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Depression in heart failure patients: prevelance, association with functional status, hospital readmission, and mortality
The 7th Annual Scientific Meeting
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S73
HFSA
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Metabolic Dyslipidemic Profile Is Highly Prevalent and Under-Treated in Patients with Chronic Heart Failure - A Single-Center, Electronic Medical Record Clinical Experience Wai Hong W. Tang,1 John P. Girod,1 Holly Miller,2 C. Martin Harris,2 Mary Partin,2 James B. Young1—1Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH; 2Department of Information Technology, Cleveland Clinic Foundation, Cleveland, OH
STAMINA-HFP (Study of Anemia in a Heart Failure Population) Registry: Rationale, Design, and Patient Characteristics Kirkwood F. Adams,1 J. Herbert Patterson,1 Ileana Pina,2 Jalal K. Ghali,3 Mandeep R. Mehra,4 Ron M. Oren,5 Jacqueline G. Nolen,6 Alan B. Miller,7 Wendy A. Gattis,8 Christopher M. O’Connor,8 Biljana Pavlovic-Surjancev,9 Kenneth J. Resser,6 Douglas D. Schocken10—1University of North Carolina at Chapel Hill, Chapel Hill, NC; 2 Case Western Reserve University, Cleveland, OH; 3Willis Knighton Heart Institute, Shreveport, LA; 4Ochsner Heart and Vascular Institute, New Orleans, LA; 5University of Iowa, Iowa City, IA; 6Amgen, Inc., Thousand Oaks, CA; 7University of Florida, Jacksonville, FL; 8Duke University, Durham, NC; 9Northwestern University, Chicago, IL; 10University of South Florida, Tampa, FL
Background: Dyslipidemic profile, such as low high-density lipoprotein cholesterol (HDL-c) level or high fasting triglyceride(TG)/HDL-c ratio, is an independent predictor of clinical outcome in patients with cardiovascular diseases. We sought to determine the prevalence of low HDL-c and high TG/HDL-c ratio, and the contemporary patterns of lipid intervention in a busy outpatient heart failure clinic. Methods: We reviewed 1,557 consecutive patients with chronic heart failure seen at a tertiary care, outpatient internal medicine (IM) and cardiology (CV) clinics between 10/99 and 5/02. Low HDL-c level was defined as ⬍⫽ 40 mg/dL for men and ⬍⫽ 50 mg/dL for women (ATP-III criteria). Clinical, demographic, laboratory data (including fasting lipid panel) and ICD-9 coding data were extracted from electronic medical records (EpiCare, Epic Systems Co.),and compared using univariate analyses. Results: In our study population (mean age 63 ⫾ 14 years, 64% male, 35% diabetics), 35% had total fasting cholesterol of ⬎200 mg/dL with mean low-density lipoprotein cholesterol (LDL-c) and HDL-c being 103 ⫾ 36 mg/dL and 43 ⫾ 14 mg/dL respectively. Overall, 58% of the patients had low HDL-c levels (compared with 38% in historical controls of secondary prevention trials), and was similar between men and women (57% vs 59% respectively, p ⫽ NS). In addition, 41% patients had a fasting triglyceride/HDL-c ratio of ⬎3.5. Among those with LDL-c ⬎⫽ 100 mg/dL (i.e. noncachetic), 43% men (mean LDL-c ⫽ 127 ⫾ 24 mg/dL) and 53% women (mean LDLc ⫽ 136 ⫾ 35 mg/dL) had low HDL-c. Patients with low HDL-c levels are more likely to be diabetic and have an ischemic etiology when compared to those with normal HDL-c levels (p ⬍ 0.05). Among all patients with low HDL-c, only 8% of patients were being treated with a lipid-modifying agent, among which only 9 patients (0.6%) were receiving niacin or fibric acid derivatives. Treatment patterns were similar between CV and IM clinics. Conclusions: Dyslipidemic profile of the metabolic syndrome is highly prevalent in ambulatory patients with chronic heart failure (up to 58% with low HDL-c), even when adjusted for noncachetic patients. The vast majority of patients with low HDL-c were not treated, and features of the metabolic syndrome were highly prevalent. Further investigation is needed to determine the potential benefits of therapy to improve this dyslipidemic profile in the heart failure population.
