Effect of obesity on mortality in congestive heart failure: a matter of left ventricular systolic function

Effect of obesity on mortality in congestive heart failure: a matter of left ventricular systolic function

S96 Journal of Cardiac Failure Vol. 10 No. 4 Suppl. 2004 Outcomes 288 290 Confusion at Large: Incorrect Assignment of Patients to the AHA/ACC Stag...

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S96

Journal of Cardiac Failure Vol. 10 No. 4 Suppl. 2004

Outcomes 288

290

Confusion at Large: Incorrect Assignment of Patients to the AHA/ACC Stages of Heart Failure in the ADVANCENT Registry Teresa De Marco, Reynolds M. Delgado, III Augustine Agocha; Department of Medicine, Division of Cardiology, University of California, San Francisco, San Francisco, CA; Department of Medicine, Texas Heart Insititute, Houston, TX; Department of Medicine, Cooper University Hospital, Camden, NJ

Effect of Obesity on Mortality in Congestive Heart Failure: A Matter of Left Ventricular Systolic Function Finn Gustafsson,1 Marie Seibaek,1 Hans Burchardt,2 Christian Torp-Pedersen,2 Lars Kober1; 1Department of Cardiology B, Rigshospitalet, Copenhagen, Denmark; 2 Department of Cardiology Y, Bispebjerg University Hospital, Copenhagen, Denmark

Introduction: The AHA/ACC Heart Failure Stages (HFS) were developed to emphasize the evolution and progression of HF and to implement early therapeutic interventions to ultimately reduce morbidity and mortality. ADVANCENT, the National Registry to Advance Heart Health is a long-term, observational, longitudinal registry that will study the management of 100,000 patients (pts) with LV dysfunction (EF ⬍ 40%). This registry captures baseline data on both NYHA functional class and AHA/ ACC HFS.Methods: We retrospectively analyzed the first 11,804 pts enrolled by 81 cardiology practices in the US participating in ADVANCENT according to NYHA class and AHA/ACC HFS.

Studies have suggested that a high body mass index (BMI) is associated with an improved outcome in congestive heart failure (CHF). However, it is not known if this applies both to patients with left ventricular (LV) systolic dysfunction as well as those with non-systolic heart failure. Using a cohort of 4700 consecutive patients hospitalized with CHF, we investigated whether a possible effect of BMI on mortality depended on left ventricular systolic function (LVEF). LVEF was analyzed off-line at a central laboratory and was available for 95 % of the cohort. Follow-up time ranged from 5–8 years. Patients were divided into four groups according to their BMI (WHO criteria): underweight (BMI⬍18.5 kg/m2, n ⫽ 196), normal weight (18.5 kg/ m2BMI⬍25 kg/m2, n ⫽ 1958), overweight (25 kg/m2BMI ⬍ 30 kg/m2, n ⫽ 1716), obese (ⱖ30 kg/m2, n ⫽ 830). Male sex, lower age, diabetes, hypertension and preserved LVEF was more commonly present in the obese patients than in nonobese. Compared with normal weight, increasing BMI at baseline was associated with a decreased risk of death even after differences in age and sex were adjusted for (risk ratios (RR) (95 % confidence intervals)): underweight 1.56 (1.33–1.84), normal weight 1, overweight 0.90 (0.83–0.97), obese 0.77 (0.70–0.86)). When the effect of BMI was tested in a multivariate model containing the baseline characteristics of the patients (age, sex, history of hypertension, ischemic heart disease, chronic pulmonary disease, renal dysfunction, valvular disease, diabetes, LVEF) a significant interaction between BMI and LVEF was found (P ⫽ 0.03). Among patients with non-systolic heart failure, mortality rate was not significantly different in obese and normal weight patients (RR 0.90 (0.76–1.06), P ⫽ 0.2). Conversely, in patients with systolic dysfunction (LVEF ⱕ 35%), obesity was associated with an increased risk of death compared with normal weight (RR 1.20 (1.00–1.44), P ⬍ 0.05). Conclusion: In unselected patients hospitalized with CHF the effect of obesity on survival depends of LV systolic function. Contrasting previous reports, obesity appears to confer an independent, excess risk to patients with LV systolic dysfunction.

Stage A NYHA NYHA NYHA NYHA Total

I (N; %) II (N; %) III (N; %) IV (N; %)

593 175 26 4 798

(5.0) (1.5) (0.22) (0.0) (6.8)

Stage B 1223 2621 364 15 4223

(10.4) (22.2) (3.1) (0.1) (35.8)

Stage C 487 3168 2684 155 6494

(4.1) (26.8) (22.7) (1.3) (55.0)

Stage D 5 36 95 153 289

(0.0) (0.3) (0.8) (1.3) (2.5)

Results: 1) Enrollment of pts into ADVANCENT requires the presence of structural heart disease with EF ⬍ 40%. Yet, 798 of 11,804 pts (6.8%) were incorrectly coded as AHA/ACC HFS A. This is the stage that defines pts at risk for developing HF but who have no identified structural or functional abnormalities. Furthermore, about 26% of the 798 patients assigned Stage A were coded as having symptoms of HF as they were classified as NYHA class II, III, or IV. 2) 3000 of 11,804 (25%) with NYHA II to IV symptoms were incorrectly coded as Stage B which was designed to defined an asymptomatic population with structural heart disease. 3) A small number of pts, 136 (1.2%), with Stage D HF were incorrectly coded as having NYHA class I, II, III symptoms Conclusions: 1) in cardiology practices participating in ADVANCENT in the US, 2 years after publication of the AHA/ACC HFS, 3934 (33%) of this cohort was misclassified, suggesting a poor understanding of the AHA/ACC HFS classification; 2) if the AHA/ACC Stages of HF is considered an important and useful classification scheme for implementation throughout the country, greater efforts at education need to be instituted.

