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Predictors of Survival Outcome in Patients with Heart Failure with Preserved Ejection Fraction
S72 Journal of Cardiac Failure Vol. 22 No. 8S August 2016
Epidemiology/Prevention 199 Acute Heart Failure Syndromes in Patients with Body Mass Index ≥30 kg/m2 Hassan Alkhawam1, Jeevan Sall1, Feras Zaiem2, Timothy J. Vittorio3; 1Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, NY; 2Mayo Clinic, Rochester, MN; 3St. Francis Hospital—Heart Center®, Roslyn, NY Introduction: The Framingham Heart Study identified obesity as a major risk factor for heart failure, with excessive body weight adversely affecting ventricular function. Hypothesis: In this study, we aim to study the effect of obesity in the outcome of different phenotypes of heart failure (HF) in patients who were admitted to the hospital for an acute HF syndrome (AHFS). Methods: A retrospective chart analysis of all patients who were admitted to the hospital for an AHFS between 2005 and 2015. Patients were divided into two groups: obese (BMI ≥ 30 kg/m2) and normal (BMI < 25). Patients with BMI from 25 to 29 were excluded. We assessed the left ventricular ejection fraction and subsequently divided the patients into two groups: HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). We studied the 30-day readmission rate, mortality rate and length of stay (LOS). Results: Of 2090 patients who were admitted to the hospital for AHFS, 362 patients (17.3%) had BMI ≥30 vs 1232 (59%) had BMI <25. Among AHFS patients and BMI ≥ 30, 61% had HFpEF and 39% had HFrEF. Approximately 54% of AHFS patients with BMI ≥ 30 were male vs 55% of AHFS with BMI <25 (P = .9). The average age of AHFS in patient with BMI ≥ 30 was 61 years vs 70 years in AHFS and BMI <25 (P < .001). Additionally, 61% of AHFS and BMI ≥ 30 had HFpEF vs 48% in HFpEF patients and BMI <25 group (OR: 1.7, P < .001). The 30-day readmission rate, mortality rate and LOS and did not differ between AHFS with BMI ≥ 30 and BMI <25 (P = .6, .07 and .06). Among AHFS and HFrEF, average age in patients with BMI ≥ 30 was 57 years vs 65 years in BMI <25 (P < .001). In the same group (AHFS and HFrEF), 30-day readmission was 19% in patients BMI <25 versus 10% in patients with BMI ≥ 30 (OR: 2.1, P = .01). The mortality rate and LOS did not differ between the two groups (P = .8 and .9). Among AHFS and HFpEF, average age of patients with BMI ≥ 30 was 65 years versus 74 years in patients with BMI < 25. In the same group (AHFS and HFpEF), patients with BMI ≥ 30 had a higher 30-day readmission rate of 23.4% versus 15.3% in BMI < 25 group (OR: 1.6, P = .01). The mortality rate and LOS did not differ between the two groups (P = .7 and .9). Subgroup analysis of HFrEF versus HFpEF among patients with AHFS and BMI ≥ 30, patients with HFpEF had a 30-day readmission rate of 20% versus 10% in HFrEF (OR: 2.2, P = .01). The mortality rate and LOS did not differ (P = .5 and .09). After we divided the patients with AHFS and BMI ≥ 30 in to two groups; BMI ≥ 30–39 and BMI ≥ 40, 64% of the patients with BMI ≥ 40 found to have HFrEF vs 13% among BMI 30–39 (OR: 6.2, P < .001). The 30-day readmission rate was 11.5% in BMI ≥ 40 vs 5% in BMI ≥ 30–39 group (OR: 2, P = .02). Conclusion: Patients with HF and BMI ≥ 30 seem to develop AHFS at an earlier age. The majority of patients with AHFS and BMI between 30 and 39 have HFpEF while patients with BMI ≥ 40 have HFrEF. The 30-day readmission rate was higher in patients with HFpEF and BMI ≥ 30. Finally, there is a direct proportion between 30-day readmission rate and increasing the BMI.
