- Email: [email protected]
Changing Survival of Patients with Heart Failure in New Zealand over 18 Years
The 11th Annual Scientific Meeting
HFSA
S165
314
316
Clinical Utility of Fluid Monitoring with Intrathoracic Impedance in ICD Patients Lisa D. Rathman1, Roy S. Small1, Jill L. Repoley1, Deanna Dukes-Graves1, Kelly J. Trynosky1, Sherri S. Delgado1, Jon G. Echterling1, Connie Kiser1, Michael A. Horst2; 1CHF Clinic, The Heart Group, Lancaster, PA; 2Department of Research and Statistics, Lancaster General Hospital, Lancaster, PA
Changing Survival of Patients with Heart Failure in New Zealand over 18 Years Cara A. Wasywich1, Greg D. Gamble2, Robert N. Doughty2; 1Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand; 2 Department of Medicine, University of Auckland, Auckland, New Zealand
Background: Decreasing thoracic impedance (Z) measured by an implantable device has been shown to be associated with heart failure (HF) hospitalization and other clinically relevant events (CRE) in CRT patients. Recently these device capabilities have extended to ICDs. We examined device-based Z recordings in patients with a CRT-D device versus ICD alone. Methods: Device-recorded Z and health record data from 67 CRT-D patients and 56 ICD patients were retrospectively reviewed. The diagnostic fluid index (FI) was automatically derived from consecutive negative deviations in the actual measured daily Z from the calculated basal or reference Z. Fluid index values higher than the programmed threshold constituted a device classified event. HF hospitalizations, CRE’s (including documented signs and symptoms of worsening HF), acute changes in diuretic therapy or volume status, pneumonia, and surgical device or lead revisions were identified for association with FI threshold crossings in both groups. Results: Mean age (71 years), follow-up duration (6.31 versus 5.84 months) and creatinine (1.43 versus 1.35 mg/dl) were similar in both groups. The CRT-D group had a lower ejection fraction (28 6 7 vs. 36 6 11, p ! 0.001). The number of FI crossings and HF hospitalizations were similar between the 2 groups. However, FI crossings were more frequently related to a clinical decompensation in the CRT-D group (10 versus 2, p ! .035). There was no difference in FI crossings between groups for pneumonia, changes in diuretic therapy, and surgical device or lead revisions. More unexplained FI crossings were observed in the ICD group (11 versus 2, p ! 0.003). However, ICD patients were less likely to be followed in the heart failure clinic (30% versus 80%, p ! 0.001). Whether these data reflect less consistent follow-up in the ICD group or a different predictive value in the ICD group is not clear. Conclusions: Continuous intrathoracic impedance measurements derived from an implantable device provide clinically relevant information which correlates with HF hospitalizations and CRE’s. However, the predictive value of these measurements may depend on the intensity of follow-up and the risk of heart failure decompensation which varies between the CRT-D and ICD populations.
315 Weighing In: BMI and Ejection Fraction in Patients Admitted for Acute Decompensated Heart Failure Mustafa M. Ahmed2, Utpal N. Sagar2, Jocelyn Andrel3, Suzanne Adams1, David J. Whellan1; 1Medicine/Cardiology, Jefferson Medical College, Philadelphia, PA; 2 Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA; 3 Biostatistics, Jefferson Medical College, Philadelphia, PA Introduction: Overweight and obesity are risk factors for cardiovascular (CV) disease and heart failure (HF). Despite evidence of adverse effects from overweight, the relationship between body mass index (BMI) and mortality in chronic disease remains controversial. Several large cohort studies showed overweight/obese patients appearing to have better survival than their healthy weight counterparts. We examined the relationship between BMI and ejection fraction (EF) for acute decompensated heart failure (ADHF) admissions. Hypothesis: Overweight and obese HF patients may have CV alterations that lead to improved clinical outcomes. Methods: We utilized the Jefferson Outcomes Database of integrated reports from administrative, clinical, and financial data to identify ADHF admissions from January 2004 through June 2006. A total of 993 records were reviewed. Patients were divided into quintiles by BMI : underweight (! 18.5), healthy weight (18.5e24.9), overweight (25.0e29.9), and obese (30.0e34.9), and morbidly obese (35e40). Categories for analyses were limited to those records reporting BMI O 15 and ! 40. Summary statistics were performed on all variables of interest. Associations with categorical variables were analyzed using logistic regression, and adjusted for age, race, and sex. Continuous variable association were determined through general liner modeling, and adjusted for the same variables. Non-normally distribution variables were transformed using the natural log, and then analyzed. All analyses were carried out in SAS version 9.1. Results: Added weight carried an increased association with diagnoses of diabetes and hypertension. Overweight and obese patients were found to have a mean EF greater than that for normal BMI subjects. Conclusions: The role this finding plays in observed survival benefit in HF patients requires further study.
