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294 The impact of renal insufficiency and chronic dialysis on patients with acute decompensated heart failure: an ADHERE® registry analysis
The 8th Annual Scientific Meeting
292 Early Enalapril Therapy in Patients with Left Ventricular Systolic Dysfunction Reduced Cardiovascular Morbidity and Mortality at 15-Years in SOLVD Sylvie A. Ahn,1 Philip Jong,2 Hubert G. Pouleur,1 Salim Yusuf,2 Shrikant I. Bangdiwala,3 Michel F. Rousseau1; 1Division of Cardiology, University of Louvain, Brussels, Belgium; 2Cardiology, McMaster University, Hamilton, ON, Canada; 3Biostatistics, University of North Carolina, Chapel Hill, NC Background: In the Studies of Left Ventricular Dysfunction (SOLVD), enalapril therapy in patients with low ejection fractions reduced morbidity and mortality over 3-4 years. We reported here the impact of early in-trial treatment with enalapril on post-trial cardiovascular morbidity and mortality at 15 years in SOLVD. Methods: Among the 558 Belgium patients randomized to enalapril or placebo in SOLVD, data on post-trial deaths and cardiovascular morbid events were collected on all 433 survivors (218 enalapril vs. 215 placebo) at close out. We defined cardiovascular morbid events to include the development of heart failure, myocardial infarction or stroke, or the need for heart transplant, device therapy or revascularization. All patients were placed on enalapril after the trial ended. Results: No patient was lost to follow-up. The median duration of follow-up was 15.5 years from randomization or 12.2 years from close out. Fewer deaths (138 vs. 150 deaths) occurred among patients treated early with enalapril as compared with placebo (63% vs. 70%, Wilcoxon P ⫽ 0.01). Deaths or cardiovascular morbid events occurred in 177 (81%) of the enalapril group and 188 (87%) of the placebo group (Wilcoxon P ⫽ 0.008, Figure). Cox regression modified by the Wei-Lin-Weissfield method to account for repeated events showed that enalapril reduced deaths or development of cardiovascular events by 19% when compared to placebo (HR, 0.81; 95% CI, 0.66 to 0.98; P ⫽ 0.03). Use of angiotensin-converting enzyme inhibitors post trial was similar between the enalapril and placebo groups (85% vs. 79%, P ⫽ 0.40). Conclusions: This 15-year followup of SOLVD showed that enalapril continued to reduce mortality and serious cardiovascular morbidity in patients with left ventricular systolic dysfunction beyond the original trial period.
•
HFSA
S97
was “mild” for 25%, “moderate” for 50% of patients; pain interfered with activities “often” and “always” for the majority of patients. Anxiety was “mild” or “moderate” for most patients (24%, 41%), but “severe” or “overwhelming” for more than 1 in 4 and interfered with activities “often” and “always” for over a third of patients. Family assessment of interference in activities by SOB “often” or “always” exceeded patient report (p ⬍ 0.1), as did rating SOB “severe” or “overwhelming” (p ⫽ 0.2). Family less commonly rated anxiety “overwhelming” or “severe” than patients (p ⬍ 0.1).
Conclusions: Family misestimated symptoms frequently, calling attention to the need to gather patient report whenever possible. Collecting patient report may improve family perception of the impact of advanced HF. Further study should evaluate correlates of symptoms with HF severity and co-morbidities.
294 The Impact of Renal Insufficiency and Chronic Dialysis on Patients with Acute Decompensated Heart Failure: An ADHERE쏐 registry analysis J. Thomas Heywood,1 John R. Wigneswaran,2 Margarita Lopatin,3 for the ADHERE쑓 Scientific Advisory Committee; 1Department of Cardiology, Loma Linda University Medical Center, Loma Linda, CA; 2Internal Medicine - Nephrology, Wright State School of Medicine, Dayton, OH; 3Scios Inc., Fremont, CA
293 The Patient Knows Best: Perceptions of Family Versus Patient Report of Symptoms Sarah J. Goodlin,1 Dale G. Renlund2; 1Institute for Health Care Delivery Research, Intermountain Health Care, Salt Lake City, UT; 2Heart Failure Prevention and Treatment Program, LDS Hospital, Salt Lake City, UT Advanced heart failure (HF) is accompanied by significant symptoms. Little is known about symptoms of patients dying from HF, although after death families report significant pain, dyspnea (SOB) and other distress. Methods: We surveyed 31 patients with advanced HF and a family member to identify symptom frequency, severity and interference with activities. Patients were identified by cardiologists and cardiothoracic surgeons at LDS Hospital a 530 bed tertiary referral hospital on as being at high likelihood of dying within a year. Surveys were administered simultaneously to patients and a spouse or adult child. Data were analyzed with SPSS for frequencies of patient and family responses on the survey. Patients and family rates were compared using Pearson chi-squared tests. Concordance between patient and family responses was described by cross-tabulating and examining the percentage of responses which fell on or near the diagonal. Results: 27 patients and 31 family members completed the survey. Patients were 22-90 years old (mean 68.9), 27% female and had EF 855% (mean 28%). 13 patients (50%) and 18 family members (58%) reported the patient had pain in the past week; 19 patients (70%) and 24 family members (77%) reported shortness of breath (SOB) and 17 patients (63%). SOB was “mild” for 32% and “moderate” for 42% patients and “seldom” interfered with activities for 26%. Pain
