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Aldosterone: Marker and Predictor of Cardiorenal and Metabolic Disease in the General Community
The 18th Annual Scientific Meeting used to assess clinical and other risk factors. Results: Median follow-up to 2008 was 9 years, with maximum follow-up 20 years. Compared to the population sample, nonrelapsed survivors diagnosed age 18-39 (N51158) had 2.5 times the risk of cardiac morbidity (RR 2.51, 95%CI 1.83-3.49); those with a relapse (N5580) had over 7 times the risk (RR 7.18, 95%CI 4.81-10.71). Among those diagnosed age $40, non-relapsed survivors (N520473) had a 13% increase in cardiac risk (RR 1.13, 95%CI 1.08-1.17), and relapsed survivors (N55223) had 52% increased risk (RR 1.52, 95%CI 1.37-1.69). The most common diagnoses seen were cardiac dysrhythmias, heart failure, and acute myocardial infarction for those diagnosed at age 40 or older; and for those diagnosed aged 18-39 the most common diagnoses were diseases of pericardium and acute pulmonary heart disease. Among non-relapsed survivors, those diagnosed with a higher stage cancer showed increased risk. Those nonrelapsed survivors diagnosed aged $40 who received combined treatment of surgery, systemic and radiation had slightly lower risk of cardiac morbidity, compared to surgery alone (RR 5 0.84, 95% CI 0.74-0.95). Conclusions: Survivors of breast cancer are at an increased risk of a cardiac morbidity years after diagnosis. This underscores the need for long-term surveillance, improved models of survivorship care and continued survivorship research.
107 Recent Trends in Clinical Characteristics, Management and Prognosis of Patients with Dilated Cardiomyopathy in Japan-A Report from the CHART Studies Ryoichi Ushigome1, Yasuhiko Sakata1, Kotaro Nochioka1, Satoshi Miyata2, Masanobu Miura1, Soichiro Tadaki1, Takeshi Yamauchi1, Jun Takahashi1, Hiroaki Shimokawa1; 1Tohoku University Graduate School of Medicinen, Sendai, Japan; 2 Tohoku University Graduate School of Medicinen, Sendai, Japan Background: Although a line of evidence has been accumulated regarding the management of dilated cardiomyopathy (DCM), it is unclear whether the daily practice and long-term prognosis of DCM patients have been improved. In this study, we aimed to elucidate the recent trend in the practice and long-term prognosis of DCM patients in Japan. Methods: Using the databases of our heart failure (HF) registry studies, including the CHART-1 (Chronic Heart Failure Analysis and Registry in the Tohoku District)-1 (2000-2005, N51,278) and the CHART-2 (2006-present, N510,219) studies, we identified a total of 1,016 DCM patients (N5306 in CHART-1 and N5710 in CHART-2). We compared the clinical characteristics, management and 3-year incidence of all-cause death and hospitalization for worsening HF between the 2 studies. Results: Between the 2 groups of DCM patients, there were no differences in the baseline characteristics, including age (62 vs. 63 yrs., P50.21), prevalence of male gender (73 vs. 73%, P50.99), systolic blood pressure (123 vs. 121 mmHg, P50.13), heart rate (73 vs. 73 bpm, P50.46) or BNP levels (median, 101 vs. 104 pg/ml, P50.83). From the CHART-1 to the CHART-2 study, the use of b-blockers (48 vs. 79%, P!0.01) and aldosterone antagonists (20 vs. 37%, P! 0.01) were significantly increased with such a trend for RAS-inhibitor as well (80 vs. 85%, P50.05), while the use of loop diuretics (75 vs. 63%, P!0.01) and digitalis (56 vs. 36%, P!0.01) was significantly decreased. The 3-year mortality rate was significantly decreased from 14% in the CHART-1 to 9% in the CHART-2 (P50.01). Subgroup analysis showed that the 3-year mortality was improved in DCM patients with LVEFO 40% (13 vs. 4%, P!0.01), but not in those with LVEF!40% (17% vs. 15%, P50.66). Notably, the proportion of cardiovascular death was dramatically decreased (CHART-1, 12.4% vs. CHART-2, 4.5%, P! 0.001), which was partly attributable to the decrease in sudden death (5.2% vs. 0.4%, P!0.01). The incidence of hospitalization for worsening HF was also significantly decreased (22.5 vs. 16.2%, P50.02), particularly in patients with LVEFO 40% (19.5 vs. 8.3%, P!0.01), but not in those with LVEF!40%, whereas the rate of hospitalization remains unchanged (27.1 vs. 27.6%, P50.66). Conclusion: These results indicate that long-term prognosis has been improved in DCM patients, particularly in those with LVEFO 40% associated with implementation of evidencebased medicine in Japan.