Background: Studies have reported improved survival for heart failure (HF) patients during the 1990’s. It is uncertain whether survival has continued to improve recently. The aims of this study were to determine temporal changes in survival for patients after HF hospitalisation (HFH) in New Zealand (NZ) 1988e2005. Methods: National statistics for hospital admissions for HFH were obtained from the NZ Health Information Service (1988 to 2005) using ICD codes for HF as the primary or secondary diagnosis. Mortality data was obtained for all patients after first HFH. HFspecific casemix was calculated from ICD codes to assess comorbidity. Results: Between 1988-2005 there were 186,681 HFH, involving 103,318 individuals. The number of HFH per year increased from 7,576 in 1988 to 11,158 in 2005. Median age increased from 71.7 years to 77.4 years. Median length of stay decreased from 8 to 5 days (1988-1999) then remained stable to 2003. HF-specific casemix increased from 2.4 to 3.0. 30-day and 6-month mortality rates decreased from 1988 to 1999 then stabilised from 1999 to 2003. Conclusions: Survival after first HFH in NZ improved during the 1990’s but is unchanged since 1999, despite increasing patient age and comorbidity. These improved outcomes may, in part, reflect evidence based HF pharmacotherapy. Despite these improvements, mortality remains high reinforcing the importance of further improvements in HF management. Mortality 1988e2003
30-day mortality, % 6-month mortality, %
1988
1991
1994
1996
1998
2000
2003
15.2 30.1
14.2 27.9
12.8 26.2
12.8 24.2
11.0 21.9
11.0 21.9
11.3 19.7
317 A Prognostic Comparison of Echocardiography vs. Cardiopulmonary-Derived Variables in Patients with Heart Failure Marco Guazzi1, Marco Vicenzi1, Rosa Raimondo2, Simona Sarzi2, Roberto Pedretti2, Ross Arena3; 1Cardiopulmonary Unit, Cardiology Division, University of Milano, San Paolo Hospital, Milano, Italy; 2Division of Cardiology, Scientific Institute of Tradate, Tradate, Italy; 3Physical Therapy, Virginia Commonwealth University, Richmond, VA Introduction: Previous investigations have established the prognostic value of variables obtained from both echocardiography and cardiopulmonary exercise testing (CPET) in patients with heart failure (HF). In the past, prognostic comparisons of variables obtained from these two techniques have been limited to the comparison of left ventricular ejection fraction (LVEF) vs. peak oxygen consumption (VO2). The present investigation undertakes a more thorough prognostic assessment of variables obtained by both techniques that are well recognized prognosticators. Methods: One hundred and fifty-six HF patients (125 male/31 female, mean age: 60.9 6 9.4 years) underwent standard 2-dimensional and Doppler echocardiography and CPET to determine the following variables: 1. the ratio between mitral early (E) to mitral annular (E0 ) velocity, 2. LVEF, LVmass, 3. LV end systolic volume (LVESV), 4. peak VO2, 5. the minute ventilation (VE)/carbon dioxide production (VCO2) slope. Subjects were tracked for cardiac mortality for two years following assessment. Results: There were 30 cardiac-related deaths during the two-year tracking period (annual mortality rate: 13.2%). Univariate Cox regression analysis revealed E/E0 (Chisquare: 28.3, p ! 0.001), LVEF (Chi-square: 6.2, p 5 0.01), LVmass (Chi-square: 37.6, p ! 0.001), LVESV (Chi-square: 26.5, p ! 0.001), peak VO2 (Chi-square: 13.6, p ! 0.001) and the VE/VCO2 slope (Chi-square: 24.1, p ! 0.001) were all prognostically significant. Multivariate Cox regression analysis found LVmass was the strongest predictor of cardiac mortality (Chi-square: 37.6, p ! 0.001). Both E/E0 (Residual chi-square: 9.2, p 5 0.002) and the VE/VCO2 slope (Residual chi-square: 7.7, p 5 0.006) added significant prognostic value and were retained in the regression. All other echocardiography and CPET variables were removed from the multivariate regression (Residual chi-square: # 1.8, p O 0.15). Conclusions: The results of the present study indicate LVmass and E/E0 are prognostically important variables obtained from Doppler echocardiography. The VE/VCO2 slope, which appears to be one of the strongest prognostic markers obtained from CPET, adds prognostic value to LVmass and E/E0 . A combinatory analysis of both noninvasive techniques may improve prognostic characterization of patients with HF.
