors (i.e. HR of more than 100/min). Even more, our approach interestingly finds specific function of risk for development of CHF depending on heart rate for any given scenario. An increasing number of multi-center computerized databases (ACTION registry, PCI registry) will make it easier to gather and analyze data. Algorithms and programs like this presented here will automatically screen data, predict outcomes and alert physicians for further course of action.
greater in pts limited by leg fatigue (*; p!0.0001) than in other groups, leading to higher peak VO2 (**; p50.0002). [Figure 1]
310 Recovery and Outcomes of Peripartum Cardiomyopathy: Results of IMAC 2 Registry Leslie T. Cooper1, G. William Dec2, Paul Mather3, Jeffrey Alexis4, Guillermo TorreAmione5, Ilan Wittstein6, Mark Zucker7, Jagat Narula8, Dennis M. McNamara9, IMAC Investigators; 1Cardiovascular Division, Mayo Clinic, Rochester, MN; 2 Cardiology, Massachusetts General Hospital, Boston, MA; 3Cardiovascular Division, Jefferson Hospital, Philadelphia, PA; 4Cardiology Division, University of Rochester, Rochester, NY; 5Cardiology Division, Methodist Hospital, Houston, TX; 6Cardiology Division, Johns Hopkins, Baltimore, MD; 7Cardiovascular Institute, Beth Israel Hospital, Newark, NJ; 8Cardiology, University of California at Irvine, Irvine, CA; 9Cardiovascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA Background: The natural history and outcomes of subjects with the recent onset of peripartum cardiomyopathy (PPCM) referred to cardiac transplant centers in the era of contemporary heart failure management remains unknown. We evaluated the therapy, recovery, and outcomes of subjects in the IMAC2 trial. Methods: Of the 373 subjects enrolled in the NHLBI sponsored Intervention in Myocarditis and Acute Cardiomyopathy Registry (IMAC 2) from 5/2002 to 12/2008, 39 met standard clinical criteria for PPCM . This consisted of non-ischemic cardiomyopathy occurring in the last month pre-delivery or within 5 months post partum. All subjects had an LVEF on ! 0.40, and were within 6 months of the onset of symptoms at the time of referral. Results: For the PPCM cohort, the mean LVEF at entry was 0.28 6 0.7, NYHA class 1/2/3/4 5 4/23/10/2, age 30.3 6 6.8 yrs, gravida 2.3 6 1.3, para 1.9 6 0.9, 15 (38%) were black, and 5 (13%) were receiving inotropes. At entry ACE inhibitor use was 87%, beta blockers use was 85%. One subject required LVAD support with a Jarvik 2000, recovered and the LVAD was explanted. LVEF at entry was 0.28 6 0.07 and increased to 0.48 6 0.12 after 6 months (p!.001), with a mean increase of 20 6 11 EF units. With median follow up of 18.4 months, transplant-free survival was 97%, with no deaths and one subject receiving a cardiac transplant. Conclusions: In a cohort of subjects newly diagnosed with PPCM referred to tertiary centers, outcomes and recovery with contemporary medical management are excellent, and evaluation for possible cardiac transplant can be safely deferred. Additional analysis is needed to determine the potential for medication discontinuation and the risk of recurrent pregnancies in this recovered population.
311 Symptomatic Limitation of Exercise beyond the Anaerobic Threshold Mahoto Kato, Daniel E. Forman, Eldrin F. Lewis, Lynne W. Stevenson, Howard L. Hartley; Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA
Conclusion: Pts describing leg fatigue as the specific limiting symptom during HF exercise may have more capacity to endure anaerobic metabolism and/or enlist further aerobic capacity. Although they achieved comparable VO2 at VeTh, pts who continued exercise until limited by leg fatigue went on to higher peak VO2 than pts who stopped due to dyspnea or fatigue. Focus on the period of exercise beyond anaerobic metabolism may enhance understanding of functional capacity in HF.
