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The Prognostic Value of Arterial Blood Gas Analysis in Acute Heart Failure Patients
The 18th Annual Scientific Meeting
O-134 Neurohormonal Balance between B-type Natriuretic Peptide Levels and Reninangiotensin-aldosterone System Factors Predicts Clinical Outcome in Acute Decompensated Heart Failure Patients HIROYUKI TAKAHAMA, YASUKI NAKADA, AKIRA FUNADA, TAKAHIRO OHARA, YASUO SUGANO, TAKUYA HASEGAWA, MASANORI ASAKURA, HIDEAKI KANZAKI, MASAFUMI KITAKAZE, TOSHIHISA ANZAI Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center Background: Although there is the counter-regulation between B-type natriuretic peptide (BNP) level and renin-angiotensin-aldosterone system (RAAS) activation, less is known about whether the balance is preserved in patients with acute decompensated heart failure (ADHF). This study aimed to determine 1) the relationships between plasma BNP levels and RAAS factors and 2) whether the balance predict clinical outcome in ADHF patients. Methods: We retrospectively studied the relationships between plasma BNP level, plasma renin activity (PRA) and aldosterone concentration (PAC) and the cardiovascular events in the ADHF patients with New York Heart Association class III-IV symptom (n592). Results: High PRA was frequently observed in ADHF patients (median: 3.4ng/ml/h). Plasma BNP levels did not correlate with PRA, though weak correlation was found with PAC. After the adjustment of systolic blood pressure, the correlation between PRA and serum BNP was found (p!0.05). The high PRA in the acute phase of ADHF was a predictor of cardiovascular events even after the accounting for the plasma BNP levels or the use of RAAS blockers (p!0.05). Conclusions: The neurohormonal imbalance between plasma BNP level and RAAS activation in the acute-phase was observed in a substantial number of patients with ADHF, and was associated with a poor prognosis. These findings suggest that the systemic hemodynamic state has the strong influence on the balance in the acute-phase of ADHF.
O-135 The Prognostic Value of Arterial Blood Gas Analysis in Acute Heart Failure Patients JIN JOO PARK, DONG-JU CHOI, BYUNG-SU YOO, SEOK-MIN KANG, JAEJOONG KIM, SANG-HONG BAEK, MYEONG-CHAN CHO, EUN-SEOK JEON, SHUNG CHULL CHAE, KYU-HYUNG RYU, BYUNG-HEE OH, ON BEHALF OF KOREA HEART FAILURE REGISTRY (KORHF) Department of Internal Medicine and Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea Background: In acute heart failure (AHF) patients, pulmonary edema and low tissue perfusion may lead to changes in the acid-base balance, which may be associated with worse outcomes. However, the prognostic value of arterial blood gas (ABG) is not well established in AHF patients. Methods and Results: ABG was measured in 1,982 patients at hospital admission. Acidosis was defined as pH!7.36, and alkalosis as pHO7.44. Mortality was stratified according to ABG results. Overall, 19% had acidosis, 37% had normal pH, and 44% had alkalosis. The most common type of acidosis was the mixed type (42%) followed by metabolic acidosis (40%), and that of alkalosis was respiratory alkalosis (58%). During follow-up (median, 465days; interquartile range, 125-964 days), 442 patients (22.3%) died. Patients with acidosis had higher mortality (acidosis 27.5%, normal pH 21.0%, and alkalosis 21.2%, P ! 0.001). In the Cox proportional-hazards regression model, acidosis was an independent predictor of mortality (HR,1.53; 95% CI, 1.06-2.19) along with N-terminal pro-brain type natriuretic peptide (NT-proBNP), among others. In contrast, alkalosis was not associated with increased mortality. pH had an incremental prognostic value over NT-proBNP (net reclassification improvement, 30%; P ! 0.001), and ABG analysis identified extra patients at increased risk for mortality among patients with an NT-proBNP level less than the median (12-month mortality: 17.5% vs. 9.9%, P 5 0.009). Conclusions: In high-risk AHF patients, the most common acidbase imbalance is respiratory alkalosis. Acidosis is observed in every fifth patient and is an independent predictor of mortality. ABG provides an additional prognostic value and may be used to optimize risk stratification in high-risk AHF patients.