Background: Renal insufficiency (RI) adversely impacts prognosis in heart failure (HF). However, it is not clear if chronic dialysis (CD) confers further risk during hospitalization for acutely decompensated heart failure (ADHF). Methods: Of the 97727 ADHF patient cases in the Acute Decompensated HEart Failure National REgistry [ADHERE] database (December 2003), data from 4438 patients who were on CD prior to admission were compared with that of 4719 patients with significant RI (serum creatinine ⬎3.0), but not on CD. Differences were determined using Chi Square, ANOVA or Wilcoxon tests. Results: RI patients tend to be older, more often male (58.7% vs. 50.0%; P ⬍ 0.0001), less often in sinus rhythm and have higher BUNs compared to CD patients. In-hospital inotrope use is more common in RI patients, as is hypotension. However, a fraction of CD (12.1%) and RI (19.6%; P ⬍ 0.004) patients who received inotropes, were hypotensive. Eligible RI patients are less likely to be prescribed ACE-I at discharge compared to eligible CD patients (34.0% vs. 52.3%; P ⬍ 0.0001). Conclusion: Outcomes such as length of hospital stay and mortality (even after adjusting for differences in in-hospital inotrope use) are worse in RI patients compared to CD patients. ADHF patients with RI and not on CD represent an even higher risk group than those on CD, and warrant closer study. Parameter Age (mean) % African American % Atrial Fibrillation % QRS ⬎120 Systolic Blood Pressure (mean mm Hg) % Systolic Blood Pressure (⬍ 90 mm Hg) Serum Creatinine (mean mg/dL) BUN (mean mg/dL) % Edema % Given Inotropes In-Hospital (dobutamine; milrinone; dopamine ⬎ 5 mcg/kg/min) Weight Change from Baseline (mean lb) Length of Hospital Stay (mean days) % Mortality
Renal Insufficiency (n ⫽ 4719)
Chronic Dialysis (n ⫽ 4438)
P Value
71.7 27.3 25.5 34.6 144.7
65.2 36.8 18.8 24.6 157.1
⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001
5.6
2.6
⬍0.0001
4.3
6.5
⬍0.0001
71.0 72.2 18.1
49.0 54.9 6.9
⬍0.0001 ⬍0.0001 ⬍0.0001
⫺8.1
⫺6.4
⬍0.0001
7.4
5.7
⬍0.0001
9.4
4.5
⬍0.0001
292 Early Enalapril Therapy in Patients with Left Ventricular Systolic Dysfunction Reduced Cardiovascular Morbidity and Mortality at 15-Years in SOLVD Sylvie A. Ahn,1 Philip Jong,2 Hubert G. Pouleur,1 Salim Yusuf,2 Shrikant I. Bangdiwala,3 Michel F. Rousseau1; 1Division of Cardiology, University of Louvain, Brussels, Belgium; 2Cardiology, McMaster University, Hamilton, ON, Canada; 3Biostatistics, University of North Carolina, Chapel Hill, NC Background: In the Studies of Left Ventricular Dysfunction (SOLVD), enalapril therapy in patients with low ejection fractions reduced morbidity and mortality over 3-4 years. We reported here the impact of early in-trial treatment with enalapril on post-trial cardiovascular morbidity and mortality at 15 years in SOLVD. Methods: Among the 558 Belgium patients randomized to enalapril or placebo in SOLVD, data on post-trial deaths and cardiovascular morbid events were collected on all 433 survivors (218 enalapril vs. 215 placebo) at close out. We defined cardiovascular morbid events to include the development of heart failure, myocardial infarction or stroke, or the need for heart transplant, device therapy or revascularization. All patients were placed on enalapril after the trial ended. Results: No patient was lost to follow-up. The median duration of follow-up was 15.5 years from randomization or 12.2 years from close out. Fewer deaths (138 vs. 150 deaths) occurred among patients treated early with enalapril as compared with placebo (63% vs. 70%, Wilcoxon P ⫽ 0.01). Deaths or cardiovascular morbid events occurred in 177 (81%) of the enalapril group and 188 (87%) of the placebo group (Wilcoxon P ⫽ 0.008, Figure). Cox regression modified by the Wei-Lin-Weissfield method to account for repeated events showed that enalapril reduced deaths or development of cardiovascular events by 19% when compared to placebo (HR, 0.81; 95% CI, 0.66 to 0.98; P ⫽ 0.03). Use of angiotensin-converting enzyme inhibitors post trial was similar between the enalapril and placebo groups (85% vs. 79%, P ⫽ 0.40). Conclusions: This 15-year followup of SOLVD showed that enalapril continued to reduce mortality and serious cardiovascular morbidity in patients with left ventricular systolic dysfunction beyond the original trial period.