312 Heart Failure Patient Attitudes about Quality of Life Assessment in Clinical Practice in Urban Versus Rural Setting Sabrina Badloe1, Prashant Vaishnava1, Lee Arcement2, Eldrin F. Lewis1; 1 Department of Medicine, Brigham and Women’s Hospital, Boston, MA; 2 Cardiovascular Group, Leonard Chabert Medical Center, Houma, LA Introduction: The importance of improving quality of life (HRQL) in heart failure (HF) has been recognized in clinical studies but little is known about implementation into clinical practice and impact of education and setting on these preferences. The objective was to understand patient preferences to discuss HRQL in clinic and identify differences in these regarding clinic locations. Methods: A total of 202 HF patients in a rural, indigent clinic and an urban, tertiary clinic completed a patient attitude questionnaire about preferences for ambulatory assessment of HRQL and discussion of these during routine visits. Similarities and differences of these attitudes were assessed. Results: No differences were found in willingness to routinely complete HRQL survey and to discuss HRQL and sexual health (Table). More subjects in rural clinic reported willingness to receive treatment if depressed (73.2 vs.92.7%, P!0.001) and wanted to know how their HRQL compares to others (73.5 vs.87.6%, P50.013). Conclusion: Despite differences in education and demographics, HF patients seem to have similar preferences for discussing feelings, sexual health and possibility of being depressed in both urban and rural settings. Willingness to seek treatment for depression varied based upon patient background. Routine assessment of HRQL may be an important opportunity to improve outcomes in the HF clinic setting irrespective of patient background. Demographics and outcomes
Introduction: Oxygen consumption (VO2) at the threshold of anaerobic metabolism is reflected objectively by the ventilatory threshold (VeTh), and is influenced by many factors that also determine VO2 at peak exercise, including central hemodynamics, peripheral oxygen delivery and muscle training. Patients (pts) with heart failure (HF) commonly describe symptoms limiting exercise duration as general fatigue, dyspnea or leg fatigue. Pts who perceive different limiting symptoms may differ in terms of the levels of VO2 achieved. Hypothesis: VeTh and peak VO2 will differ between patient groups according to their limiting symptoms; fatigue, dyspnea, or leg fatigue, during cardio-pulmonary exercise test (CPET). Methods: CPET was performed between January and December 2008 in 319 consecutive pts with HF. After they stopped during the cycle ergometer protocol, pts were asked to choose from a list of reasons for terminating exercise, which included fatigue, dyspnea, or leg fatigue. Groups defined by these symptoms were compared for VO2 at VeTh and at peak exercise. Differences among groups were assessed using parametric and nonparametric ANOVA (p!0.05 significant). Results: The reason for CPET termination was defined as fatigue by 32 (10 %) pts, dyspnea by 118 (35 %), and leg fatigue by 130 (41 %), with 47 (14%) listing other reasons. Pts in leg fatigue group were slightly younger (51 vs 55yrs, p!0.0254) and more likely male (78 vs 59%, p!0.0023), but other clinical parameters were comparable. No significant differences were observed between groups for VO2 at VeTh. However, further increase in VO2 after VeTh was
Characteristic Total patients Male Mean age6SD Working Disability #High school degree NYHA class 3/4 Mean LVEF6SD Willing to complete 5-minute survey Willing to focus clinic on feeling better Interested in knowing if depressed Willing to receive treatment if depressed Interested in discussing sexual dysfunction Interested in knowing how HRQL compares to others
Urban
Rural
p-value
(49%) (57.6%) 6 11 (22.2%) (53.1%) (89.9%) (40.4%) 6 14 (96.8%) (50.5%) (94.8%) (92.7%)
0.015 0.266 0.002 0.001 !0.001 !0.001 0.844 0.470 0.165 0.193 !0.001
55 (57.9%)
61 (62.9%)
0.479
72 (73.5%)
85 (87.6%)
0.013
103 (51%) 76 (73.4%) 56 6 15 44 (42.7%) 31 (30.1%) 32 (31.1%) 34 (33%) 39 6 16 89 (94.7%) 38 (40.4%) 88 (89.8%) 71 (73.2%)
99 57 58 22 52 89 40 38 91 47 91 89
306 New Heart Failure Score Predicts Outcomes in Heart Failure Patients Konstadina Darsaklis, Sophia Farooki, Viviane Nguyen, Nadia Giannetti; Cardiology, McGill University Health Center - Royal Victoria Hospital, Montreal, QC, Canada Introduction: Heart failure patients are at risk of adverse cardiac events. Because heart failure is a heterogenous disease, a comprehensive assessment of these patients, inclusive of history, physical exam, and laboratory investigations, may best predict adverse outcomes. The McGill Heart Failure Score (MHFS) is a comprehensive assessment comprised of 3 sections (table 1). Items in each section are graded on a scale from 0 (no symptoms) to 3 (severe symptoms). All three sections are summed for a total possible maximum score of 48. Hypothesis: We hypothesize that the MHFS can accurately predict