200 Understanding the Health Burden of Mitral Regurgitation Through Clinical Data Repositories Abhishek Khemka1, Richard Kovacs1, Wanzhu Tu2, Ross Hayden2, Abdullah Masud2, George Eckert3, William M. Tierney4, Irmina Gradu-Pizlo1; 1Indiana University School of Medicine, Indianapolis, IN; 2Regenstrief Institute, Indianapolis, IN; 3Indiana University-Purdue University Indianapolis, Indianapolis, IN; 4Dell Medical School, University of Texas, Austin, TX Introduction: Mitral regurgitation (MR) is the most common valvular abnormality in the US. Guidelines recommend intervention on symptomatic severe MR and periodic monitoring for less than severe MR. This is a novel investigation using clinical data repositories to evaluate patients with moderate or worse MR (m-w MR) compared to patients with mild or less MR (m-l MR) to delineate comorbidities and survival. Methods: This was a retrospective analysis using clinical data repositories at the Regenstrief Institute in collaboration with Indiana University Health (IU) to evaluate clinical outcomes in patients with m-w MR. The echo database at IU was searched for patients with m-w MR (age 18–90) with enlarged left atrium (LAE). Searching the years from 2010–2015, 2524 unique patients met the criteria of m-w MR. Patients were excluded from the analysis if they had pre-specified exclusion criteria (endocarditis, mitral valve replacement, mitral stenosis, or other severe cardiac structural abnormalities that would confound the longitudinal course of m-w MR. 1067 patients with m-w MR and LAE were compared with a control population matched for age, race and gender. The control group was selected from patients undergoing echocardiograms during the same time period, but indicating m-l MR. Results: The m-w MR cohort had 70% of patients with moderate MR, 20% with moderate to severe MR and 10% with severe MR. Patients with m-w MR had significantly lower survival probability compared to the control population (Figure). Mortality was similar for patients with moderate, moderate to severe or severe MR. There was also significant difference between average BNP (MR 1,057.9 vs control 454.5, p = < .0001) and average ejection fraction (MR = 43.1% vs control = 54.3%,
p = < .0001). There was also considerable difference in comorbidities including heart failure (HF) (MR = 64% vs control = 28%, p = < .0001) and hypertension (MR = 79% vs control = 57%, p = < .0001). The MR cohort was responsible for 23,847 inpatient encounters of which 12,055 encounters were related to HF or HF plus other heart disease. Conclusion: patients with m-w MR have significant comorbidities and decreased survival. Patients with moderate MR have similarly poor survival rates as patients with severe MR. Patients with moderate MR may benefit from more aggressive treatment at an earlier stage.
201 Predictors of Survival Outcome in Patients with Heart Failure with Preserved Ejection Fraction Sherry Zhang1, Paul Clopton2, Melanee Schimmel2, Payman Zamani3, Barry Greenberg2; 1 San Diego School of Medicine, University of California, La Jolla, CA; 2University of California, San Diego, La Jolla, CA; 3University of Pennsylvania, Philadelphia, PA Objective: We sought to determine the effects of ethnicity and various comorbidities on prognosis in patients with heart failure with preserved ejection fraction (HFpEF). Background: Patients with HFpEF are known to have a high prevalence of comorbidities including coronary artery disease (CAD), atrial fibrillation, hypertension, chronic obstructive pulmonary disease (COPD), renal disease and hyperlipidemia. The impact of these comorbidities, and how they interact with ethnicity, on the clinical outcome of HFpEF patients is not certain. Methods: We conducted retrospective chart reviews of electronic medical records of patients who had echocardiograms at UCSD Medical Center from January 2009 to January 2014. A population of HFpEF patients was defined from the database using a clinical diagnosis of heart failure, normal or mildly abnormal systolic left ventricular function with ejection fraction > 50% and established echocardiographic criteria of diastolic left ventricular dysfunction. The presence of comorbidities was determined from review of each patient’s chart. Basic demographic information, survival status and cause of death were also collected. Results: From the database, 449 patients met the inclusion criteria for HFpEF. Of these, 62.1% were Caucasian, 12.5% African American, 6.0% Asian and 18.7% Other/Unknown. The average age was 74 years, with 60.6% female. In this population, 42.1% had CAD, 39.4% atrial fibrillation, 81.1% hypertension, 18.5% COPD, 29.6% renal disease and 53.0% hyperlipidemia. Although there were trends toward higher all-cause and cardiovascular mortality in patients with CAD, atrial fibrillation and COPD, lower allcause and cardiovascular mortality in hypertensive patients, and a higher rate of death but a lower rate of cardiovascular death in patients with renal disease, none of these achieved statistical significance. There was, however, a significant relationship between ethnicity and cardiovascular mortality, with African Americans experiencing a higher rate of cardiovascular death (P = .037) and Caucasians experiencing a lower rate of cardiovascular death (P = .009). Prevalence of comorbid conditions was similar between these two ethnic groups. Conclusion: This study demonstrated that ethnicity significantly influenced the rate of cardiovascular mortality in this HFpEF population, with a higher rate in African Americans and a lower rate in Caucasians. This difference in survival outcomes did not appear to be explained by differences in comorbidities. Whether survival differences were due to underlying differences in pathophysiology or other factors requires further study. Regardless, the higher rate of cardiovascular mortality in African Americans indicates the need for more aggressive management strategies to improve outcomes in this group.