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sample patient records were manually reviewed to identify mental health issue documentation in the dictated History & Physical, discharge summary, and/or consult notes. Three reviewers copied text suggesting any mental health issue into a data spreadsheet and recorded where text was found. Documented text was reviewed by all three reviewers and consensus reached to indicate a mental health issue. Reviewers were blinded to administrative coding data. Agreement was calculated using the Kappa statistic for non-random agreement. Results: Thirty four percent (n51285) of the total HF population were coded for a mental health issue, and 33% of the study sample (n5164). Agreement between coding and chart review to identify mental health issue was 89%, with a 4% false positive and 10% false negative rate. Positive predictive value was 87% and negative predictive value was 85%. The Kappa statistic was .69: CI .61-.79, interpreted as substantial agreement. There was no significant difference in rates of mental health categories between manual chart review and ICD-9 coding for anxiety/depression, 31% vs. 29% (p5.59); dementia, 25% vs. 18% (p5.10); and alcohol/drug abuse, 14% vs. 18% (p5.39). Conclusion: ICD-9 coding appears to be a reliable method for identifying mental health issues for patients hospitalized with heart failure. To our knowledge this is the first study to determine agreement between coding and clinician documentation of mental health issues/categories for hospitalized heart failure patients.
109 Clinical Characteristics, Psychosocial Profile and Outcomes in Patients with Heart Failure Stratified by Glomerular Filtration Rate: A Substudy of the HART Trial Ashvarya Mangla1,2, Rami Doukky3, Elizabeth Avery2, DeJuran Richardson2, Lynda H. Powell2; 1OSF St. Francis Medical Center, Peoria, IL; 2Rush University Medical Center, Chicago, IL; 3Rush University Medical Center, Chicago, IL Background: Heart failure (HF) and kidney disease often coexist. We sought to compare the clinical characteristics, psychosocial profile and outcomes in patients with HF stratified by different stages of chronic kidney disease (CKD). Methods: We analyzed data from the Heart Failure Adherence and Retention Trial (HART) which assessed the efficacy of self-management counseling vs education alone in patients with NYHA class II and III symptoms. Study population was stratified into 3 groups based on baseline GFR: ! 30, 30-59 and $ 60 ml/kg/m2. Patients were compared across key baseline sociodemographic, medical and psychosocial variables, and incidence of the primary outcome of death or HF-related hospitalization. Results: Of the 902 patients enrolled in HART, 700 had GFR data; 82 had GFR !30, 268 had GFR of 30-59, and 350 had GFR $ 60. There were no significant baseline differences between patients with and without GFR data. Mean follow up was 30 months. Patients with GFR ! 30, followed by those with GFR 30-59, were significantly older (73 vs 70 vs 56 years), female (61% vs 46% vs 42%), Caucasian (71% vs 68% vs 50%), NYHA class III (46% vs 31% vs 26%), had shorter distances on 6 minute walk test (595 vs 768 vs 883 feet), lower BMI (26 2 vs 27 7 vs 34 4 kg/m2), $ 3 comorbidities (74% vs 66% vs 57%) and higher prevalence of CAD (66% vs 61% vs 48%); all P values # 0.01. Patients with GFR of 30-59 were most likely to have atrial fibrillation (41% vs 54% vs 40%, P ! 0.01). Patients with GFR $ 60 were most likely to have sleep apnea (20% vs 12% vs 23%, P ! 0.01), score highest on geriatric depression scale, lowest on quality of life, and lowest on social support (P values ! 0.05). The incidence of primary outcome of death or HF-related hospitalization was highest in patients with GFR !30 (50% vs 42% vs 32%, P ! 0.01.) Mean number of hospital days and all-cause hospitalizations were similar across the GFR groups. Conclusion: Lower GFR is associated with poor functional status and increased risk of death or HF-related hospitalization. Paradoxically, psychosocial profile was better for patients with lower GFR values suggesting that their high risk status is a medical, not a psychosocial problem. It is also possible that stronger psychosocial profile confers a survival advantage in patients with HF as only patients with better profile survive progression of CKD in the setting of HF.
