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Correlates of Cognitive Impairment Among Patients With Heart Failure: Results of a Multicenter Survey
Methods: Patients with a recent admission for HF due to LV systolic dysfunction (left ventricular ejection fraction [LVEF] ⬍40%) were assigned randomly either to HTM, NTS, or UC in a 2:2:1 ratio. The HTM comprised twicedaily patient self-measurement of weight, blood pressure, heart rate, and rhythm with automated devices linked to a cardiac center. The NTS consisted of specialist nurses who were available to patients by telephone. Primary care physicians delivered UC. The primary end point was days hospitalized or mortality with NTS versus HTM at 240 days. Results: A total of 426 HF patients were randomized in this study, of whom 48% were aged ⬎70 years, mean LVEF was 25% (SD, 8) and median plasma N-terminal pro-brain natriuretic peptide was 3070 pg/mL (interquartile range 1285 to 6749 pg/ml). Respectively, 19.5%, 15.9% and 12.7% of days were lost (from 240 days of follow-up) as the result of death or hospitalization for UC, NTS, and HTM (no significant difference). The number of admissions and mortality rates were similar among patients randomly assigned to NTS or HTM, but the mean duration of admissions was reduced by 6 days (95% confidence interval [CI] 1–11) with HTM. Patients receiving UC had higher 1-year mortality (45%) than did patients assigned to receive NTS (27%) or HTM (29%) (p⫽0.032). Conclusions: The researchers conclude that HTM may have a role in the management of HF. Perspective: This was a small study, but it suggests that intensive monitoring either by nurses or by telemanagement may reduce hospital stay and improve mortality compared to usual care. Current thinking is that patients with advanced HF will benefit from referral to a HF program for close monitoring and follow-up when it is available. Ragavendra Baliga
analyses were applied to adjust for differences in baseline risk. The post-baseline events of shock, stroke and CHF were considered, along with arrhythmic events and mechanical complications. Results: PAC was performed in 735 patients (2.8%), with a median time to insertion of 24 h. Patients undergoing PAC were older (median, 67 vs. 64 years), more often diabetic (25.7% vs. 16.2%) and more likely to present with STsegment elevation (81.6% vs. 70.2%) or Killip class III or IV (7.9% vs. 1.4%). The US patients were 3.8 times more likely than non-US patients to undergo PAC. Patients managed with PAC also underwent more procedures, including percutaneous intervention (40.7% vs. 18.1%), coronary artery bypass grafting (12.5% vs. 7.7%) and endotracheal intubation (29.3% vs. 2.2%). Mortality at 30 days was substantially higher among patients with PAC for both unadjusted (odds ratio [OR] 8.7; 95% confidence interval [CI] 7.3– 10.2) and adjusted analyses (OR 6.4; 95% CI 5.4 –7.6) in all groups except in patients with cardiogenic shock (OR 0.99; 95% CI 0.80 –1.23). Conclusions: The investigators concluded that PAC was associated with increased mortality, both before and after adjustment for baseline patient differences and subsequent events that may have led to PAC use. Perspective: This observational study demonstrated no benefit associated with PAC use in patients with ACS. Because accurate adjustment for treatment selection bias may not be possible within observational studies, randomized trials are more likely to provide definitive evidence of the risk/benefit of PA catheters in critically ill patients. Four such randomized controlled trials (RCTs) have been performed to date on the use of PAC in critically ill patients. None of these RCTs found evidence that PAC benefits critically ill patients; furthermore, many of the studies found a higher mortality in those undergoing PAC. Based on currently available data, the role of PA catheters in the management of critically ill patients appears quite limited and decisions on use of PA catheters must be weighed carefully on an individual case basis. Debabrata Mukherjee
Correlates of Cognitive Impairment Among Patients With Heart Failure: Results of a Multicenter Survey Zuccala G, Marzetti E, Cesari M, et al. Am J Med 2005;118:496 –502. Study Question: What are the determinants of cognitive function in patients with heart failure (HF)? Methods: Cognitive function was determined in 1511 patients with HF by using the Hodkinson Abbreviated Mental Test Score—a score of ⬍7 was considered cognitive impairment. This was correlated with patient demographics using multivariate logistic regression. Results: After adjusting for potential confounders, the investigators found that cognitive impairment was independently associated with age (per each decade: OR⫽2.01; 95% confidence interval [CI] 1.72–2.35), the comorbidity score (OR 1.11; 95% CI 1.03–1.20), education (OR 0.88; 95% CI 0.84 – 0.2), low serum albumin (OR 1.78; 95% CI 1.35–2.34), sodium (OR 1.56; 95% CI 1.06 –2.29), and potassium levels (OR 1.58; 95% CI 1.09 –2.29), hyperglycemia (OR 1.33; 95% CI 1.02–1.73), anemia (OR 1.38;
Noninvasive Home Telemonitoring for Patients With Heart Failure at High Risk of Recurrent Admission and Death: The Trans-European Network–HomeCare Management System (TEN-HMS) Study Cleland JGF, Louis AA, Rigby, AS, Janssens U, Balk AHMM, on behalf of the TEN–HMS Investigators. J Am Coll Cardiol 2005;45:1654 – 64. Study Question: Does home telemonitoring (HTM) improve outcomes for patients with heart failure (HF) who are at high risk of hospitalization or death, compared with nurse telephone support (NTS) and usual care (UC)?