318 Table 1. LVEF measures and BMI in patients admitted for ADHF (n 5 993) BMI Quintiles 18e25 25e30 30e35 35e40
Co-Efficient (%EF Change) baseline 5.57 5.44 9.12
95% CI (1.82, 9.32) (1.24, 9.64) (3.45, 14.79)
t
p
2.92 2.54 3.16
! .001 0.004 0.011 0.022
Cardiopulmonary Exercise Testing Maintains Prognostic Value in Obese Patients with Heart Failure Paul Chase1, Daniel Bensimhon1, Jonathan Myers2, Mary Ann Peberdy3, Marco Guazzi4, Ross Arena3; 1LeBauer Cardiovascular Research Foundation; 2VA Palo Alto Health Care System; 3Virginia Commonwealth University; 4University of Milano, San Paolo Hospital Introduction: The minute ventilation (VE)/carbon dioxide production (VCO2) slope and peak oxygen consumption (VO2) consistently provide valuable prognostic
HFSA
S165
314
316
Clinical Utility of Fluid Monitoring with Intrathoracic Impedance in ICD Patients Lisa D. Rathman1, Roy S. Small1, Jill L. Repoley1, Deanna Dukes-Graves1, Kelly J. Trynosky1, Sherri S. Delgado1, Jon G. Echterling1, Connie Kiser1, Michael A. Horst2; 1CHF Clinic, The Heart Group, Lancaster, PA; 2Department of Research and Statistics, Lancaster General Hospital, Lancaster, PA
Changing Survival of Patients with Heart Failure in New Zealand over 18 Years Cara A. Wasywich1, Greg D. Gamble2, Robert N. Doughty2; 1Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand; 2 Department of Medicine, University of Auckland, Auckland, New Zealand
Background: Decreasing thoracic impedance (Z) measured by an implantable device has been shown to be associated with heart failure (HF) hospitalization and other clinically relevant events (CRE) in CRT patients. Recently these device capabilities have extended to ICDs. We examined device-based Z recordings in patients with a CRT-D device versus ICD alone. Methods: Device-recorded Z and health record data from 67 CRT-D patients and 56 ICD patients were retrospectively reviewed. The diagnostic fluid index (FI) was automatically derived from consecutive negative deviations in the actual measured daily Z from the calculated basal or reference Z. Fluid index values higher than the programmed threshold constituted a device classified event. HF hospitalizations, CRE’s (including documented signs and symptoms of worsening HF), acute changes in diuretic therapy or volume status, pneumonia, and surgical device or lead revisions were identified for association with FI threshold crossings in both groups. Results: Mean age (71 years), follow-up duration (6.31 versus 5.84 months) and creatinine (1.43 versus 1.35 mg/dl) were similar in both groups. The CRT-D group had a lower ejection fraction (28 6 7 vs. 36 6 11, p ! 0.001). The number of FI crossings and HF hospitalizations were similar between the 2 groups. However, FI crossings were more frequently related to a clinical decompensation in the CRT-D group (10 versus 2, p ! .035). There was no difference in FI crossings between groups for pneumonia, changes in diuretic therapy, and surgical device or lead revisions. More unexplained FI crossings were observed in the ICD group (11 versus 2, p ! 0.003). However, ICD patients were less likely to be followed in the heart failure clinic (30% versus 80%, p ! 0.001). Whether these data reflect less consistent follow-up in the ICD group or a different predictive value in the ICD group is not clear. Conclusions: Continuous intrathoracic impedance measurements derived from an implantable device provide clinically relevant information which correlates with HF hospitalizations and CRE’s. However, the predictive value of these measurements may depend on the intensity of follow-up and the risk of heart failure decompensation which varies between the CRT-D and ICD populations.