•
HFSA
S97
was “mild” for 25%, “moderate” for 50% of patients; pain interfered with activities “often” and “always” for the majority of patients. Anxiety was “mild” or “moderate” for most patients (24%, 41%), but “severe” or “overwhelming” for more than 1 in 4 and interfered with activities “often” and “always” for over a third of patients. Family assessment of interference in activities by SOB “often” or “always” exceeded patient report (p ⬍ 0.1), as did rating SOB “severe” or “overwhelming” (p ⫽ 0.2). Family less commonly rated anxiety “overwhelming” or “severe” than patients (p ⬍ 0.1).
Conclusions: Family misestimated symptoms frequently, calling attention to the need to gather patient report whenever possible. Collecting patient report may improve family perception of the impact of advanced HF. Further study should evaluate correlates of symptoms with HF severity and co-morbidities.
294 The Impact of Renal Insufficiency and Chronic Dialysis on Patients with Acute Decompensated Heart Failure: An ADHERE쏐 registry analysis J. Thomas Heywood,1 John R. Wigneswaran,2 Margarita Lopatin,3 for the ADHERE쑓 Scientific Advisory Committee; 1Department of Cardiology, Loma Linda University Medical Center, Loma Linda, CA; 2Internal Medicine - Nephrology, Wright State School of Medicine, Dayton, OH; 3Scios Inc., Fremont, CA
293 The Patient Knows Best: Perceptions of Family Versus Patient Report of Symptoms Sarah J. Goodlin,1 Dale G. Renlund2; 1Institute for Health Care Delivery Research, Intermountain Health Care, Salt Lake City, UT; 2Heart Failure Prevention and Treatment Program, LDS Hospital, Salt Lake City, UT Advanced heart failure (HF) is accompanied by significant symptoms. Little is known about symptoms of patients dying from HF, although after death families report significant pain, dyspnea (SOB) and other distress. Methods: We surveyed 31 patients with advanced HF and a family member to identify symptom frequency, severity and interference with activities. Patients were identified by cardiologists and cardiothoracic surgeons at LDS Hospital a 530 bed tertiary referral hospital on as being at high likelihood of dying within a year. Surveys were administered simultaneously to patients and a spouse or adult child. Data were analyzed with SPSS for frequencies of patient and family responses on the survey. Patients and family rates were compared using Pearson chi-squared tests. Concordance between patient and family responses was described by cross-tabulating and examining the percentage of responses which fell on or near the diagonal. Results: 27 patients and 31 family members completed the survey. Patients were 22-90 years old (mean 68.9), 27% female and had EF 855% (mean 28%). 13 patients (50%) and 18 family members (58%) reported the patient had pain in the past week; 19 patients (70%) and 24 family members (77%) reported shortness of breath (SOB) and 17 patients (63%). SOB was “mild” for 32% and “moderate” for 42% patients and “seldom” interfered with activities for 26%. Pain
Background: Renal insufficiency (RI) adversely impacts prognosis in heart failure (HF). However, it is not clear if chronic dialysis (CD) confers further risk during hospitalization for acutely decompensated heart failure (ADHF). Methods: Of the 97727 ADHF patient cases in the Acute Decompensated HEart Failure National REgistry [ADHERE] database (December 2003), data from 4438 patients who were on CD prior to admission were compared with that of 4719 patients with significant RI (serum creatinine ⬎3.0), but not on CD. Differences were determined using Chi Square, ANOVA or Wilcoxon tests. Results: RI patients tend to be older, more often male (58.7% vs. 50.0%; P ⬍ 0.0001), less often in sinus rhythm and have higher BUNs compared to CD patients. In-hospital inotrope use is more common in RI patients, as is hypotension. However, a fraction of CD (12.1%) and RI (19.6%; P ⬍ 0.004) patients who received inotropes, were hypotensive. Eligible RI patients are less likely to be prescribed ACE-I at discharge compared to eligible CD patients (34.0% vs. 52.3%; P ⬍ 0.0001). Conclusion: Outcomes such as length of hospital stay and mortality (even after adjusting for differences in in-hospital inotrope use) are worse in RI patients compared to CD patients. ADHF patients with RI and not on CD represent an even higher risk group than those on CD, and warrant closer study. Parameter Age (mean) % African American % Atrial Fibrillation % QRS ⬎120 Systolic Blood Pressure (mean mm Hg) % Systolic Blood Pressure (⬍ 90 mm Hg) Serum Creatinine (mean mg/dL) BUN (mean mg/dL) % Edema % Given Inotropes In-Hospital (dobutamine; milrinone; dopamine ⬎ 5 mcg/kg/min) Weight Change from Baseline (mean lb) Length of Hospital Stay (mean days) % Mortality
Renal Insufficiency (n ⫽ 4719)
Chronic Dialysis (n ⫽ 4438)
P Value
71.7 27.3 25.5 34.6 144.7
65.2 36.8 18.8 24.6 157.1
⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001
5.6
2.6
⬍0.0001
4.3
6.5
⬍0.0001
71.0 72.2 18.1
49.0 54.9 6.9
⬍0.0001 ⬍0.0001 ⬍0.0001
⫺8.1
⫺6.4
⬍0.0001
7.4
5.7
⬍0.0001
9.4
4.5
⬍0.0001