O-141 High Serum Levels of Thrombospondin-2 Correlate with Poor Prognosis of Patients with Heart Failure with Preserved Ejection Fraction YUICHI KIMURA, YASUHIRO IZUMIYA, YOSHIRO ONOUE, SHINSUKE HANATANI, SATOSHI ARAKI, HISAO OGAWA Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan Introduction: Thrombospondin-2 (TSP-2) is highly expressed in hypertensive heart. Interstitial fibrosis is frequently observed in hypertensive heart, and it is a characteristic feature of heart failure with preserved ejection fraction (HFpEF). We hypothesize that high TSP-2 serum levels reflect disease severity and can predict poor prognosis of patients with HFpEF. Methods and Results: Serum TSP-2 levels were measured by ELISA in 150 patients with HFpEF. The median TSP-2 level was 19.2 (14.4-26.0) ng/ml. TSP-2 levels correlated with the New York Heart Association (NYHA) functional class. Patients were divided into high and low TSP-2 groups based on the median value. Pulmonary capillary wedge pressure, and circulating levels of BNP and cardiac troponin T were significantly higher in the highTSP-2 group. Whereas, cardiac index was significantly lower in the high TSP-2 group. Kaplan-Meier survival curve showed high risk of adverse cardiovascular events in the high TSP-2 group, and that the combination of high TSP-2 and high
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BNP (O100 pg/ml) was associated with the worst event-free survival rate. Multivariate Cox proportional hazard analysis identified BNP and TSP-2 as independent predictors of risk of death and cardiovascular events. Conclusions: Circulating TSP-2 correlates with disease severity in patients with HFpEF. TSP-2 is a potentially useful predictor of future adverse cardiovascular events in patients with HFpEF.
O-142 Elevated Fibroblast Growth Factor-23 levels is Associated with Diastolic Dysfunction among No-CKD Patients with Preserved Left Ventricular Ejection Function KAZUSHI SAKANE, MICHISHIGE OHZEKI, HIDEAKI MORITA, MASAAKI HOSHIGA, NOBUKAZU ISHIZAKA Department of Cardiology, Osaka Medical College, Osaka, Japan Background: Fibroblast growth factor-23 (FGF23) plays a crucial role in phosphate metabolism via suppressing renal tubular phosphate re-absorption. Recent studies showed that patients with higher serum FGF23 more likely to have cardiac hypertrophy, which is independent of renal function, and blood pressure. Purpose: We investigated whether serum FGF23 concentrations were associated with cardiac diastolic function-related parameters among cardiac patients with preserved left ventricular ejection fraction. Methods: The current study enrolled 245 patients with age of O50 years who had a left ventricular ejection fraction of O50%. Cardiac diastolic function was assessed by E/e0 , E/A, DcT, BNP, and cardiac hypertrophy. Results: Log(FGF23) was correlated positively with BNP (R50.192, P!0.001). On the other hand, log(FGF23) was not significantly correlated with age, left ventricular mass index, left ventricular ejection fraction, E/A, E/e0 , or DcT. After adjusting for age, gender, and eGFR, log(FGF23) was not significantly associated with diastolic dysfunction (data not shown); however, when limited to the patients without chronic kidney disease (CKD), log(FGF23) was positively associated with diastolic dysfunction with an odds ratio of 16.3 (per 1 SD increase, P!0.05). On the other hand, log(FGF23) was not associated with diastolic dysfunction among patients with preserved renal function. Conclusions: Among patients with preserved left ventricular function and no-CKD, patients with elevated FGF23 concentrations were at higher risk for diastolic dysfunction.