266 Renal Artery Stenosis in Heart Failure - Prevalence And Associated Factors Ramesh de Silva,1 Anthony Nicholson,2 Sudiptha Chattopadhyay,1 Justin Ghosh,1 Pritwish Bannergee,1 Klaus K.A. Witte,1 Nikolay P. Nikitin,1 Sunil Bhandari,3 Andrew L. Clark,1 John G.F. Cleland1—1Academic Cardiology, University of Hull, Hull, East Yorkshire, United Kingdom; 2Department of Radiology, Hull and East Yorkshire NHS Trust, Hull, East Yorkshire, United Kingdom; 3Department of Nephrology, Hull and East Yorkshire NHS Trust, Hull, East Yorkshire, United Kingdom Background: Renal dysfunction is common in patients with heart failure, is probably multi-factorial and may contribute to its progression. There are few published data on the prevalence of renovascular disease in an unselected population with chronic heart failure (CHF). Aims: To assess the prevalence of and factors associated with renal artery stenosis (RAS) in patients with CHF, many of whom have renal dysfunction. Methods: 76 patients with symptoms and signs of CHF and a left ventricular ejection fraction (LVEF) ⬍40% on echocardiography were identified. 48 (63%) patients had renal dysfunction defined as a creatinine clearance (CrCl) ⬍60ml/min calculated by the Cockcroft-Gault equation [(140-age) × weight (kg)/(Creat (m mol/L) × 0.81) × 0.85 if female]. Patients were assessed by gadolinium enhanced magnetic resonance angiography (MRA) of the renal arteries. Results: 56 (74%) were male. The average age was 68 years. 49 (65%) patients had RAS of which 39 (51%) had significant RAS, defined as a stenosis of ⬎50%. 12 (16%) were bilateral. 12 (16%) patients had RAS ⬎70% of which 1 (1%) was bilateral. 40 of the 49 (82%) patients with RAS ⬎50% had reduced CrCl in comparison to only 12 of the 27 (43%) patients without RAS (p ⬍ 0.01). Patients with RAS were older (74 (9) v 64 (9) years (p ⬍ 0.005)) and more likely to have a past history of hypertension (n ⫽ 23 v n ⫽ 11; p ⬍ 0.05). LVEF and weight were not different between the two groups and nor was a history of diabetes, ischaemic heart disease (IHD), peripheral vascular disease (PVD) or stroke. An important incidental finding was the presence of 8 (11%) previously undetected abdominal aortic aneurysms requiring further assessment. Conclusions: Gadolinium enhanced MRA is a safe and effective technique for the assessment of patients with renal dysfunction and heart failure and may detect other important vascular disease. RAS is common in this patient group, appears to contribute importantly to renal dysfunction in patients with heart failure and may complicate the optimal pharmacological management of patients with heart failure. The risks and benefits of renal angioplasty in such cases have yet to be determined.