Epidemiology/Prevention 199 Acute Heart Failure Syndromes in Patients with Body Mass Index ≥30 kg/m2 Hassan Alkhawam1, Jeevan Sall1, Feras Zaiem2, Timothy J. Vittorio3; 1Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, NY; 2Mayo Clinic, Rochester, MN; 3St. Francis Hospital—Heart Center®, Roslyn, NY Introduction: The Framingham Heart Study identified obesity as a major risk factor for heart failure, with excessive body weight adversely affecting ventricular function. Hypothesis: In this study, we aim to study the effect of obesity in the outcome of different phenotypes of heart failure (HF) in patients who were admitted to the hospital for an acute HF syndrome (AHFS). Methods: A retrospective chart analysis of all patients who were admitted to the hospital for an AHFS between 2005 and 2015. Patients were divided into two groups: obese (BMI ≥ 30 kg/m2) and normal (BMI < 25). Patients with BMI from 25 to 29 were excluded. We assessed the left ventricular ejection fraction and subsequently divided the patients into two groups: HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). We studied the 30-day readmission rate, mortality rate and length of stay (LOS). Results: Of 2090 patients who were admitted to the hospital for AHFS, 362 patients (17.3%) had BMI ≥30 vs 1232 (59%) had BMI <25. Among AHFS patients and BMI ≥ 30, 61% had HFpEF and 39% had HFrEF. Approximately 54% of AHFS patients with BMI ≥ 30 were male vs 55% of AHFS with BMI <25 (P = .9). The average age of AHFS in patient with BMI ≥ 30 was 61 years vs 70 years in AHFS and BMI <25 (P < .001). Additionally, 61% of AHFS and BMI ≥ 30 had HFpEF vs 48% in HFpEF patients and BMI <25 group (OR: 1.7, P < .001). The 30-day readmission rate, mortality rate and LOS and did not differ between AHFS with BMI ≥ 30 and BMI <25 (P = .6, .07 and .06). Among AHFS and HFrEF, average age in patients with BMI ≥ 30 was 57 years vs 65 years in BMI <25 (P < .001). In the same group (AHFS and HFrEF), 30-day readmission was 19% in patients BMI <25 versus 10% in patients with BMI ≥ 30 (OR: 2.1, P = .01). The mortality rate and LOS did not differ between the two groups (P = .8 and .9). Among AHFS and HFpEF, average age of patients with BMI ≥ 30 was 65 years versus 74 years in patients with BMI < 25. In the same group (AHFS and HFpEF), patients with BMI ≥ 30 had a higher 30-day readmission rate of 23.4% versus 15.3% in BMI < 25 group (OR: 1.6, P = .01). The mortality rate and LOS did not differ between the two groups (P = .7 and .9). Subgroup analysis of HFrEF versus HFpEF among patients with AHFS and BMI ≥ 30, patients with HFpEF had a 30-day readmission rate of 20% versus 10% in HFrEF (OR: 2.2, P = .01). The mortality rate and LOS did not differ (P = .5 and .09). After we divided the patients with AHFS and BMI ≥ 30 in to two groups; BMI ≥ 30–39 and BMI ≥ 40, 64% of the patients with BMI ≥ 40 found to have HFrEF vs 13% among BMI 30–39 (OR: 6.2, P < .001). The 30-day readmission rate was 11.5% in BMI ≥ 40 vs 5% in BMI ≥ 30–39 group (OR: 2, P = .02). Conclusion: Patients with HF and BMI ≥ 30 seem to develop AHFS at an earlier age. The majority of patients with AHFS and BMI between 30 and 39 have HFpEF while patients with BMI ≥ 40 have HFrEF. The 30-day readmission rate was higher in patients with HFpEF and BMI ≥ 30. Finally, there is a direct proportion between 30-day readmission rate and increasing the BMI.