O-143 A Distinct Pathophysiological Role of Vascular Inflammatory Markers in Heart failure-Another Role of Angiopoietin-like 2 TOKO MITSUI1, YASUKO BANDO K1, TAKAHIRO OKUMURA2, ATSUYA SHIMIZU1, TOYOAKI MUROHARA1 1 Department of Cardiology, Nagoya University, 2Department of Cardiology, Nagoya Univeristy Graduate School of Medicine, Nagoya, Japan, 3Department of Cardiology, National Center for Geriatrics and Gentrolgy Background: Vascular endothelial inflammation (VEI) contributes to the pathophysiology underlying heart failure. Angiopoietin-like 2 (Angptl2) is a secreted glycoprotein with homology to the angiopoietins and play a pivotal role in vascular inflammation particularly associated with metabolic disorders such as diabetes. We thus examined a link between VEI in HFREF without active coronary artery disease (CAD). Methods and Results: Fourty five consecutive patients of HFREF (mean EF; 29.9610.0%, mean BNP; 293.06424.6 pg/ml) without CAD were retrospectively evaluated. VEI was monitored by 3 surrogate markers, Angptl2, sDPP4, and soluble ICAM (sICAM). Vascular atherosclerotic remodeling was assessed by mean IMT value and plaque score measured by carotid echography. Angptl2 was positively associated exclusively to sDPP4. Angptl2 and DPP4 was correlated with diastolic indices (R50.43 for E/A (P!0.01) and R50.44 for E/e (P!0.01), respectively), which was augmented by comorbid diabetes (R50.64 for E/e (PP!0.01)). The sICAM exhibited no association with neither systolic and diastolic functional indices. Furthermore, we found sICAM exclusively correlated to IMT value not in sDPP4 and Angptl2. Conclusions: The present study supports the pivotal role of Angplt2 and DPP4 that presumably reflect microvascular inflammation contributing to progression of diastolic dysfunction. The sICAM, another vascular inflammatory marker, may reflect vascular inflammation occurred in large vessel such as carotid artery, which was found as an independent factor for cardiac dysfunction.
O-144 The Usefulness of Combined Assessment of E/e0 Ratio and Transmitral Flow Pattern to Interpret Heart Condition MASAYOSHI OIKAWA, ATSUSHI KOBAYASHI, HIROYUKI YAMAUCHI, SATOSHI SUZUKI, AKIOMI YOSHIHISA, KAZUHIKO NAKAZATO, HITOSHI SUZUKI, SHU-ICHI SAITOH, YASUCHIKA TAKEISHI Department of Cardiology and Hematology, Fukushima Medical University, Fukushima, Japan A mitral inflow E velocity to tissue Doppler e0 (E/e0 ) ratio is widely used to estimate left ventricular (LV) filling pressure, and the ratio of early (E) and late (A) diastolic filling velocity, E/A ratio, is also a useful parameter to assess LV diastolic function. However, the relationship between E/e0 ratio and E/A ratio is not fully understood. We analyzed 415 patients who presented high E/e0 ratio more than 15, and they were divided into two groups based on the value of E/A ratio: low E/A group (E/A!0.8, n5128) and high E/A group (E/AO0.8, n5287). Low E/A group showed lower estimated right ventricle systolic pressure (33610 mmHg vs. 40612
O-134 Neurohormonal Balance between B-type Natriuretic Peptide Levels and Reninangiotensin-aldosterone System Factors Predicts Clinical Outcome in Acute Decompensated Heart Failure Patients HIROYUKI TAKAHAMA, YASUKI NAKADA, AKIRA FUNADA, TAKAHIRO OHARA, YASUO SUGANO, TAKUYA HASEGAWA, MASANORI ASAKURA, HIDEAKI KANZAKI, MASAFUMI KITAKAZE, TOSHIHISA ANZAI Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center Background: Although there is the counter-regulation between B-type natriuretic peptide (BNP) level and renin-angiotensin-aldosterone system (RAAS) activation, less is known about whether the balance is preserved in patients with acute decompensated heart failure (ADHF). This study aimed to determine 1) the relationships between plasma BNP levels and RAAS factors and 2) whether the balance predict clinical outcome in ADHF patients. Methods: We retrospectively studied the relationships between plasma BNP level, plasma renin activity (PRA) and aldosterone concentration (PAC) and the cardiovascular events in the ADHF patients with New York Heart Association class III-IV symptom (n592). Results: High PRA was frequently observed in ADHF patients (median: 3.4ng/ml/h). Plasma BNP levels did not correlate with PRA, though weak correlation was found with PAC. After the adjustment of systolic blood pressure, the correlation between PRA and serum BNP was found (p!0.05). The high PRA in the acute phase of ADHF was a predictor of cardiovascular events even after the accounting for the plasma BNP levels or the use of RAAS blockers (p!0.05). Conclusions: The neurohormonal imbalance between plasma BNP level and RAAS activation in the acute-phase was observed in a substantial number of patients with ADHF, and was associated with a poor prognosis. These findings suggest that the systemic hemodynamic state has the strong influence on the balance in the acute-phase of ADHF.