Background: Anemia is recognized as a potentially important pathophysiological factor in heart failure (HF), possibly by reducing oxygen delivery and likely other mechanisms. However, little is known about the prevalence of anemia or clinical factors associated with the occurrence of anemia in unselected patients with HF. Available data are primarily derived from retrospective analyses of prospectively collected data from selected HF populations. The primary objectives of the STAMINAHFP registry are to estimate the prevalence and incidence of anemia and identify factors associated with anemia in a broad population of outpatients with HF. Methods. The STAMINA-HFP Registry is currently ongoing and utilizes a prospective, observational design. 1000 outpatients will be randomly selected from HF specialty clinics involved in the UNITE-HF database (n ⫽ 400) and community cardiology practice clinics (n ⫽ 600). Inclusion criteria are broad. HF was clinically diagnosed based on the occurrence of fluid retention and/or dyspnea due to cardiac cause regardless of left ventricular ejection fraction. Baseline assessment includes a comprehensive clinical history, CBC and serum creatinine. Follow-up in the outpatient clinic is naturalistic for one year with serial hemoglobin measurements obtained by finger stick at clinically indicated visits. Patient reported outcomes (PRO) will be assessed by telephone contact at baseline and every three months for one year using the Kansas City Cardiomyopathy Questionnaire, Minnesota Living with Heart Failure Questionnaire, and the FACIT-Fatigue instrument. Data on death and hospitalization will be collected and these outcomes evaluated using an event committee. Results. To date, 942 subjects have been enrolled at 56 sites. Baseline data from 625 subjects (173 specialty and 452 community) revealed that the cohort is 43% female and 75% Caucasian with mean (⫾SD) age of 64 ⫾ 14 years (57 ⫾ 15 years in specialty and 68 ⫾ 13 years in community sites, p ⬍ 0.001). 24% of subjects had a hemoglobin level ⬍12 g/dL; a history of diabetes was present in 39% and hypertension in 72% of subjects. Conclusion. The STAMINA-HFP Registry will provide contemporary data on the prevalence of anemia in outpatients with HF seen in specialty and community cardiology clinics. The registry will identify factors associated with anemia and evaluate the relationship between anemia and PRO in a broad population of subjects with HF.
267 Depression in Heart Failure Patients: Prevelance, Association with Functional Status, Hospital Readmission, and Mortality Wafaa Elatre,1 Leslie Aria,1 Richard Cayasoo,1 Bonita L. Huiskes,1 Kimberly Beckwith,1 J. Thomas Heywood1—1Cardiology, Loma Linda University Medical Center, Loma Linda, CA Background: Depression has been associated with symptoms of congestive heart failure (CHF). In particular, depression has been linked to poor compliance, impaired self-management, and overestimation of functional impairment. Purpose This study sought to identify the prevalence of depression within a large sampled population of patients with CHF, in an outpatient clinic. A second goal was to evaluate the relationship between depression and disease-specific subjective health symptoms as indicted by New York Heart Association ( NYHA) classification. Thirdly, to determine if depression is associated with rehospitalisation and mortality. Methods: A consecutive sample of 120 CHF patients over 18 years old who agreed to be in the study were recruited from an outpatient CHF clinic at Loma Linda University Medical Center [June 2002–January 2003]. All participants completed two questionnaires: a demographic data sheet, and the Hospital Anxiety and Depression Scale (HADS). The HADS is a 14-item self-administered measure that is rated on a four point Likert scale. The patients’ charts were reviwed to determine NYHA classification, ejection fraction, rehospitalization, and mortality during the study period. Analysis: Chi square test was used to test between NYHA and depression grade . The demographic criteria for the patients displyed in table 1. Results: graph 1 In the 120 patients, 24(19%) were normal[ Grade 0]. 17 (13.5) had mild depression[Grade 1], 22(17.5%) had moderate depression[Grade 3]. 