110 Administrative Coding and Clinician Documentation of Mental Health Issues for Hospitalized Heart Failure Patients: Is There Agreement? Miriam Bender1, Tyler Smith2, Freshta Nejati3; 1Sharp HealthCare, San Diego, CA; 2 National University, San Diego, CA; 3Sharp HealthCare, San Diego, CA
Aldosterone: Marker and Predictor of Cardiorenal and Metabolic Disease in the General Community Alessia Buglioni1, Valentina Cannone1, S. Jeson Sangaralingham1, Denise M. Heublein1, Christopher G. Scott1, Kent R. Bailey1, Richard J. Rodeheffer1, Riccardo Sarzani2, John C. Burnett1; 1Mayo Clinic, Rochester, MN; 2Universita Politecnica delle Marche, Ancona, Italy
Purpose: Previous research suggests an association between depression and poorer clinical outcomes for heart failure patients. Administrative ICD-9 coding is used extensively in health services research to capture variables of interest for outcomes studies, such as mental health issues. However, there is limited evidence of the accuracy of administrative ICD-9 coding for identifying patient-level mental health issues. The purpose of this study was to determine the agreement between ICD-9 coding and ‘gold standard’ clinician documentation in a patient’s History & Physical, consult notes and/or discharge summary of a mental health issue, as part of a larger study examining predictors of readmission for hospitalized heart failure patients. Methods: Study sample (n5504) was randomly chosen from the population of all unique patients (n53770) hospitalized with a heart failure primary diagnosis from 2009-2012 at one of four Sharp HealthCare (a large community based health system) hospitals with complete electronic records. A mental health issue was defined as any ICD-9 code between 290-319 in any discharge diagnosis position from 1-30. Study
Introduction: Elevated circulating aldosterone is associated with heart failure, sodium retention and fibrosis; we have recently found that in the general community plasma aldosterone concentration (PAC), even within the normal range, is strongly associated with hypertension (HTN), renal disease (CKD) and obesity. In the current study we re-examined our original cohort of randomly selected subjects from the general community in Olmsted County MN, 4-year following (Visit 2, 2001-2004) their initial recruitment (Visit 1). This study permitted us 1) to determine if the associations between PAC and cardiorenal and metabolic morbidities were maintained at Visit 2, and 2) to investigate the predictive value of PAC measured at Visit 1 on the future development of cardiorenal and metabolic diseases at Visit 2. Hypothesis: We hypothesized that the associations between PAC and cardiorenal and metabolic disease at Visit 2 are sustained, and that PAC predicts, after 4-year follow-up, new onset cardiorenal and metabolic diseases. Methods: We evaluated PAC (1368 subjects, 65.1569.54 years), clinical associations and outcome at Visit 2. We also
108
S46 Journal of Cardiac Failure Vol. 20 No. 8S August 2014 evaluated new onset disease at Visit 2 according to PAC at Visit 1 (1140 subjects, 65.5269.68 years). Results: PAC was higher at Visit 2 (4.70 vs 6.20 ng/dl, p!.001) but still within the normal range. When PAC was analyzed as continuous variable and according to tertiles (specifically the 3rd tertile) at Visit 2, we found a strong association with obesity after adjustment for age, sex and GFR. We also found equally strong associations with HTN, CKD and diastolic dysfunction after adjusting for the same model + BMI. From a predictive standpoint, when PAC at Visit 1 was analyzed as continuous variable, we found the hormone to predict new incidence of central obesity (p50.0113, OR51.36, CI51.07-1.73), HTN (p50.0012, OR51.36, CI51.13-1.63) and use of antilipemic drugs (p50.0119, OR51.25, CI51.05-1.48), after adjusting for age, sex and BMI. When PAC at Visit 1 was analyzed according to tertiles, the 3rd tertile predicted new onset of type 2 diabetes (T2DM) (p50.0392, OR51.96, CI51.03-3.70), use