O-135 The Prognostic Value of Arterial Blood Gas Analysis in Acute Heart Failure Patients JIN JOO PARK, DONG-JU CHOI, BYUNG-SU YOO, SEOK-MIN KANG, JAEJOONG KIM, SANG-HONG BAEK, MYEONG-CHAN CHO, EUN-SEOK JEON, SHUNG CHULL CHAE, KYU-HYUNG RYU, BYUNG-HEE OH, ON BEHALF OF KOREA HEART FAILURE REGISTRY (KORHF) Department of Internal Medicine and Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea Background: In acute heart failure (AHF) patients, pulmonary edema and low tissue perfusion may lead to changes in the acid-base balance, which may be associated with worse outcomes. However, the prognostic value of arterial blood gas (ABG) is not well established in AHF patients. Methods and Results: ABG was measured in 1,982 patients at hospital admission. Acidosis was defined as pH!7.36, and alkalosis as pHO7.44. Mortality was stratified according to ABG results. Overall, 19% had acidosis, 37% had normal pH, and 44% had alkalosis. The most common type of acidosis was the mixed type (42%) followed by metabolic acidosis (40%), and that of alkalosis was respiratory alkalosis (58%). During follow-up (median, 465days; interquartile range, 125-964 days), 442 patients (22.3%) died. Patients with acidosis had higher mortality (acidosis 27.5%, normal pH 21.0%, and alkalosis 21.2%, P ! 0.001). In the Cox proportional-hazards regression model, acidosis was an independent predictor of mortality (HR,1.53; 95% CI, 1.06-2.19) along with N-terminal pro-brain type natriuretic peptide (NT-proBNP), among others. In contrast, alkalosis was not associated with increased mortality. pH had an incremental prognostic value over NT-proBNP (net reclassification improvement, 30%; P ! 0.001), and ABG analysis identified extra patients at increased risk for mortality among patients with an NT-proBNP level less than the median (12-month mortality: 17.5% vs. 9.9%, P 5 0.009). Conclusions: In high-risk AHF patients, the most common acidbase imbalance is respiratory alkalosis. Acidosis is observed in every fifth patient and is an independent predictor of mortality. ABG provides an additional prognostic value and may be used to optimize risk stratification in high-risk AHF patients.
O-141 High Serum Levels of Thrombospondin-2 Correlate with Poor Prognosis of Patients with Heart Failure with Preserved Ejection Fraction YUICHI KIMURA, YASUHIRO IZUMIYA, YOSHIRO ONOUE, SHINSUKE HANATANI, SATOSHI ARAKI, HISAO OGAWA Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan Introduction: Thrombospondin-2 (TSP-2) is highly expressed in hypertensive heart. Interstitial fibrosis is frequently observed in hypertensive heart, and it is a characteristic feature of heart failure with preserved ejection fraction (HFpEF). We hypothesize that high TSP-2 serum levels reflect disease severity and can predict poor prognosis of patients with HFpEF. Methods and Results: Serum TSP-2 levels were measured by ELISA in 150 patients with HFpEF. The median TSP-2 level was 19.2 (14.4-26.0) ng/ml. TSP-2 levels correlated with the New York Heart Association (NYHA) functional class. Patients were divided into high and low TSP-2 groups based on the median value. Pulmonary capillary wedge pressure, and circulating levels of BNP and cardiac troponin T were significantly higher in the highTSP-2 group. Whereas, cardiac index was significantly lower in the high TSP-2 group. Kaplan-Meier survival curve showed high risk of adverse cardiovascular events in the high TSP-2 group, and that the combination of high TSP-2 and high
JHFS
S169
BNP (O100 pg/ml) was associated with the worst event-free survival rate. Multivariate Cox proportional hazard analysis identified BNP and TSP-2 as independent predictors of risk of death and cardiovascular events. Conclusions: Circulating TSP-2 correlates with disease severity in patients with HFpEF. TSP-2 is a potentially useful predictor of future adverse cardiovascular events in patients with HFpEF.