adverse outcomes in heart failure patients at 1 year follow-up. Methods: Patients at the Royal Victoria Hospital’s Heart Failure Clinic were recruited into this prospective observational study. Baseline evaluation included MHFS and NYHA assessment. Primary outcomes recorded at follow-up included i) ER visits !24 hours for CHF, ii) hospital admissions for CHF, iii) death and iv) heart transplant. A total MHFS cutoff of 10 was chosen. Outcomes and NYHA classes in patients above and below the cutoff of 10 were compared. Results: Eighty patients with abnormal ejection fractions were recruited. Forty-four patients had a total score !10. Their mean NYHA class was 1.68 6 0.52 and their average EF was 24.5%. Six out of 44 patients had a primary outcome event. The percentages of patients with adverse events were 2.3%, 4.5%, 6.8%, and 0% for outcomes i through iv, respectively. Thirty-six patients had a total score O10. Their mean NYHA class was 2.11 6 0.52 and their average EF was 29.8%. Seventeen patients out of 36 had a primary outcome event. The percentages of patients with adverse events were 2.8%, 25%, 16.7%, and 2.8% for outcomes i through iv, respectively. There were significantly more patients who had adverse events in the cohort with a total score O10 (p!0.001), despite similar NYHA classes. Conclusion: In heart failure patients, a McGill Heart Failure Score O10 predicts a worse cardiac prognosis, within the next year. This may be a more reliable predictor than NYHA classification at initial evaluation. Further validation in a larger sample size is warranted. The McGill Heart Failure Score History
Physician Evaluation
Laboratory
Dyspnea walking 2m on flat surface Dyspnea climbing 1 flight of stairs Dyspnea lying flat Lack of energy Difficulty completing daily tasks
Adjustment of diuretic (last month) Systolic blood pressure
Urea
Leg edema Pulmonary rales Adjustment of diuretics today
Sodium Albumin Bilirubin
HFSA
(n51172)(P50.924). The mean number of inpatient days was 13.6 (SD527.0) in the exercise training group compared to 15.0 (SD531.4) days in usual care (P50.21). Additional measures of medical resource use, including urgent care visits, outpatient visits and procedures, home IV therapy, skilled nursing and rehabilitative care were similar between groups, with the exception of trends indicating that fewer patients in the exercise training group underwent high-cost inpatient procedures including heart transplant and/or placement of a left ventricular assist device (n544 [3.7%] vs. n531 [2.7%], P50.14). Total direct medical costs were estimated at $50,857 (SD581,488) in the exercise training group and $56,177 (SD592,749) in the usual care group (95% CI for difference: $-12,755 to $1547). Direct cost of exercise training was estimated at $1006 (SD5337): $632 for supervised training and $374 for home-based training. Conclusions: Exercise training had little systematic impact on medical resource use overall, but the cost of exercise training may have been offset through a reduction in high-cost procedures.
308 Predictors of Mortality in African Americans Hospitalized with Systolic Heart Failure Jareer Farah1, Hammam D. Zmily1, Sandip Zalawadiya1, Omaima Ali1, Suleiman Daifallah1, Jalal K. Ghali2; 1Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, MI; 2Cardiology, Detroit Medical Center, Detroit, MI Introduction: Predictors of mortality in systolic heart failure (HF) have not been well characterized in African Americans. Methods: We studied 312 patients hospitalized with systolic HF in urban hospital between Jan and May-2007. Mortality was the primary outcome. We analyzed variables like clinical characteristics, co-morbidities, and laboratory findings. Multi-variate logistic regression analysis was constructed which included all statistically significant variables (p-value # 0.05). Results: The mean age was 61.7 6 16.7. Males were 56.7%. Sixty eight patients (21.8%) died. They were older (70.5 6 16.9 vs 59.3 6 15.9, p50.000), female gender (51.5% vs 41.0%, p50.123), had lower BMI (28.0 6 8.1 vs 30.6 6 8.9, p50.027), lower admission SBP (139.5 6 34.5 vs150.7 6 33.6, p50.016), and admission DBP (80.1 6 18.1 vs 91.4 6 23.1, p50.000). They were more likely to have PVD (16.2% vs 6.6% p50.013), ischemic HF (54.4% vs 37.7%, p50.013), wall motion abnormalities on echocardiogram (47.1% vs 30.7%, p50.012), lower serum calcium on discharge (8.4 6 0.9 vs 8.7 6 0.6 , p5 0.003), to have serum bicarbonate level of O28meq/dl on discharge (48.5% vs 34.0%, p50.029), GFR !60 on discharge (55.9% vs 41.8%, p50.039), had higher MCV on admission (88.7 6 9.9 vs 87.4 6 7.4, p50.233), higher MCV on discharge (89.1 6 9.4 vs 87.6 6 7.2, p50.163) and higher RDW on admission (16.6 6 2.1 vs 15.9 6 2.0, p50.011) and on discharge (16.9 6 2.5 vs 15.7 6 1.9, p50.000). They were less likely to have new onset HF (5.9% vs 16.0%, p50.025), or be discharged on ACEI (52.9% vs 67.2%, p50.030). Multivariate logistic regression analysis for mortality is shown below.