of antilipemic therapy (p50.0162, OR51.59, CI51.09-2.31) and HTN (p50.049, OR1.44, CI51.00-2.08) at Visit 2, after adjusting for age, sex and BMI. Conclusions: In a general community-based cohort, PAC is strongly associated with HTN, CKD and obesity as confirmed in our analyses at Visit 2. Importantly, PAC predicts the future development of new onset HTN, visceral obesity, use of antilipemic drugs and T2DM. This study supports aldosterone as potential mediator and biomarker for human cardiorenal and metabolic disease even at normal circulating levels. Further studies are warranted to evaluate possible therapeutic interventions targeting PAC as a strategy to delay and/or prevent cardiorenal and metabolic disease progression in the general population.
111 Implantable Cardioverter-Defibrillator Use to Prevent Sudden Cardiac Death in Eligible Heart Failure Patients is Rare in Singapore Jin-Faye Lee1, Poh Shuan Daniel Yeo2,3, Amanda Koh3, Chia-Yen Ho3, Chee Guan David Foo3; 1Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; 2Apex Heart Clinic, Gleneagles Hospital, Singapore, Singapore; 3Tan Tock Seng Hospital, Singapore, Singapore Background: Sudden Cardiac Death in patients with Heart Failure with Reduced Left Ventricular Ejection Fraction (LVEF) is preventable by the Implantable Cardioverter-Defibrillator (ICD). However, the ICD implant rate for eligible patients is low in Singapore. Heart failure (HF) is a leading cause of hospitalization in Singapore (O5800 public hospital discharges in 2013). Our tertiary public hospital receives about 1500 HF admissions annually. We aimed to ascertain the ICD implant rate and outcomes in the HF patients in our hospital. Methods: Patients admitted with a clinical diagnosis of HF from Jan 2007 to Dec 2011 were recruited into the Heart Failure Disease Management Program (HFDMP). All patients were managed by cardiologists and followed-up in a dedicated HF clinic with guideline-directed medical therapy. Education, counseling, and telephone follow-up were provided by HF nurses. We included those who were in the HFDMP for at least 1 year, or who died within 1 year while still in the HFDMP. We identified those who had device implant and evaluated their outcomes. Results: We recruited 1981 patients to the HFDMP, and 1719 met the study criteria. 262 were excluded due to refusal to follow-up with or compliance with the HFDMP. Demographics are: Age 68.2613.3 years, 61.3% Male, LVEF 32 6 14%. Coronary artery disease was the main HF etiology (62.77%). 1150 (66.9%) had LVEF # 35% upon recruitment. Only 52 (4.52%) had ICD (n534) or Cardiac-Resynchronization-Therapy-Defibrillator (CRTD) (n518) implant. Another 53 had pacemaker and 4 had CRT-Pacing (without defibrillator) implanted. Reasons for ICD refusal include cost and fear of surgery. The crude average 1-year mortality was 16% (15.74% LVEF # 35%, n5181; 16.52% LVEF O 35%, n594). There was a trend to lower 1-year mortality in patients with ICD/CRTD (n56, 11.5%) compared to non-ICD/CRTD (n5269, 16.1%), c250.793, p50.373. Notable complications within 1 year include 1 peri-procedural death, 1 skin erosion requiring ICD explant, and 1 infection requiring explant and reimplantation. There was also 1 failed conversion of PPM to CRTD. Conclusion: In our cohort of HF patients with reduced LVEF, there is a high 1-year mortality (16%). The subgroup of those with ICD or CRTD had a trend to lower mortality of 11.5%. This was not statistically significant likely due to the small number of patients who had ICD or CRTD implanted. However, ICD or CRTD use is rare - only 4.52% of eligible patients have ICD or CRTD. Procedural complications are infrequent and outweighed by the potential benefits. Guideline-directed ICD or CRTD implantation can substantially reduce the mortality rate, and thus measures to improve ICD or CRTD use in Singapore should be explored. Prospective data is crucial and results from 2 ongoing large regional multi-centre registries will enlighten us.