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95% CI 1.09 –1.75), and systolic blood pressure levels ⱖ130 mm Hg (OR 0.60; 95% CI 0.37– 0.97). They found that restoration of normal glucose, potassium, and hemoglobin levels during hospital stay in patients with abnormal values on admission was associated with cognitive improvement on discharge. Conclusions: The investigators concluded that cognitive improvement in HF patients is associated with treatment of comorbid conditions such as anemia, hypoglycemia or hypokalemia. Perspective: This is an important study that endorses our clinical practice, which is to vigorously correct comorbid conditions such as hypoglycemia, hypokalemia and anemia in patients with HF and impaired cognition. Impaired cognitive function in HF patients should prompt the physician to pursue aggressively both hemodynamic and metabolic stabilization. Ragavendra Baliga
Conclusions: The researchers concluded that LV remodeling after ASA occurs early and progresses on midterm followup, modulated by infarct size and location. Perspective: The study reports that LV remodeling after ASA occurred early and progressed on midterm follow-up, modulated by infarct size and location. Regression of nonseptal, remote myocardial mass was significantly associated with infarct location and correlated with the reduction in LVOT pressure gradient at 6-month follow-up. These findings support the theory that myocardial hypertrophy in patients with HOCM is, at least in part, afterload dependent and reversible and thus is not caused exclusively by the genetic disorder. Debabrata Mukherjee
Early Onset and Progression of Left Ventricular Remodeling After Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy
Leya FS, Arab D, Joyal D, et al. J Am Coll Cardiol 2005;45:1900 –2.
The Efficacy of Brain Natriuretic Peptide Levels in Differentiating Constrictive Pericarditis From Restrictive Cardiomyopathy Study Question: Are levels of brain natriuretic peptide (BNP) useful in the noninvasive discrimination of constrictive pericarditis and restrictive cardiomyopathy? Methods: The BNP levels were measured in 11 patients suspected of having either constrictive pericarditis or restrictive cardiomyopathy, all of whom underwent invasive hemodynamic assessment on the same day as BNP measurement. Results: Based on established hemodynamic criteria, 6 patients had constrictive pericarditis and 5 had restrictive cardiomyopathy. Intracardiac pressures were elevated to a similar degree among patients with constrictive pericarditis and restrictive cardiomyopathy. Despite similar intracardiac pressures, mean plasma BNP levels were significantly higher in patients with restrictive cardiomyopathy compared with those with constrictive pericarditis (825.8⫾172.2 pg/mL vs. 128.0⫾52.7 pg/mL, p⬍0.001, respectively). Conclusions: Levels of BNP are significantly elevated in patients with restrictive cardiomyopathy compared to those with constrictive pericarditis; BNP appears to be a useful noninvasive marker for the clinical differentiation of the two conditions. Perspective: On first blush, it may appear problematic to base clinical diagnostics on a study with only 11 patients. However, Hatle’s hallmark 1989 study using echocardiographic/Doppler to differentiate constrictive and restrictive filling relied on only 12 subjects. There is imperfect distribution between groups of left ventricular end-diastolic pressures (LVEDP was ⬎30 mm Hg in 3 of 5 patients with restriction and in no patients with constriction) that could have contributed to observed differences in BNP. However, the data support excellent discrimination of pathology based on BNP. Of the myriad utilities of echocardiography and Doppler, I for one am delighted to yield the mantle of the “constriction vs. restriction” conundrum to the realm of BNP. David Bach
van Dockum WG, Beek AM, ten Cate FJ, et al. Circulation 2005;111:2503– 8. Study Question: The study evaluated changes and potential modulating factors of these changes in LV remodeling during the first 6 months after alcohol septal ablation (ASA) using cardiac MRI (CMR). Methods: Consecutive patients with hypertrophic obstructive cardiomyopathy (HOCM) scheduled to undergo ASA in referral centers in the Netherlands were candidates for the study. Thirty-three consecutive patients were enrolled initially. Four patients were excluded from the final analysis: 3 required pacemaker implantation because of development of complete atrioventricular block after ASA, and 1 declined to return for the follow-up examinations. The remaining 29 patients formed the final study group. The CMR was performed at baseline and 1 and 6 months after ASA in 29 patients with HOCM (age 52⫾16 years). Results: Contrast-enhanced CMR showed no infarct-related hyperenhancement outside the target septal area. Septal mass decreased from 75⫾23 g at baseline to 68⫾22 g and 58⫾19 g (p⬍0.001) at 1- and 6-month follow-up, respectively. Remote, nonseptal mass decreased from 141⫾41 g to 132⫾40 g and 111⫾27 g (p⬍0.001), respectively. Analysis of temporal trends revealed that septal mass reduction was positively associated with contrast-enhanced infarct size and transmural or left-sided septal infarct location at both 1 and 6 months. Remote mass reduction was associated with infarct location at 6 months but not with contrastenhanced infarct size. Using linear regression analysis, percentage remote mass reduction correlated significantly with left ventricular outflow tract (LVOT) gradient reduction at 6-month follow-up (p⫽0.03).