58 (46%) had severe depression[Grade 4]. Chi-square result indicated a significant relationship between the severity of depression and NYHA class (P-value ⫽ 0.000), mortality (Pvalue ⫽ 0.03). However, there was no significant association with number of rehospitalizations (PValue ⫽ 0.17) Conclusion: These findings emphasize the high prevalence of severe depression in outpatients with congestive heart failure, and suggests that depression should be more actively sought out in these patients. Moreover the severity of depression correlates with functional status and mortality. Future studies should evaluate the effects of pharmacologic antidepressant therapy on symptoms and functional status in significantly depressed. patients with heart failure. Demographics of the study populations Race Caucasians African American Oriental & Others Heart Failure Etiology Ischemic Idiopathic Hypertension Others New York Heart Association NYHA I NYHA II NYHA III NYHA IV
79.8% 16% 3.3% 36.2% 33% 5.4% 36% 11 41 64 7
(8.9%) (33.1%) (51.6%) (5.6%)
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S73
HFSA
264
265
Metabolic Dyslipidemic Profile Is Highly Prevalent and Under-Treated in Patients with Chronic Heart Failure - A Single-Center, Electronic Medical Record Clinical Experience Wai Hong W. Tang,1 John P. Girod,1 Holly Miller,2 C. Martin Harris,2 Mary Partin,2 James B. Young1—1Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH; 2Department of Information Technology, Cleveland Clinic Foundation, Cleveland, OH
STAMINA-HFP (Study of Anemia in a Heart Failure Population) Registry: Rationale, Design, and Patient Characteristics Kirkwood F. Adams,1 J. Herbert Patterson,1 Ileana Pina,2 Jalal K. Ghali,3 Mandeep R. Mehra,4 Ron M. Oren,5 Jacqueline G. Nolen,6 Alan B. Miller,7 Wendy A. Gattis,8 Christopher M. O’Connor,8 Biljana Pavlovic-Surjancev,9 Kenneth J. Resser,6 Douglas D. Schocken10—1University of North Carolina at Chapel Hill, Chapel Hill, NC; 2 Case Western Reserve University, Cleveland, OH; 3Willis Knighton Heart Institute, Shreveport, LA; 4Ochsner Heart and Vascular Institute, New Orleans, LA; 5University of Iowa, Iowa City, IA; 6Amgen, Inc., Thousand Oaks, CA; 7University of Florida, Jacksonville, FL; 8Duke University, Durham, NC; 9Northwestern University, Chicago, IL; 10University of South Florida, Tampa, FL
Background: Dyslipidemic profile, such as low high-density lipoprotein cholesterol (HDL-c) level or high fasting triglyceride(TG)/HDL-c ratio, is an independent predictor of clinical outcome in patients with cardiovascular diseases. We sought to determine the prevalence of low HDL-c and high TG/HDL-c ratio, and the contemporary patterns of lipid intervention in a busy outpatient heart failure clinic. Methods: We reviewed 1,557 consecutive patients with chronic heart failure seen at a tertiary care, outpatient internal medicine (IM) and cardiology (CV) clinics between 10/99 and 5/02. Low HDL-c level was defined as ⬍⫽ 40 mg/dL for men and ⬍⫽ 50 mg/dL for women (ATP-III criteria). Clinical, demographic, laboratory data (including fasting lipid panel) and ICD-9 coding data were extracted from electronic medical records (EpiCare, Epic Systems Co.),and compared using univariate analyses. Results: In our study population (mean age 63 ⫾ 14 years, 64% male, 35% diabetics), 35% had total fasting cholesterol of ⬎200 mg/dL with mean low-density lipoprotein cholesterol (LDL-c) and HDL-c being 103 ⫾ 36 mg/dL and 43 ⫾ 14 mg/dL respectively. Overall, 58% of the patients had low HDL-c levels (compared with 38% in historical controls of secondary prevention trials), and was similar between men and women (57% vs 59% respectively, p ⫽ NS). In addition, 41% patients had a fasting triglyceride/HDL-c ratio of ⬎3.5. Among those with LDL-c ⬎⫽ 100 mg/dL (i.e. noncachetic), 43% men (mean LDL-c ⫽ 127 ⫾ 24 mg/dL) and 53% women (mean LDLc ⫽ 136 ⫾ 35 mg/dL) had low HDL-c. Patients with low HDL-c levels are more likely to be diabetic and have an ischemic etiology when compared to those with normal HDL-c levels (p ⬍ 0.05). Among all patients with low HDL-c, only 8% of patients were being treated with a lipid-modifying agent, among which only 9 patients (0.6%) were receiving niacin or fibric acid derivatives. Treatment patterns were similar between CV and IM clinics. Conclusions: Dyslipidemic profile of the metabolic syndrome is highly prevalent in ambulatory patients with chronic heart failure (up to 58% with low HDL-c), even when adjusted for noncachetic patients. The vast majority of patients with low HDL-c were not treated, and features of the metabolic syndrome were highly prevalent. Further investigation is needed to determine the potential benefits of therapy to improve this dyslipidemic profile in the heart failure population.