289 Peripartum Cardiomyopathy Outcomes in the Beta-blocker Era Ankie M. Hata,1 Wissam A. Jaber,1 Stuart D. Russell1; 1Cardiology, Duke University Medical Center, Durham, NC Introduction: Peripartum cardiomyopathy (PPCM) is a form of heart failure (CHF) that develops in the last month of pregnancy or within five months of delivery in patients without pre-existing CHF. Prior studies have shown that a large proportion of patients fail to recover to a normal ejection fraction (EF) (60–80%) and that the mortality is high (7–50%). However, these earlier studies were small and pre-dated current advances in CHF therapy. Given advances in medical therapy, improved survival and recovery may occur. Clinical experience suggests that if signs of recovery are seen within two months of diagnosis, there is a greater chance of full recovery of cardiac function. The objectives of this study are to demonstrate the outcome of patients with PPCM in the contemporary era and to determine predictors of poor outcome in this group. Methods: Patients with PPCM at Duke University Medical Center from 1990 to 2004 were identified through screening of CHF clinics and echocardiography records. Patients who fulfilled the four criteria of PPCM were included. Exclusion criteria were diagnosis before 1990, known pre-pregnancy cardiac disease, history of toxic exposures, and other co-morbid illnesses. Data were obtained by chart review. Results: 54 patients were identified. Follow-up was 43 months. The mean age was 35 (SD 6). The mean initial EF was 20% (SD 8). Compared to their initial EF, 62% of patients improved, 25% were unchanged, and 13% worsened. Of the patients who worsened, none died and 5 patients required transplant. At 2 months after diagnosis, 75% of patients who eventually recovered had an EF ⬎45% whereas 0% of those who did not recover had EF’s ⬎35% (p ⫽ 0.0005). Patients who were transplanted were younger than those who did not require transplant (mean age 21 vs 29, respectively, p ⫽ 0.001). African American women were less likely to recover to a normal EF than white women (31% vs 64%, respectively, p ⫽ 0.04). Recovery was not associated with timing of symptoms around pregnancy, hypertension, initial EF, or diabetes. Once patients recovered, discontinuation of CHF medications was not associated with decompensation. Conclusions To our knowledge, this is the largest clinical experience of PPCM reported. This study demonstrates several important features of this disease. First, the morbidity related to PPCM is less than previously reported, and in our study, EF at 2 months was predictive of who would recover full cardiac function. Second, African American race was associated with a worse prognosis. Third, transplanted patients were younger. Finally, discontinuation of heart failure medications did not impede recovery.

291 Anemia and Survival in Patients with Heart Failure and Preserved Systolic Function G. Michael Felker,1 Linda K. Shaw,1 Wendy A. Gattis,1 Christopher M. O’Connor1; 1 Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Durham, NC Background: Anemia has been shown to be associated with increased mortality in patients with heart failure due to impaired left ventricular systolic function (ISF). Although heart failure with preserved systolic function (PSF) accounts for up to 50% of heart failure cases, the relationship between anemia and outcomes in patients with heart failure and PSF has not been evaluated. Methods: Patients undergoing diagnostic angiography from 1995 to 2003 with symptomatic heart failure (NYHA class II or greater) were studied (N ⫽ 4905). Patients with recent MI, severe valvular disease, or congenital heart disease were excluded. Patients with EF ⱕ 0.40 were considered the ISF group and patient with EF ⬎ 0.40 were classified as the PSF group. Anemia was defined using the WHO definition (Hb ⬍ 13g/dl for men and ⬍12 g/dl for women). Multivariable Cox proportional hazards models were used to assess the impact of anemia on mortality and to adjust for baseline differences. The possibility of a differential effect of anemia by systolic function was tested using an interaction term in the multivariable model. Results: Anemia was independently associated with increased mortality across the study cohort (adjusted hazard ratio ⫽ 1.67, p ⬍ 0.0001), and patients with ISF had a worse prognosis that those with PSF (adjusted hazard ratio⫽1.56, p ⬍ 0.0001). The adjusted hazard ratio for anemia was 1.59 for PSF patients and 1.76 for ISF patients, a risk that was not significantly different between the 2 groups as measured by the interaction term (p ⫽ 0.36). Conclusions: Anemia is an independent predictor of mortality in heart failure, and has a similar impact on mortality regardless of whether patients have preserved or impaired LV systolic function. This is the first report of an association between anemia and increased mortality in patients with heart failure and PSF. Future investigations of therapies for anemia in heart failure should consider including patients with PSF.