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analyses were applied to adjust for differences in baseline risk. The post-baseline events of shock, stroke and CHF were considered, along with arrhythmic events and mechanical complications. Results: PAC was performed in 735 patients (2.8%), with a median time to insertion of 24 h. Patients undergoing PAC were older (median, 67 vs. 64 years), more often diabetic (25.7% vs. 16.2%) and more likely to present with STsegment elevation (81.6% vs. 70.2%) or Killip class III or IV (7.9% vs. 1.4%). The US patients were 3.8 times more likely than non-US patients to undergo PAC. Patients managed with PAC also underwent more procedures, including percutaneous intervention (40.7% vs. 18.1%), coronary artery bypass grafting (12.5% vs. 7.7%) and endotracheal intubation (29.3% vs. 2.2%). Mortality at 30 days was substantially higher among patients with PAC for both unadjusted (odds ratio [OR] 8.7; 95% confidence interval [CI] 7.3– 10.2) and adjusted analyses (OR 6.4; 95% CI 5.4 –7.6) in all groups except in patients with cardiogenic shock (OR 0.99; 95% CI 0.80 –1.23). Conclusions: The investigators concluded that PAC was associated with increased mortality, both before and after adjustment for baseline patient differences and subsequent events that may have led to PAC use. Perspective: This observational study demonstrated no benefit associated with PAC use in patients with ACS. Because accurate adjustment for treatment selection bias may not be possible within observational studies, randomized trials are more likely to provide definitive evidence of the risk/benefit of PA catheters in critically ill patients. Four such randomized controlled trials (RCTs) have been performed to date on the use of PAC in critically ill patients. None of these RCTs found evidence that PAC benefits critically ill patients; furthermore, many of the studies found a higher mortality in those undergoing PAC. Based on currently available data, the role of PA catheters in the management of critically ill patients appears quite limited and decisions on use of PA catheters must be weighed carefully on an individual case basis. Debabrata Mukherjee
Correlates of Cognitive Impairment Among Patients With Heart Failure: Results of a Multicenter Survey Zuccala G, Marzetti E, Cesari M, et al. Am J Med 2005;118:496 –502. Study Question: What are the determinants of cognitive function in patients with heart failure (HF)? Methods: Cognitive function was determined in 1511 patients with HF by using the Hodkinson Abbreviated Mental Test Score—a score of ⬍7 was considered cognitive impairment. This was correlated with patient demographics using multivariate logistic regression. Results: After adjusting for potential confounders, the investigators found that cognitive impairment was independently associated with age (per each decade: OR⫽2.01; 95% confidence interval [CI] 1.72–2.35), the comorbidity score (OR 1.11; 95% CI 1.03–1.20), education (OR 0.88; 95% CI 0.84 – 0.2), low serum albumin (OR 1.78; 95% CI 1.35–2.34), sodium (OR 1.56; 95% CI 1.06 –2.29), and potassium levels (OR 1.58; 95% CI 1.09 –2.29), hyperglycemia (OR 1.33; 95% CI 1.02–1.73), anemia (OR 1.38;
Noninvasive Home Telemonitoring for Patients With Heart Failure at High Risk of Recurrent Admission and Death: The Trans-European Network–HomeCare Management System (TEN-HMS) Study Cleland JGF, Louis AA, Rigby, AS, Janssens U, Balk AHMM, on behalf of the TEN–HMS Investigators. J Am Coll Cardiol 2005;45:1654 – 64. Study Question: Does home telemonitoring (HTM) improve outcomes for patients with heart failure (HF) who are at high risk of hospitalization or death, compared with nurse telephone support (NTS) and usual care (UC)?