107 Recent Trends in Clinical Characteristics, Management and Prognosis of Patients with Dilated Cardiomyopathy in Japan-A Report from the CHART Studies Ryoichi Ushigome1, Yasuhiko Sakata1, Kotaro Nochioka1, Satoshi Miyata2, Masanobu Miura1, Soichiro Tadaki1, Takeshi Yamauchi1, Jun Takahashi1, Hiroaki Shimokawa1; 1Tohoku University Graduate School of Medicinen, Sendai, Japan; 2 Tohoku University Graduate School of Medicinen, Sendai, Japan Background: Although a line of evidence has been accumulated regarding the management of dilated cardiomyopathy (DCM), it is unclear whether the daily practice and long-term prognosis of DCM patients have been improved. In this study, we aimed to elucidate the recent trend in the practice and long-term prognosis of DCM patients in Japan. Methods: Using the databases of our heart failure (HF) registry studies, including the CHART-1 (Chronic Heart Failure Analysis and Registry in the Tohoku District)-1 (2000-2005, N51,278) and the CHART-2 (2006-present, N510,219) studies, we identified a total of 1,016 DCM patients (N5306 in CHART-1 and N5710 in CHART-2). We compared the clinical characteristics, management and 3-year incidence of all-cause death and hospitalization for worsening HF between the 2 studies. Results: Between the 2 groups of DCM patients, there were no differences in the baseline characteristics, including age (62 vs. 63 yrs., P50.21), prevalence of male gender (73 vs. 73%, P50.99), systolic blood pressure (123 vs. 121 mmHg, P50.13), heart rate (73 vs. 73 bpm, P50.46) or BNP levels (median, 101 vs. 104 pg/ml, P50.83). From the CHART-1 to the CHART-2 study, the use of b-blockers (48 vs. 79%, P!0.01) and aldosterone antagonists (20 vs. 37%, P! 0.01) were significantly increased with such a trend for RAS-inhibitor as well (80 vs. 85%, P50.05), while the use of loop diuretics (75 vs. 63%, P!0.01) and digitalis (56 vs. 36%, P!0.01) was significantly decreased. The 3-year mortality rate was significantly decreased from 14% in the CHART-1 to 9% in the CHART-2 (P50.01). Subgroup analysis showed that the 3-year mortality was improved in DCM patients with LVEFO 40% (13 vs. 4%, P!0.01), but not in those with LVEF!40% (17% vs. 15%, P50.66). Notably, the proportion of cardiovascular death was dramatically decreased (CHART-1, 12.4% vs. CHART-2, 4.5%, P! 0.001), which was partly attributable to the decrease in sudden death (5.2% vs. 0.4%, P!0.01). The incidence of hospitalization for worsening HF was also significantly decreased (22.5 vs. 16.2%, P50.02), particularly in patients with LVEFO 40% (19.5 vs. 8.3%, P!0.01), but not in those with LVEF!40%, whereas the rate of hospitalization remains unchanged (27.1 vs. 27.6%, P50.66). Conclusion: These results indicate that long-term prognosis has been improved in DCM patients, particularly in those with LVEFO 40% associated with implementation of evidencebased medicine in Japan.