315 Weighing In: BMI and Ejection Fraction in Patients Admitted for Acute Decompensated Heart Failure Mustafa M. Ahmed2, Utpal N. Sagar2, Jocelyn Andrel3, Suzanne Adams1, David J. Whellan1; 1Medicine/Cardiology, Jefferson Medical College, Philadelphia, PA; 2 Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA; 3 Biostatistics, Jefferson Medical College, Philadelphia, PA Introduction: Overweight and obesity are risk factors for cardiovascular (CV) disease and heart failure (HF). Despite evidence of adverse effects from overweight, the relationship between body mass index (BMI) and mortality in chronic disease remains controversial. Several large cohort studies showed overweight/obese patients appearing to have better survival than their healthy weight counterparts. We examined the relationship between BMI and ejection fraction (EF) for acute decompensated heart failure (ADHF) admissions. Hypothesis: Overweight and obese HF patients may have CV alterations that lead to improved clinical outcomes. Methods: We utilized the Jefferson Outcomes Database of integrated reports from administrative, clinical, and financial data to identify ADHF admissions from January 2004 through June 2006. A total of 993 records were reviewed. Patients were divided into quintiles by BMI : underweight (! 18.5), healthy weight (18.5e24.9), overweight (25.0e29.9), and obese (30.0e34.9), and morbidly obese (35e40). Categories for analyses were limited to those records reporting BMI O 15 and ! 40. Summary statistics were performed on all variables of interest. Associations with categorical variables were analyzed using logistic regression, and adjusted for age, race, and sex. Continuous variable association were determined through general liner modeling, and adjusted for the same variables. Non-normally distribution variables were transformed using the natural log, and then analyzed. All analyses were carried out in SAS version 9.1. Results: Added weight carried an increased association with diagnoses of diabetes and hypertension. Overweight and obese patients were found to have a mean EF greater than that for normal BMI subjects. Conclusions: The role this finding plays in observed survival benefit in HF patients requires further study.
Background: Studies have reported improved survival for heart failure (HF) patients during the 1990’s. It is uncertain whether survival has continued to improve recently. The aims of this study were to determine temporal changes in survival for patients after HF hospitalisation (HFH) in New Zealand (NZ) 1988e2005. Methods: National statistics for hospital admissions for HFH were obtained from the NZ Health Information Service (1988 to 2005) using ICD codes for HF as the primary or secondary diagnosis. Mortality data was obtained for all patients after first HFH. HFspecific casemix was calculated from ICD codes to assess comorbidity. Results: Between 1988-2005 there were 186,681 HFH, involving 103,318 individuals. The number of HFH per year increased from 7,576 in 1988 to 11,158 in 2005. Median age increased from 71.7 years to 77.4 years. Median length of stay decreased from 8 to 5 days (1988-1999) then remained stable to 2003. HF-specific casemix increased from 2.4 to 3.0. 30-day and 6-month mortality rates decreased from 1988 to 1999 then stabilised from 1999 to 2003. Conclusions: Survival after first HFH in NZ improved during the 1990’s but is unchanged since 1999, despite increasing patient age and comorbidity. These improved outcomes may, in part, reflect evidence based HF pharmacotherapy. Despite these improvements, mortality remains high reinforcing the importance of further improvements in HF management. Mortality 1988e2003