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95% CI 1.09 –1.75), and systolic blood pressure levels ⱖ130 mm Hg (OR 0.60; 95% CI 0.37– 0.97). They found that restoration of normal glucose, potassium, and hemoglobin levels during hospital stay in patients with abnormal values on admission was associated with cognitive improvement on discharge. Conclusions: The investigators concluded that cognitive improvement in HF patients is associated with treatment of comorbid conditions such as anemia, hypoglycemia or hypokalemia. Perspective: This is an important study that endorses our clinical practice, which is to vigorously correct comorbid conditions such as hypoglycemia, hypokalemia and anemia in patients with HF and impaired cognition. Impaired cognitive function in HF patients should prompt the physician to pursue aggressively both hemodynamic and metabolic stabilization. Ragavendra Baliga
Conclusions: The researchers concluded that LV remodeling after ASA occurs early and progresses on midterm followup, modulated by infarct size and location. Perspective: The study reports that LV remodeling after ASA occurred early and progressed on midterm follow-up, modulated by infarct size and location. Regression of nonseptal, remote myocardial mass was significantly associated with infarct location and correlated with the reduction in LVOT pressure gradient at 6-month follow-up. These findings support the theory that myocardial hypertrophy in patients with HOCM is, at least in part, afterload dependent and reversible and thus is not caused exclusively by the genetic disorder. Debabrata Mukherjee
Early Onset and Progression of Left Ventricular Remodeling After Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy
Leya FS, Arab D, Joyal D, et al. J Am Coll Cardiol 2005;45:1900 –2.
The Efficacy of Brain Natriuretic Peptide Levels in Differentiating Constrictive Pericarditis From Restrictive Cardiomyopathy Study Question: Are levels of brain natriuretic peptide (BNP) useful in the noninvasive discrimination of constrictive pericarditis and restrictive cardiomyopathy? Methods: The BNP levels were measured in 11 patients suspected of having either constrictive pericarditis or restrictive cardiomyopathy, all of whom underwent invasive hemodynamic assessment on the same day as BNP measurement. Results: Based on established hemodynamic criteria, 6 patients had constrictive pericarditis and 5 had restrictive cardiomyopathy. Intracardiac pressures were elevated to a similar degree among patients with constrictive pericarditis and restrictive cardiomyopathy. Despite similar intracardiac pressures, mean plasma BNP levels were significantly higher in patients with restrictive cardiomyopathy compared with those with constrictive pericarditis (825.8⫾172.2 pg/mL vs. 128.0⫾52.7 pg/mL, p⬍0.001, respectively). Conclusions: Levels of BNP are significantly elevated in patients with restrictive cardiomyopathy compared to those with constrictive pericarditis; BNP appears to be a useful noninvasive marker for the clinical differentiation of the two conditions. Perspective: On first blush, it may appear problematic to base clinical diagnostics on a study with only 11 patients. However, Hatle’s hallmark 1989 study using echocardiographic/Doppler to differentiate constrictive and restrictive filling relied on only 12 subjects. There is imperfect distribution between groups of left ventricular end-diastolic pressures (LVEDP was ⬎30 mm Hg in 3 of 5 patients with restriction and in no patients with constriction) that could have contributed to observed differences in BNP. However, the data support excellent discrimination of pathology based on BNP. Of the myriad utilities of echocardiography and Doppler, I for one am delighted to yield the mantle of the “constriction vs. restriction” conundrum to the realm of BNP. David Bach
van Dockum WG, Beek AM, ten Cate FJ, et al. Circulation 2005;111:2503– 8. Study Question: The study evaluated changes and potential modulating factors of these changes in LV remodeling during the first 6 months after alcohol septal ablation (ASA) using cardiac MRI (CMR). Methods: Consecutive patients with hypertrophic obstructive cardiomyopathy (HOCM) scheduled to undergo ASA in referral centers in the Netherlands were candidates for the study. Thirty-three consecutive patients were enrolled initially. Four patients were excluded from the final analysis: 3 required pacemaker implantation because of development of complete atrioventricular block after ASA, and 1 declined to return for the follow-up examinations. The remaining 29 patients formed the final study group. The CMR was performed at baseline and 1 and 6 months after ASA in 29 patients with HOCM (age 52⫾16 years). Results: Contrast-enhanced CMR showed no infarct-related hyperenhancement outside the target septal area. Septal mass decreased from 75⫾23 g at baseline to 68⫾22 g and 58⫾19 g (p⬍0.001) at 1- and 6-month follow-up, respectively. Remote, nonseptal mass decreased from 141⫾41 g to 132⫾40 g and 111⫾27 g (p⬍0.001), respectively. Analysis of temporal trends revealed that septal mass reduction was positively associated with contrast-enhanced infarct size and transmural or left-sided septal infarct location at both 1 and 6 months. Remote mass reduction was associated with infarct location at 6 months but not with contrastenhanced infarct size. Using linear regression analysis, percentage remote mass reduction correlated significantly with left ventricular outflow tract (LVOT) gradient reduction at 6-month follow-up (p⫽0.03).
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