Creatinine
Recent EF
307 Cost of Exercise Training and Its Impact on Medical Resource Use and Costs: Results of HF-ACTION Shelby D. Reed1, David J. Whellan2, Yanhong Li1, Joelle Y. Friedman1, Ileana L. Pina3, Sharon J. Settles1, Linda Davidson-Ray1, Johanna Johnson1, Lawton S. Cooper4, Christopher M. O’Connor1, Kevin A. Schulman1; 1Duke Clinical Research Institute, Durham, NC; 2Thomas Jefferson University, Philadelphia, PA; 3 Case Western Reserve University School of Medicine, Cleveland, OH; 4National Heart Lung and Blood Institute, Bethesda, MD Introduction: HF-ACTION demonstrated modest clinical benefits with exercise training in heart failure patients. Hypothesis: Exercise training reduces medical resource use and direct medical costs. Methods: Between April 2003 and February 2007, HF-ACTION randomized 2331 patients with NYHA Class II-IV heart failure with reduced ejection fraction to usual care plus exercise training, consisting of 36 supervised sessions followed by home-based training, versus usual care alone. Throughout the trial, extensive data on medical resource use and hospital bills were collected to estimate direct medical costs. Intervention-related costs were estimated using patient-level data from the trial, administrative records, and published unit costs. Costs were reported in 2008 US dollars. Counts of hospitalizations and inpatient days were compared using negative binomial regression models. Confidence intervals for cost differences were derived using nonparametric bootstrapping. Results: Mean follow-up was 2.5 years in both groups. There were 2297 hospitalizations in the exercise training group (n51159) and 2332 in the usual care group
S93
Variable Age Presence of diastolic dysfunction Wall motion abnormality Discharge RDW Discharge MCV Discharge serum sodium bicarbonate Discharge Calcium
Odds Ratio
P value
1.04 0.44 1.97 1.36 1.04 2.06 0.65
0.000 0.043 0.033 0.000 0.025 0.022 0.044
Confidence Interval 1.02-1.06 0.20-0.97 1.06-3.68 1.17-1.59 1.01-1.09 1.11-3.83 0.43-0.99
Conclusion: Novel predictors of mortality in African Americans were identified including higher discharge MCV, RDW, serum sodium bicarbonate and lower serum calcium levels. Additional studies are needed to define the role of these factors.
309 Prediction of Congestive Heart Failure as Adverse Outcome of Non-STElevation Myocardial Infarction Lukasz R. Kiljanek, Pramil Cheriyath; Department of Medicine, PinnacleHealth Systems, Harrisburg Hospital, Harrisburg, PA Background: Non ST segment elevation myocardial infarction (NSTEMI) as the initial presentation of coronary artery disease (CAD) often leads to development of congestive heart failure (CHF). The incidence of CHF after NSTEMI is about 4.9 %. Our objective is to create prediction model for developing CHF as an adverse outcome of NSTEMI using Random Forest tool. Methods: The database was collected 20022004 for the CRUSADE registry (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes). Mean age of patients was 61.8 years. Females were 41%, 83% were Caucasians, 30% had diabetes and 22% of the patients had signs of CHF at initial presentation. To analyze the dataset, we used the Random Forest (RF) machine learning algorithm. Results: Mean AUC for the model was 0.95 with sensitivity of 86 %, specificity of 91%, and positive predictive value of 60%
S94 Journal of Cardiac Failure Vol. 15 No. 6S Suppl. 2009 and negative predictive value of 98%. As suspected, variable indicating presence of signs of CHF on initial presentation was the strongest predictor. To further validate our model, we repeated all analyses without the ‘‘signs of CHF on initial presentation’’ as a predictor. Mean AUC for this model was 0.77 with sensitivity of 29% and specificity of 91%, positive predictive value of 33% and negative predictive value of 89%. Discussion: Congestive Heart Failure as an adverse outcome of NSTEMI can be well predicted with Random Forest method even when number of cases and variables used for training is limited. Our results are in agreement with earlier suggested predictors (i.e. HR of more than 100/min). Even more, our approach interestingly finds specific function of risk for development of CHF depending on heart rate for any given scenario. An increasing number of multi-center computerized databases (ACTION registry, PCI registry) will make it easier to gather and analyze data. Algorithms and programs like this presented here will automatically screen data, predict outcomes and alert physicians for further course of action.