266 Renal Artery Stenosis in Heart Failure - Prevalence And Associated Factors Ramesh de Silva,1 Anthony Nicholson,2 Sudiptha Chattopadhyay,1 Justin Ghosh,1 Pritwish Bannergee,1 Klaus K.A. Witte,1 Nikolay P. Nikitin,1 Sunil Bhandari,3 Andrew L. Clark,1 John G.F. Cleland1—1Academic Cardiology, University of Hull, Hull, East Yorkshire, United Kingdom; 2Department of Radiology, Hull and East Yorkshire NHS Trust, Hull, East Yorkshire, United Kingdom; 3Department of Nephrology, Hull and East Yorkshire NHS Trust, Hull, East Yorkshire, United Kingdom Background: Renal dysfunction is common in patients with heart failure, is probably multi-factorial and may contribute to its progression. There are few published data on the prevalence of renovascular disease in an unselected population with chronic heart failure (CHF). Aims: To assess the prevalence of and factors associated with renal artery stenosis (RAS) in patients with CHF, many of whom have renal dysfunction. Methods: 76 patients with symptoms and signs of CHF and a left ventricular ejection fraction (LVEF) ⬍40% on echocardiography were identified. 48 (63%) patients had renal dysfunction defined as a creatinine clearance (CrCl) ⬍60ml/min calculated by the Cockcroft-Gault equation [(140-age) × weight (kg)/(Creat (m mol/L) × 0.81) × 0.85 if female]. Patients were assessed by gadolinium enhanced magnetic resonance angiography (MRA) of the renal arteries. Results: 56 (74%) were male. The average age was 68 years. 49 (65%) patients had RAS of which 39 (51%) had significant RAS, defined as a stenosis of ⬎50%. 12 (16%) were bilateral. 12 (16%) patients had RAS ⬎70% of which 1 (1%) was bilateral. 40 of the 49 (82%) patients with RAS ⬎50% had reduced CrCl in comparison to only 12 of the 27 (43%) patients without RAS (p ⬍ 0.01). Patients with RAS were older (74 (9) v 64 (9) years (p ⬍ 0.005)) and more likely to have a past history of hypertension (n ⫽ 23 v n ⫽ 11; p ⬍ 0.05). LVEF and weight were not different between the two groups and nor was a history of diabetes, ischaemic heart disease (IHD), peripheral vascular disease (PVD) or stroke. An important incidental finding was the presence of 8 (11%) previously undetected abdominal aortic aneurysms requiring further assessment. Conclusions: Gadolinium enhanced MRA is a safe and effective technique for the assessment of patients with renal dysfunction and heart failure and may detect other important vascular disease. RAS is common in this patient group, appears to contribute importantly to renal dysfunction in patients with heart failure and may complicate the optimal pharmacological management of patients with heart failure. The risks and benefits of renal angioplasty in such cases have yet to be determined.
