A Risk Score Predicting Non Sudden Cardiac Death in Congestive Heart Failure

The 10th Annual Scientific Meeting




HFSA

S111

Clinical Care/Management Strategies 364 Sustained Reduction in Symptoms Related to Reduction of Filling Pressures during Hospitalization for Heart Failure J.G. Rogers1, G. Tasissa1, G.S. Francis2, T.G. DiSalvo4, C.V. Leier5, L.E. Wagoner6, I.L. Pina7, L.W. Stevenson8, G. Sopko9, C.M. O’Connor1; 1Duke Clinical Research Institute, DUMC, Durham, NC; 2The Cleveland Clinic, Cleveland, OH 3UNC, Chapel Hill, NC; 4Vanderbilt, Nashville, TN; 5The Ohio State University, Columbus, OH; 6University Hospital, Cincinnati, OH; 7Case Western Reserve University, Cleveland, OH; 8Brigham and Women’s Hospital, Boston, MA; 9 NHLBI, NIH, Bethesda, MD Introduction: Diuresis and symptomatic improvement commonly occur during hospitalization for heart failure (HF), but the association between reduction in filling pressures and improvement in symptoms remains unclear. This analysis of the ESCAPE trial was designed to test the hypothesis that the extent of filling pressure reduction correlates with the degree of clinical improvement measured and described by patients. Methods: In ESCAPE, 122 patients were identified with invasive pulmonary capillary wedge (PCW) measurements demonstrating PCW reduction after therapy adjusted to goals of PCW pressure ! 16 and right atrial pressure ! 8 mm Hg. Dyspnea during activity, 6-minute walk, patient visual analog scale of dyspnea, global assessment, and worst symptoms were obtained at baseline, discharge, and 3 months. Minnesota Living with Heart Failure (MLHF) questionnaire was completed at baseline, 1, and 3 months. Results: Reduction of PCW was ! 15% in 17 patients, 15e32% in 43 patients, and O 33% in 64 patients. All symptoms were improved most in those patients with the greatest reduction in PCW, both at discharge and at 3 months (figure). Six-minute walk distance increased for most patients during hospitalization, but improvement at 3 months was noted only in those patients with O 15% reduction in PCW during hospitalization. Conclusions: Early improvement in symptoms leading to HF hospitalization is closely related to reduction in PCW during therapy tailored to reduce filling pressures to near-normal levels, and this improvement is sustained at 3 months. Improvement in exercise capacity may require longer time during which decreased dyspnea allows greater activity and reconditioning.

(p ! 0.0001), ischemic heart disease(p 5 0.0009), and peripheral vascular disease (p 5 0.0216) to be significant predictors of non SCD. Dyslipidemia was shown to be protective from non SCD (p 5 0.0190) and SCD (p 5 0.020). QRS O 120ms (p 5 0.0034), and CCI ! 3 (p ! 0.0001) significantly predicted SCD. The risk of total mortality and non SCD increased with increasing Charlson index (p ! 0.0001), whereas the risk of SCD decreased (p 5 0.0305). A risk score of ! 3 predicted a 4% risk of non SCD with 89% specificity, whereas a score O 7 predicted a 58% risk of non SCD with 96% specificity (ROC 5 0.822). The risk of SCD remained constant at 5% irrespective of the risk score. Conclusion: Patients with higher risk scores, reflecting increasing comorbidity, may not derive benefit from ICD’s due to the increased relative risk of non SCD. These findings may have implications in optimal selection of patients for ICD therapy.

366 A Simple 7-Item Prognostic Index Predicts Long-Term Mortality in Elderly Patients Hospitalized for Heart Failure Bao L. Huynh, Aleksandr Rovner, Michael W. Rich; Dept of Medicine, Washington University, St Louis, MO Background: The growing heart failure (HF) epidemic imposes a substantial burden on the U.S. health care system. The objectives of this study were to determine predictors of long-term survival and to develop a mortality risk score based on readily available clinical parameters in elderly patients hospitalized for HF. Methods: 282 HF patients (mean age 79.2 yrs) were followed for up to 14 years after enrollment in a prospective multidisciplinary disease management trial conducted from 19901994. Clinically relevant patient characteristics from univariate analysis were used to construct a multivariate model to identify independent predictors of long-term survival. Results: Median survival in the control group and intervention group were 790 days and 999 days, respectively (p 5 0.50). Non-survivors differed from survivors with respect to age (p 5 0.008), NYHA class (p 5 0.048), Short Blessed score (a test of cognitive function; p 5 0.002), BUN (p 5 0.015), serum creatinine (p 5 0.001), and presence of CAD (p 5 0.002). Cox regression identified 7 independent predictors of shorter survival time (Table). A mortality risk score was developed using the 7 predictor variables. Patients with $ 4 risk factors had 6-month, 1-year, and 5-year mortality rates of 59.5%, 73.0%, and 100%, respectively. In contrast, patients with 0 or 1 risk factor had mortality rates of 7.9%, 9.0%, and 57.3% for the same time intervals (Figure). Patients with $ 4 risk factors had hazard ratios for 6-month mortality of 7.56 and 6.06 compared to those with 0-1 risk factor and 2-3 risk factors. Conclusions: A simple risk score, based on 7 readily obtainable variables, can effectively stratify mortality risk into low, intermediate, and high risk categories to help guide diagnostic and therapeutic decision-making. Hazard Ratio (95% CI) Age, per yr Na, per meq/L CAD Dementia PVD SBP, per mmHg BUN, per mg/dl

365 A Risk Score Predicting Non Sudden Cardiac Death in Congestive Heart Failure Brian Clarke1,2, Ratika Parkash1,2, Jonathan Howlett1,2; 1Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, NS, Canada; 2Queen Elizabeth II Health Science Center, Halifax, NS, Canada Introduction: Implantable cardioverter-defibrillators (ICD) have been identified as a lifesaving therapy in congestive heart failure patients with left ventricular systolic dysfunction, however the ability to identify those patients who may or may not gain the most benefit from ICD’s has yet to be determined. Objectives: To identify significant predictors of sudden cardiac death (SCD) and non SCD and to develop a clinically relevant risk score, reflecting underlying comorbidities, to identify patients at highest risk of non SCD. Methods: A retrospective analysis of 830 patients followed in a tertiary care congestive heart failure clinic from December 1998- December 2004 was performed. Demographic, clinical, and laboratory variables were examined for their relation to SCD and non SCD by multivariate logistic regression analysis. The association between medical comorbidities and modality of death was examined using the Charlson comorbidity index (CCI). A risk score was derived from those variables that were significant for non SCD. Results: Mean follow up was 4.4 years over which 221 (27%) patients died. Mean age was 64.1 6 14.7years, 68.6% were male, mean EF was 32.8 6 13.5%, 60.6% were NYHA III/IV, 59.4% had ischemic heart disease, 31.6% had a least one rehospitalization for CHF, and 34.4% had a Charlson comorbidity index ! 3. Multivariate analysis revealed age O 75 (p 5 0.0007), NYHA III/IV(p 5 0.0011), QRS duration O 150ms (p 5 0.0118), creatinine O 180mmol/L (p 5 0.0382), rehospitalization for CHF (p 5 0.0404), CCI O 3

1.025 0.958 1.520 1.953 1.757 0.995 1.019

(1.004e1.046) (0.924e0.994) (1.172e1.969) (1.089e3.497) (1.212e2.551) (0.991e0.998) (1.012e1.026)

p-value 0.018 0.022 0.002 0.025 0.003 0.005 !0.001