greater in pts limited by leg fatigue (*; p!0.0001) than in other groups, leading to higher peak VO2 (**; p50.0002). [Figure 1]
310 Recovery and Outcomes of Peripartum Cardiomyopathy: Results of IMAC 2 Registry Leslie T. Cooper1, G. William Dec2, Paul Mather3, Jeffrey Alexis4, Guillermo TorreAmione5, Ilan Wittstein6, Mark Zucker7, Jagat Narula8, Dennis M. McNamara9, IMAC Investigators; 1Cardiovascular Division, Mayo Clinic, Rochester, MN; 2 Cardiology, Massachusetts General Hospital, Boston, MA; 3Cardiovascular Division, Jefferson Hospital, Philadelphia, PA; 4Cardiology Division, University of Rochester, Rochester, NY; 5Cardiology Division, Methodist Hospital, Houston, TX; 6Cardiology Division, Johns Hopkins, Baltimore, MD; 7Cardiovascular Institute, Beth Israel Hospital, Newark, NJ; 8Cardiology, University of California at Irvine, Irvine, CA; 9Cardiovascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA Background: The natural history and outcomes of subjects with the recent onset of peripartum cardiomyopathy (PPCM) referred to cardiac transplant centers in the era of contemporary heart failure management remains unknown. We evaluated the therapy, recovery, and outcomes of subjects in the IMAC2 trial. Methods: Of the 373 subjects enrolled in the NHLBI sponsored Intervention in Myocarditis and Acute Cardiomyopathy Registry (IMAC 2) from 5/2002 to 12/2008, 39 met standard clinical criteria for PPCM . This consisted of non-ischemic cardiomyopathy occurring in the last month pre-delivery or within 5 months post partum. All subjects had an LVEF on ! 0.40, and were within 6 months of the onset of symptoms at the time of referral. Results: For the PPCM cohort, the mean LVEF at entry was 0.28 6 0.7, NYHA class 1/2/3/4 5 4/23/10/2, age 30.3 6 6.8 yrs, gravida 2.3 6 1.3, para 1.9 6 0.9, 15 (38%) were black, and 5 (13%) were receiving inotropes. At entry ACE inhibitor use was 87%, beta blockers use was 85%. One subject required LVAD support with a Jarvik 2000, recovered and the LVAD was explanted. LVEF at entry was 0.28 6 0.07 and increased to 0.48 6 0.12 after 6 months (p!.001), with a mean increase of 20 6 11 EF units. With median follow up of 18.4 months, transplant-free survival was 97%, with no deaths and one subject receiving a cardiac transplant. Conclusions: In a cohort of subjects newly diagnosed with PPCM referred to tertiary centers, outcomes and recovery with contemporary medical management are excellent, and evaluation for possible cardiac transplant can be safely deferred. Additional analysis is needed to determine the potential for medication discontinuation and the risk of recurrent pregnancies in this recovered population.
311 Symptomatic Limitation of Exercise beyond the Anaerobic Threshold Mahoto Kato, Daniel E. Forman, Eldrin F. Lewis, Lynne W. Stevenson, Howard L. Hartley; Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA
Conclusion: Pts describing leg fatigue as the specific limiting symptom during HF exercise may have more capacity to endure anaerobic metabolism and/or enlist further aerobic capacity. Although they achieved comparable VO2 at VeTh, pts who continued exercise until limited by leg fatigue went on to higher peak VO2 than pts who stopped due to dyspnea or fatigue. Focus on the period of exercise beyond anaerobic metabolism may enhance understanding of functional capacity in HF.