30-day mortality, % 6-month mortality, %
1988
1991
1994
1996
1998
2000
2003
15.2 30.1
14.2 27.9
12.8 26.2
12.8 24.2
11.0 21.9
11.0 21.9
11.3 19.7
317 A Prognostic Comparison of Echocardiography vs. Cardiopulmonary-Derived Variables in Patients with Heart Failure Marco Guazzi1, Marco Vicenzi1, Rosa Raimondo2, Simona Sarzi2, Roberto Pedretti2, Ross Arena3; 1Cardiopulmonary Unit, Cardiology Division, University of Milano, San Paolo Hospital, Milano, Italy; 2Division of Cardiology, Scientific Institute of Tradate, Tradate, Italy; 3Physical Therapy, Virginia Commonwealth University, Richmond, VA Introduction: Previous investigations have established the prognostic value of variables obtained from both echocardiography and cardiopulmonary exercise testing (CPET) in patients with heart failure (HF). In the past, prognostic comparisons of variables obtained from these two techniques have been limited to the comparison of left ventricular ejection fraction (LVEF) vs. peak oxygen consumption (VO2). The present investigation undertakes a more thorough prognostic assessment of variables obtained by both techniques that are well recognized prognosticators. Methods: One hundred and fifty-six HF patients (125 male/31 female, mean age: 60.9 6 9.4 years) underwent standard 2-dimensional and Doppler echocardiography and CPET to determine the following variables: 1. the ratio between mitral early (E) to mitral annular (E0 ) velocity, 2. LVEF, LVmass, 3. LV end systolic volume (LVESV), 4. peak VO2, 5. the minute ventilation (VE)/carbon dioxide production (VCO2) slope. Subjects were tracked for cardiac mortality for two years following assessment. Results: There were 30 cardiac-related deaths during the two-year tracking period (annual mortality rate: 13.2%). Univariate Cox regression analysis revealed E/E0 (Chisquare: 28.3, p ! 0.001), LVEF (Chi-square: 6.2, p 5 0.01), LVmass (Chi-square: 37.6, p ! 0.001), LVESV (Chi-square: 26.5, p ! 0.001), peak VO2 (Chi-square: 13.6, p ! 0.001) and the VE/VCO2 slope (Chi-square: 24.1, p ! 0.001) were all prognostically significant. Multivariate Cox regression analysis found LVmass was the strongest predictor of cardiac mortality (Chi-square: 37.6, p ! 0.001). Both E/E0 (Residual chi-square: 9.2, p 5 0.002) and the VE/VCO2 slope (Residual chi-square: 7.7, p 5 0.006) added significant prognostic value and were retained in the regression. All other echocardiography and CPET variables were removed from the multivariate regression (Residual chi-square: # 1.8, p O 0.15). Conclusions: The results of the present study indicate LVmass and E/E0 are prognostically important variables obtained from Doppler echocardiography. The VE/VCO2 slope, which appears to be one of the strongest prognostic markers obtained from CPET, adds prognostic value to LVmass and E/E0 . A combinatory analysis of both noninvasive techniques may improve prognostic characterization of patients with HF.
318 Table 1. LVEF measures and BMI in patients admitted for ADHF (n 5 993) BMI Quintiles 18e25 25e30 30e35 35e40
Co-Efficient (%EF Change) baseline 5.57 5.44 9.12
95% CI (1.82, 9.32) (1.24, 9.64) (3.45, 14.79)
t
p
2.92 2.54 3.16
! .001 0.004 0.011 0.022
Cardiopulmonary Exercise Testing Maintains Prognostic Value in Obese Patients with Heart Failure Paul Chase1, Daniel Bensimhon1, Jonathan Myers2, Mary Ann Peberdy3, Marco Guazzi4, Ross Arena3; 1LeBauer Cardiovascular Research Foundation; 2VA Palo Alto Health Care System; 3Virginia Commonwealth University; 4University of Milano, San Paolo Hospital Introduction: The minute ventilation (VE)/carbon dioxide production (VCO2) slope and peak oxygen consumption (VO2) consistently provide valuable prognostic