Background: Anemia is recognized as a potentially important pathophysiological factor in heart failure (HF), possibly by reducing oxygen delivery and likely other mechanisms. However, little is known about the prevalence of anemia or clinical factors associated with the occurrence of anemia in unselected patients with HF. Available data are primarily derived from retrospective analyses of prospectively collected data from selected HF populations. The primary objectives of the STAMINAHFP registry are to estimate the prevalence and incidence of anemia and identify factors associated with anemia in a broad population of outpatients with HF. Methods. The STAMINA-HFP Registry is currently ongoing and utilizes a prospective, observational design. 1000 outpatients will be randomly selected from HF specialty clinics involved in the UNITE-HF database (n ⫽ 400) and community cardiology practice clinics (n ⫽ 600). Inclusion criteria are broad. HF was clinically diagnosed based on the occurrence of fluid retention and/or dyspnea due to cardiac cause regardless of left ventricular ejection fraction. Baseline assessment includes a comprehensive clinical history, CBC and serum creatinine. Follow-up in the outpatient clinic is naturalistic for one year with serial hemoglobin measurements obtained by finger stick at clinically indicated visits. Patient reported outcomes (PRO) will be assessed by telephone contact at baseline and every three months for one year using the Kansas City Cardiomyopathy Questionnaire, Minnesota Living with Heart Failure Questionnaire, and the FACIT-Fatigue instrument. Data on death and hospitalization will be collected and these outcomes evaluated using an event committee. Results. To date, 942 subjects have been enrolled at 56 sites. Baseline data from 625 subjects (173 specialty and 452 community) revealed that the cohort is 43% female and 75% Caucasian with mean (⫾SD) age of 64 ⫾ 14 years (57 ⫾ 15 years in specialty and 68 ⫾ 13 years in community sites, p ⬍ 0.001). 24% of subjects had a hemoglobin level ⬍12 g/dL; a history of diabetes was present in 39% and hypertension in 72% of subjects. Conclusion. The STAMINA-HFP Registry will provide contemporary data on the prevalence of anemia in outpatients with HF seen in specialty and community cardiology clinics. The registry will identify factors associated with anemia and evaluate the relationship between anemia and PRO in a broad population of subjects with HF.
267 Depression in Heart Failure Patients: Prevelance, Association with Functional Status, Hospital Readmission, and Mortality Wafaa Elatre,1 Leslie Aria,1 Richard Cayasoo,1 Bonita L. Huiskes,1 Kimberly Beckwith,1 J. Thomas Heywood1—1Cardiology, Loma Linda University Medical Center, Loma Linda, CA Background: Depression has been associated with symptoms of congestive heart failure (CHF). In particular, depression has been linked to poor compliance, impaired self-management, and overestimation of functional impairment. Purpose This study sought to identify the prevalence of depression within a large sampled population of patients with CHF, in an outpatient clinic. A second goal was to evaluate the relationship between depression and disease-specific subjective health symptoms as indicted by New York Heart Association ( NYHA) classification. Thirdly, to determine if depression is associated with rehospitalisation and mortality. Methods: A consecutive sample of 120 CHF patients over 18 years old who agreed to be in the study were recruited from an outpatient CHF clinic at Loma Linda University Medical Center [June 2002–January 2003]. All participants completed two questionnaires: a demographic data sheet, and the Hospital Anxiety and Depression Scale (HADS). The HADS is a 14-item self-administered measure that is rated on a four point Likert scale. The patients’ charts were reviwed to determine NYHA classification, ejection fraction, rehospitalization, and mortality during the study period. Analysis: Chi square test was used to test between NYHA and depression grade . The demographic criteria for the patients displyed in table 1. Results: graph 1 In the 120 patients, 24(19%) were normal[ Grade 0]. 17 (13.5) had mild depression[Grade 1], 22(17.5%) had moderate depression[Grade 3]. 58 (46%) had severe depression[Grade 4]. Chi-square result indicated a significant relationship between the severity of depression and NYHA class (P-value ⫽ 0.000), mortality (Pvalue ⫽ 0.03). However, there was no significant association with number of rehospitalizations (PValue ⫽ 0.17) Conclusion: These findings emphasize the high prevalence of severe depression in outpatients with congestive heart failure, and suggests that depression should be more actively sought out in these patients. Moreover the severity of depression correlates with functional status and mortality. Future studies should evaluate the effects of pharmacologic antidepressant therapy on symptoms and functional status in significantly depressed. patients with heart failure. Demographics of the study populations Race Caucasians African American Oriental & Others Heart Failure Etiology Ischemic Idiopathic Hypertension Others New York Heart Association NYHA I NYHA II NYHA III NYHA IV
79.8% 16% 3.3% 36.2% 33% 5.4% 36% 11 41 64 7
(8.9%) (33.1%) (51.6%) (5.6%)