312 Heart Failure Patient Attitudes about Quality of Life Assessment in Clinical Practice in Urban Versus Rural Setting Sabrina Badloe1, Prashant Vaishnava1, Lee Arcement2, Eldrin F. Lewis1; 1 Department of Medicine, Brigham and Women’s Hospital, Boston, MA; 2 Cardiovascular Group, Leonard Chabert Medical Center, Houma, LA Introduction: The importance of improving quality of life (HRQL) in heart failure (HF) has been recognized in clinical studies but little is known about implementation into clinical practice and impact of education and setting on these preferences. The objective was to understand patient preferences to discuss HRQL in clinic and identify differences in these regarding clinic locations. Methods: A total of 202 HF patients in a rural, indigent clinic and an urban, tertiary clinic completed a patient attitude questionnaire about preferences for ambulatory assessment of HRQL and discussion of these during routine visits. Similarities and differences of these attitudes were assessed. Results: No differences were found in willingness to routinely complete HRQL survey and to discuss HRQL and sexual health (Table). More subjects in rural clinic reported willingness to receive treatment if depressed (73.2 vs.92.7%, P!0.001) and wanted to know how their HRQL compares to others (73.5 vs.87.6%, P50.013). Conclusion: Despite differences in education and demographics, HF patients seem to have similar preferences for discussing feelings, sexual health and possibility of being depressed in both urban and rural settings. Willingness to seek treatment for depression varied based upon patient background. Routine assessment of HRQL may be an important opportunity to improve outcomes in the HF clinic setting irrespective of patient background. Demographics and outcomes
Introduction: Oxygen consumption (VO2) at the threshold of anaerobic metabolism is reflected objectively by the ventilatory threshold (VeTh), and is influenced by many factors that also determine VO2 at peak exercise, including central hemodynamics, peripheral oxygen delivery and muscle training. Patients (pts) with heart failure (HF) commonly describe symptoms limiting exercise duration as general fatigue, dyspnea or leg fatigue. Pts who perceive different limiting symptoms may differ in terms of the levels of VO2 achieved. Hypothesis: VeTh and peak VO2 will differ between patient groups according to their limiting symptoms; fatigue, dyspnea, or leg fatigue, during cardio-pulmonary exercise test (CPET). Methods: CPET was performed between January and December 2008 in 319 consecutive pts with HF. After they stopped during the cycle ergometer protocol, pts were asked to choose from a list of reasons for terminating exercise, which included fatigue, dyspnea, or leg fatigue. Groups defined by these symptoms were compared for VO2 at VeTh and at peak exercise. Differences among groups were assessed using parametric and nonparametric ANOVA (p!0.05 significant). Results: The reason for CPET termination was defined as fatigue by 32 (10 %) pts, dyspnea by 118 (35 %), and leg fatigue by 130 (41 %), with 47 (14%) listing other reasons. Pts in leg fatigue group were slightly younger (51 vs 55yrs, p!0.0254) and more likely male (78 vs 59%, p!0.0023), but other clinical parameters were comparable. No significant differences were observed between groups for VO2 at VeTh. However, further increase in VO2 after VeTh was
Characteristic Total patients Male Mean age6SD Working Disability #High school degree NYHA class 3/4 Mean LVEF6SD Willing to complete 5-minute survey Willing to focus clinic on feeling better Interested in knowing if depressed Willing to receive treatment if depressed Interested in discussing sexual dysfunction Interested in knowing how HRQL compares to others
Urban
Rural
p-value
(49%) (57.6%) 6 11 (22.2%) (53.1%) (89.9%) (40.4%) 6 14 (96.8%) (50.5%) (94.8%) (92.7%)
0.015 0.266 0.002 0.001 !0.001 !0.001 0.844 0.470 0.165 0.193 !0.001
55 (57.9%)
61 (62.9%)
0.479
72 (73.5%)
85 (87.6%)
0.013
103 (51%) 76 (73.4%) 56 6 15 44 (42.7%) 31 (30.1%) 32 (31.1%) 34 (33%) 39 6 16 89 (94.7%) 38 (40.4%) 88 (89.8%) 71 (73.2%)
99 57 58 22 52 89 40 38 91 47 91 89