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sample patient records were manually reviewed to identify mental health issue documentation in the dictated History & Physical, discharge summary, and/or consult notes. Three reviewers copied text suggesting any mental health issue into a data spreadsheet and recorded where text was found. Documented text was reviewed by all three reviewers and consensus reached to indicate a mental health issue. Reviewers were blinded to administrative coding data. Agreement was calculated using the Kappa statistic for non-random agreement. Results: Thirty four percent (n51285) of the total HF population were coded for a mental health issue, and 33% of the study sample (n5164). Agreement between coding and chart review to identify mental health issue was 89%, with a 4% false positive and 10% false negative rate. Positive predictive value was 87% and negative predictive value was 85%. The Kappa statistic was .69: CI .61-.79, interpreted as substantial agreement. There was no significant difference in rates of mental health categories between manual chart review and ICD-9 coding for anxiety/depression, 31% vs. 29% (p5.59); dementia, 25% vs. 18% (p5.10); and alcohol/drug abuse, 14% vs. 18% (p5.39). Conclusion: ICD-9 coding appears to be a reliable method for identifying mental health issues for patients hospitalized with heart failure. To our knowledge this is the first study to determine agreement between coding and clinician documentation of mental health issues/categories for hospitalized heart failure patients.
109 Clinical Characteristics, Psychosocial Profile and Outcomes in Patients with Heart Failure Stratified by Glomerular Filtration Rate: A Substudy of the HART Trial Ashvarya Mangla1,2, Rami Doukky3, Elizabeth Avery2, DeJuran Richardson2, Lynda H. Powell2; 1OSF St. Francis Medical Center, Peoria, IL; 2Rush University Medical Center, Chicago, IL; 3Rush University Medical Center, Chicago, IL Background: Heart failure (HF) and kidney disease often coexist. We sought to compare the clinical characteristics, psychosocial profile and outcomes in patients with HF stratified by different stages of chronic kidney disease (CKD). Methods: We analyzed data from the Heart Failure Adherence and Retention Trial (HART) which assessed the efficacy of self-management counseling vs education alone in patients with NYHA class II and III symptoms. Study population was stratified into 3 groups based on baseline GFR: ! 30, 30-59 and $ 60 ml/kg/m2. Patients were compared across key baseline sociodemographic, medical and psychosocial variables, and incidence of the primary outcome of death or HF-related hospitalization. Results: Of the 902 patients enrolled in HART, 700 had GFR data; 82 had GFR !30, 268 had GFR of 30-59, and 350 had GFR $ 60. There were no significant baseline differences between patients with and without GFR data. Mean follow up was 30 months. Patients with GFR ! 30, followed by those with GFR 30-59, were significantly older (73 vs 70 vs 56 years), female (61% vs 46% vs 42%), Caucasian (71% vs 68% vs 50%), NYHA class III (46% vs 31% vs 26%), had shorter distances on 6 minute walk test (595 vs 768 vs 883 feet), lower BMI (26 2 vs 27 7 vs 34 4 kg/m2), $ 3 comorbidities (74% vs 66% vs 57%) and higher prevalence of CAD (66% vs 61% vs 48%); all P values # 0.01. Patients with GFR of 30-59 were most likely to have atrial fibrillation (41% vs 54% vs 40%, P ! 0.01). Patients with GFR $ 60 were most likely to have sleep apnea (20% vs 12% vs 23%, P ! 0.01), score highest on geriatric depression scale, lowest on quality of life, and lowest on social support (P values ! 0.05). The incidence of primary outcome of death or HF-related hospitalization was highest in patients with GFR !30 (50% vs 42% vs 32%, P ! 0.01.) Mean number of hospital days and all-cause hospitalizations were similar across the GFR groups. Conclusion: Lower GFR is associated with poor functional status and increased risk of death or HF-related hospitalization. Paradoxically, psychosocial profile was better for patients with lower GFR values suggesting that their high risk status is a medical, not a psychosocial problem. It is also possible that stronger psychosocial profile confers a survival advantage in patients with HF as only patients with better profile survive progression of CKD in the setting of HF.