200 Understanding the Health Burden of Mitral Regurgitation Through Clinical Data Repositories Abhishek Khemka1, Richard Kovacs1, Wanzhu Tu2, Ross Hayden2, Abdullah Masud2, George Eckert3, William M. Tierney4, Irmina Gradu-Pizlo1; 1Indiana University School of Medicine, Indianapolis, IN; 2Regenstrief Institute, Indianapolis, IN; 3Indiana University-Purdue University Indianapolis, Indianapolis, IN; 4Dell Medical School, University of Texas, Austin, TX Introduction: Mitral regurgitation (MR) is the most common valvular abnormality in the US. Guidelines recommend intervention on symptomatic severe MR and periodic monitoring for less than severe MR. This is a novel investigation using clinical data repositories to evaluate patients with moderate or worse MR (m-w MR) compared to patients with mild or less MR (m-l MR) to delineate comorbidities and survival. Methods: This was a retrospective analysis using clinical data repositories at the Regenstrief Institute in collaboration with Indiana University Health (IU) to evaluate clinical outcomes in patients with m-w MR. The echo database at IU was searched for patients with m-w MR (age 18–90) with enlarged left atrium (LAE). Searching the years from 2010–2015, 2524 unique patients met the criteria of m-w MR. Patients were excluded from the analysis if they had pre-specified exclusion criteria (endocarditis, mitral valve replacement, mitral stenosis, or other severe cardiac structural abnormalities that would confound the longitudinal course of m-w MR. 1067 patients with m-w MR and LAE were compared with a control population matched for age, race and gender. The control group was selected from patients undergoing echocardiograms during the same time period, but indicating m-l MR. Results: The m-w MR cohort had 70% of patients with moderate MR, 20% with moderate to severe MR and 10% with severe MR. Patients with m-w MR had significantly lower survival probability compared to the control population (Figure). Mortality was similar for patients with moderate, moderate to severe or severe MR. There was also significant difference between average BNP (MR 1,057.9 vs control 454.5, p = < .0001) and average ejection fraction (MR = 43.1% vs control = 54.3%,
p = < .0001). There was also considerable difference in comorbidities including heart failure (HF) (MR = 64% vs control = 28%, p = < .0001) and hypertension (MR = 79% vs control = 57%, p = < .0001). The MR cohort was responsible for 23,847 inpatient encounters of which 12,055 encounters were related to HF or HF plus other heart disease. Conclusion: patients with m-w MR have significant comorbidities and decreased survival. Patients with moderate MR have similarly poor survival rates as patients with severe MR. Patients with moderate MR may benefit from more aggressive treatment at an earlier stage.
201 Predictors of Survival Outcome in Patients with Heart Failure with Preserved Ejection Fraction Sherry Zhang1, Paul Clopton2, Melanee Schimmel2, Payman Zamani3, Barry Greenberg2; 1 San Diego School of Medicine, University of California, La Jolla, CA; 2University of California, San Diego, La Jolla, CA; 3University of Pennsylvania, Philadelphia, PA Objective: We sought to determine the effects of ethnicity and various comorbidities on prognosis in patients with heart failure with preserved ejection fraction (HFpEF). Background: Patients with HFpEF are known to have a high prevalence of comorbidities including coronary artery disease (CAD), atrial fibrillation, hypertension, chronic obstructive pulmonary disease (COPD), renal disease and hyperlipidemia. The impact of these comorbidities, and how they interact with ethnicity, on the clinical outcome of HFpEF patients is not certain. Methods: We conducted retrospective chart reviews of electronic medical records of patients who had echocardiograms at UCSD Medical Center from January 2009 to January 2014. A population of HFpEF patients was defined from the database using a clinical diagnosis of heart failure, normal or mildly abnormal systolic left ventricular function with ejection fraction > 50% and established echocardiographic criteria of diastolic left ventricular dysfunction. The presence of comorbidities was determined from review of each patient’s chart. Basic demographic information, survival status and cause of death were also collected. Results: From the database, 449 patients met the inclusion criteria for HFpEF. Of these, 62.1% were Caucasian, 12.5% African American, 6.0% Asian and 18.7% Other/Unknown. The average age was 74 years, with 60.6% female. In this population, 42.1% had CAD, 39.4% atrial fibrillation, 81.1% hypertension, 18.5% COPD, 29.6% renal disease and 53.0% hyperlipidemia. Although there were trends toward higher all-cause and cardiovascular mortality in patients with CAD, atrial fibrillation and COPD, lower allcause and cardiovascular mortality in hypertensive patients, and a higher rate of death but a lower rate of cardiovascular death in patients with renal disease, none of these achieved statistical significance. There was, however, a significant relationship between ethnicity and cardiovascular mortality, with African Americans experiencing a higher rate of cardiovascular death (P = .037) and Caucasians experiencing a lower rate of cardiovascular death (P = .009). Prevalence of comorbid conditions was similar between these two ethnic groups. Conclusion: This study demonstrated that ethnicity significantly influenced the rate of cardiovascular mortality in this HFpEF population, with a higher rate in African Americans and a lower rate in Caucasians. This difference in survival outcomes did not appear to be explained by differences in comorbidities. Whether survival differences were due to underlying differences in pathophysiology or other factors requires further study. Regardless, the higher rate of cardiovascular mortality in African Americans indicates the need for more aggressive management strategies to improve outcomes in this group.