O-142 Elevated Fibroblast Growth Factor-23 levels is Associated with Diastolic Dysfunction among No-CKD Patients with Preserved Left Ventricular Ejection Function KAZUSHI SAKANE, MICHISHIGE OHZEKI, HIDEAKI MORITA, MASAAKI HOSHIGA, NOBUKAZU ISHIZAKA Department of Cardiology, Osaka Medical College, Osaka, Japan Background: Fibroblast growth factor-23 (FGF23) plays a crucial role in phosphate metabolism via suppressing renal tubular phosphate re-absorption. Recent studies showed that patients with higher serum FGF23 more likely to have cardiac hypertrophy, which is independent of renal function, and blood pressure. Purpose: We investigated whether serum FGF23 concentrations were associated with cardiac diastolic function-related parameters among cardiac patients with preserved left ventricular ejection fraction. Methods: The current study enrolled 245 patients with age of O50 years who had a left ventricular ejection fraction of O50%. Cardiac diastolic function was assessed by E/e0 , E/A, DcT, BNP, and cardiac hypertrophy. Results: Log(FGF23) was correlated positively with BNP (R50.192, P!0.001). On the other hand, log(FGF23) was not significantly correlated with age, left ventricular mass index, left ventricular ejection fraction, E/A, E/e0 , or DcT. After adjusting for age, gender, and eGFR, log(FGF23) was not significantly associated with diastolic dysfunction (data not shown); however, when limited to the patients without chronic kidney disease (CKD), log(FGF23) was positively associated with diastolic dysfunction with an odds ratio of 16.3 (per 1 SD increase, P!0.05). On the other hand, log(FGF23) was not associated with diastolic dysfunction among patients with preserved renal function. Conclusions: Among patients with preserved left ventricular function and no-CKD, patients with elevated FGF23 concentrations were at higher risk for diastolic dysfunction.
O-143 A Distinct Pathophysiological Role of Vascular Inflammatory Markers in Heart failure-Another Role of Angiopoietin-like 2 TOKO MITSUI1, YASUKO BANDO K1, TAKAHIRO OKUMURA2, ATSUYA SHIMIZU1, TOYOAKI MUROHARA1 1 Department of Cardiology, Nagoya University, 2Department of Cardiology, Nagoya Univeristy Graduate School of Medicine, Nagoya, Japan, 3Department of Cardiology, National Center for Geriatrics and Gentrolgy Background: Vascular endothelial inflammation (VEI) contributes to the pathophysiology underlying heart failure. Angiopoietin-like 2 (Angptl2) is a secreted glycoprotein with homology to the angiopoietins and play a pivotal role in vascular inflammation particularly associated with metabolic disorders such as diabetes. We thus examined a link between VEI in HFREF without active coronary artery disease (CAD). Methods and Results: Fourty five consecutive patients of HFREF (mean EF; 29.9610.0%, mean BNP; 293.06424.6 pg/ml) without CAD were retrospectively evaluated. VEI was monitored by 3 surrogate markers, Angptl2, sDPP4, and soluble ICAM (sICAM). Vascular atherosclerotic remodeling was assessed by mean IMT value and plaque score measured by carotid echography. Angptl2 was positively associated exclusively to sDPP4. Angptl2 and DPP4 was correlated with diastolic indices (R50.43 for E/A (P!0.01) and R50.44 for E/e (P!0.01), respectively), which was augmented by comorbid diabetes (R50.64 for E/e (PP!0.01)). The sICAM exhibited no association with neither systolic and diastolic functional indices. Furthermore, we found sICAM exclusively correlated to IMT value not in sDPP4 and Angptl2. Conclusions: The present study supports the pivotal role of Angplt2 and DPP4 that presumably reflect microvascular inflammation contributing to progression of diastolic dysfunction. The sICAM, another vascular inflammatory marker, may reflect vascular inflammation occurred in large vessel such as carotid artery, which was found as an independent factor for cardiac dysfunction.
O-144 The Usefulness of Combined Assessment of E/e0 Ratio and Transmitral Flow Pattern to Interpret Heart Condition MASAYOSHI OIKAWA, ATSUSHI KOBAYASHI, HIROYUKI YAMAUCHI, SATOSHI SUZUKI, AKIOMI YOSHIHISA, KAZUHIKO NAKAZATO, HITOSHI SUZUKI, SHU-ICHI SAITOH, YASUCHIKA TAKEISHI Department of Cardiology and Hematology, Fukushima Medical University, Fukushima, Japan A mitral inflow E velocity to tissue Doppler e0 (E/e0 ) ratio is widely used to estimate left ventricular (LV) filling pressure, and the ratio of early (E) and late (A) diastolic filling velocity, E/A ratio, is also a useful parameter to assess LV diastolic function. However, the relationship between E/e0 ratio and E/A ratio is not fully understood. We analyzed 415 patients who presented high E/e0 ratio more than 15, and they were divided into two groups based on the value of E/A ratio: low E/A group (E/A!0.8, n5128) and high E/A group (E/AO0.8, n5287). Low E/A group showed lower estimated right ventricle systolic pressure (33610 mmHg vs. 40612