110 Administrative Coding and Clinician Documentation of Mental Health Issues for Hospitalized Heart Failure Patients: Is There Agreement? Miriam Bender1, Tyler Smith2, Freshta Nejati3; 1Sharp HealthCare, San Diego, CA; 2 National University, San Diego, CA; 3Sharp HealthCare, San Diego, CA
Aldosterone: Marker and Predictor of Cardiorenal and Metabolic Disease in the General Community Alessia Buglioni1, Valentina Cannone1, S. Jeson Sangaralingham1, Denise M. Heublein1, Christopher G. Scott1, Kent R. Bailey1, Richard J. Rodeheffer1, Riccardo Sarzani2, John C. Burnett1; 1Mayo Clinic, Rochester, MN; 2Universita Politecnica delle Marche, Ancona, Italy
Purpose: Previous research suggests an association between depression and poorer clinical outcomes for heart failure patients. Administrative ICD-9 coding is used extensively in health services research to capture variables of interest for outcomes studies, such as mental health issues. However, there is limited evidence of the accuracy of administrative ICD-9 coding for identifying patient-level mental health issues. The purpose of this study was to determine the agreement between ICD-9 coding and ‘gold standard’ clinician documentation in a patient’s History & Physical, consult notes and/or discharge summary of a mental health issue, as part of a larger study examining predictors of readmission for hospitalized heart failure patients. Methods: Study sample (n5504) was randomly chosen from the population of all unique patients (n53770) hospitalized with a heart failure primary diagnosis from 2009-2012 at one of four Sharp HealthCare (a large community based health system) hospitals with complete electronic records. A mental health issue was defined as any ICD-9 code between 290-319 in any discharge diagnosis position from 1-30. Study
Introduction: Elevated circulating aldosterone is associated with heart failure, sodium retention and fibrosis; we have recently found that in the general community plasma aldosterone concentration (PAC), even within the normal range, is strongly associated with hypertension (HTN), renal disease (CKD) and obesity. In the current study we re-examined our original cohort of randomly selected subjects from the general community in Olmsted County MN, 4-year following (Visit 2, 2001-2004) their initial recruitment (Visit 1). This study permitted us 1) to determine if the associations between PAC and cardiorenal and metabolic morbidities were maintained at Visit 2, and 2) to investigate the predictive value of PAC measured at Visit 1 on the future development of cardiorenal and metabolic diseases at Visit 2. Hypothesis: We hypothesized that the associations between PAC and cardiorenal and metabolic disease at Visit 2 are sustained, and that PAC predicts, after 4-year follow-up, new onset cardiorenal and metabolic diseases. Methods: We evaluated PAC (1368 subjects, 65.1569.54 years), clinical associations and outcome at Visit 2. We also
108
S46 Journal of Cardiac Failure Vol. 20 No. 8S August 2014 evaluated new onset disease at Visit 2 according to PAC at Visit 1 (1140 subjects, 65.5269.68 years). Results: PAC was higher at Visit 2 (4.70 vs 6.20 ng/dl, p!.001) but still within the normal range. When PAC was analyzed as continuous variable and according to tertiles (specifically the 3rd tertile) at Visit 2, we found a strong association with obesity after adjustment for age, sex and GFR. We also found equally strong associations with HTN, CKD and diastolic dysfunction after adjusting for the same model + BMI. From a predictive standpoint, when PAC at Visit 1 was analyzed as continuous variable, we found the hormone to predict new incidence of central obesity (p50.0113, OR51.36, CI51.07-1.73), HTN (p50.0012, OR51.36, CI51.13-1.63) and use of antilipemic drugs (p50.0119, OR51.25, CI51.05-1.48), after adjusting for age, sex and BMI. When PAC at Visit 1 was analyzed according to tertiles, the 3rd tertile predicted new onset of type 2 diabetes (T2DM) (p50.0392, OR51.96, CI51.03-3.70), use of antilipemic therapy (p50.0162, OR51.59, CI51.09-2.31) and HTN (p50.049, OR1.44, CI51.00-2.08) at Visit 2, after adjusting for age, sex and BMI. Conclusions: In a general community-based cohort, PAC is strongly associated with HTN, CKD and obesity as confirmed in our analyses at Visit 2. Importantly, PAC predicts the future development of new onset HTN, visceral obesity, use of antilipemic drugs and T2DM. This study supports aldosterone as potential mediator and biomarker for human cardiorenal and metabolic disease even at normal circulating levels. Further studies are warranted to evaluate possible therapeutic interventions targeting PAC as a strategy to delay and/or prevent cardiorenal and metabolic disease progression in the general population.
111 Implantable Cardioverter-Defibrillator Use to Prevent Sudden Cardiac Death in Eligible Heart Failure Patients is Rare in Singapore Jin-Faye Lee1, Poh Shuan Daniel Yeo2,3, Amanda Koh3, Chia-Yen Ho3, Chee Guan David Foo3; 1Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; 2Apex Heart Clinic, Gleneagles Hospital, Singapore, Singapore; 3Tan Tock Seng Hospital, Singapore, Singapore Background: Sudden Cardiac Death in patients with Heart Failure with Reduced Left Ventricular Ejection Fraction (LVEF) is preventable by the Implantable Cardioverter-Defibrillator (ICD). However, the ICD implant rate for eligible patients is low in Singapore. Heart failure (HF) is a leading cause of hospitalization in Singapore (O5800 public hospital discharges in 2013). Our tertiary public hospital receives about 1500 HF admissions annually. We aimed to ascertain the ICD implant rate and outcomes in the HF patients in our hospital. Methods: Patients admitted with a clinical diagnosis of HF from Jan 2007 to Dec 2011 were recruited into the Heart Failure Disease Management Program (HFDMP). All patients were managed by cardiologists and followed-up in a dedicated HF clinic with guideline-directed medical therapy. Education, counseling, and telephone follow-up were provided by HF nurses. We included those who were in the HFDMP for at least 1 year, or who died within 1 year while still in the HFDMP. We identified those who had device implant and evaluated their outcomes. Results: We recruited 1981 patients to the HFDMP, and 1719 met the study criteria. 262 were excluded due to refusal to follow-up with or compliance with the HFDMP. Demographics are: Age 68.2613.3 years, 61.3% Male, LVEF 32 6 14%. Coronary artery disease was the main HF etiology (62.77%). 1150 (66.9%) had LVEF # 35% upon recruitment. Only 52 (4.52%) had ICD (n534) or Cardiac-Resynchronization-Therapy-Defibrillator (CRTD) (n518) implant. Another 53 had pacemaker and 4 had CRT-Pacing (without defibrillator) implanted. Reasons for ICD refusal include cost and fear of surgery. The crude average 1-year mortality was 16% (15.74% LVEF # 35%, n5181; 16.52% LVEF O 35%, n594). There was a trend to lower 1-year mortality in patients with ICD/CRTD (n56, 11.5%) compared to non-ICD/CRTD (n5269, 16.1%), c250.793, p50.373. Notable complications within 1 year include 1 peri-procedural death, 1 skin erosion requiring ICD explant, and 1 infection requiring explant and reimplantation. There was also 1 failed conversion of PPM to CRTD. Conclusion: In our cohort of HF patients with reduced LVEF, there is a high 1-year mortality (16%). The subgroup of those with ICD or CRTD had a trend to lower mortality of 11.5%. This was not statistically significant likely due to the small number of patients who had ICD or CRTD implanted. However, ICD or CRTD use is rare - only 4.52% of eligible patients have ICD or CRTD. Procedural complications are infrequent and outweighed by the potential benefits. Guideline-directed ICD or CRTD implantation can substantially reduce the mortality rate, and thus measures to improve ICD or CRTD use in Singapore should be explored. Prospective data is crucial and results from 2 ongoing large regional multi-centre registries will enlighten us.