Elevated B-Type Natriuretic Peptide (BNP) in the Absence of Heart Failure Predicts Future Mortality

The 9th Annual Scientific Meeting

311 Misperceptions about Heart Failure: It’s No Wonder Rehospitalization Rates Are High Nancy M. Albert1; 1Nursing Research & Innovation, The Cleveland Clinic Foundation, Cleveland, OH Introduction: Implicit illness beliefs (IB) pts have about HF include cognitive conceptual (knowledge) and perceptual (symptoms/sensations) information. Attributes of conceptual IB are identity (label/meaning), timeline (acute/chronic), consequences (short/long term prognosis), and cure/control (self-care actions to cure/control the illness). In non-HF research, when IB were interpreted as a threat or danger, pts coped by engaging in recommended self-care. Accurate IB attributes may lead to selfcare behavior adherence that could decrease HF exacerbation and rehospitalization. Methods: This prospective one-group study used a stratified (by physician type) random sample of 219 pts (internal medicine, n ⫽ 69 [IM]; cardiologist, n ⫽ 68 [C]; and HF specialist, n ⫽ 82 [HFSp]) to assess the accuracy of conceptual IB, the level of certainty pts had for their IB and predictors of IB accuracy. The Survey of IB in HF tool measured IB; a 14-item valid, reliable Likert scale (range of 1–4; mean score ⱖ 3.0 ⫽ accurate IB). Analysis included descriptive stats, Pearson Product Moment Correlation, ANOVA and Kruskal-Wallis test. Results: Mean age, 65.8 years (SD ⫾ 12.43); mean EF, 26% (SD ⫾ 8.88); mean NYHA FC, 2.01(SD ⫾ .91); 71% were male and 86% were Caucasian. Mean IB score of 2.99 reflected inaccurate IB. Pts had a low level of certainty about IB they scored accurately on; highest mean item score was 3.33 (out of 4). Of the 4 IB attributes, control and consequences were inaccurate (mean scores 2.78 and 2.93, respectively). Identity and timeline were accurate (mean scores 3.04 and 3.06, respectively). Identity beliefs were partially based on an acute episodic model (belief that HF comes and goes; does not believe it can occur silently). Of all IB, the most inaccurate was that fluids should be drunk when thirsty; mean score, 2.65. Pts believed that their lifestyle could make HF worse (mean item score, 3.33) but also believed they could not control HF by behavior (mean item score, 2.94). Age 50–69 years, Caucasian, higher education, higher family income, nonuse of CRT or ICD Tx, ETOH use, and lower NYHA-FC predicted accurate IB scores. By physician type, 36% of IM, 46% of C and 61% of HFSp pts had accurate IB (p ⬍ 0.001). Conclusions: Overall, pts had inaccurate IB. Inaccurate identity attributes (episodic model) plus inaccurate consequence attributes that may not create enough danger or threat to prompt recommended self-care behaviors and inaccurate control attributes might explain self-care nonadherence and fluid and sodium indiscretion that leads to rehospitalization.

312 Signs but Not Symptoms Predict Outcome in Heart Failure with Preserved and Reduced Ejection Fraction: Analysis from the DIG Study Ahmad Y. Al-Hindi1, Craig R. Lee2, J. Herbert Patterson2, Todd A. Schwartz3, Francois M. Alla4, Kirkwood F. Adams1; 1Medicine, University of North Carolina - Chapel Hill, Chapel Hill, NC; 2Pharmacy; 3Biostatistics, University of North Carolina Chapel Hill, Chapel Hill, NC; 4Epidemiology, University of Nancy, Nancy, France Background: Simple clinical characteristics that predict outcome in chronic heart failure (HF) are clinically useful. Summary scores of signs and symptoms have been shown to be associated with adverse outcomes in HF. However, the role of signs versus symptoms in the prediction of future events has not been well investigated. Methods: To study the predictive value of signs, symptoms, and a combined HF score at baseline in HF due to left ventricular dysfunction (LVD ⫽ LVEF ⱕ 45%) or preserved ejection fraction (PEF ⫽ LVEF ⬎ 45%), we performed a retrospective analysis of the risk of death and the combined endpoint of death or hospitalization for HF (Combined EP) in the 7788 patients (Pts) enrolled in the DIG Trial (6800 with LVD; 988 with PEF). Signs of HF consisted of edema by exam, rales, S3 gallop, and JVD. Symptoms were defined as dyspnea on exertion, orthopnea, PND, and edema. Chest X-Ray (CXR) evidence of congestion was also determined. An HF score was computed using signs, symptoms, and CXR results. Mean (⫾SD) length of follow-up was 2.9 ⫾ 1.2 years with vital status available in 99% of Pts. Multivariable modeling of these endpoints adjusted for baseline clinical characteristics including gender, age, estimated glomerular filtration rate, diabetes, previous digoxin use, systolic blood pressure, LVEF, body mass index, and digoxin vs placebo. Results: Presence of signs (p ⱕ 0.001), and symptoms (p ⱕ 0.001) were significant unadjusted predictors of mortality and the Combined EP. HF Score was a significant independent predictor of mortality and the Combined EP (both p ⬍ 0.001). Results of multivariable modeling including these predictors for death and the Combined EP are shown below. Conclusion: Symptoms were not independent predictors of morbidity and mortality in Pts with HF due to LVD or PEF. Signs were independent predictors mortality in LVD and PEF.

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HFSA

S173

management program receiving standard medical therapy including Ace inhibitors and beta blocker medications. Also, the independant effect of anemia on survival has not been well described in a rural indigent population. We sought to describe the prevalence of anemia in such a population and to determine the impact of anemia on survival in patients on standard medical therapy. Methods: The sample included 328 patients with EF ⱕ 40% who enrolled in a heart failure disease management program from 1999 to 2003 in rural South Louisiana. Our database was reviewed and a proportional hazards survival model was estimated. Anemia was defined as a hemoglobin of ⬍12g/dl in females and ⬍13 g/dl in males. Terms considered for inclusion into the model were gender, African-American race, age, ejection fraction (⬍25% vs. 25–40%), QRS duration, NYHA class (III/IV vs I/II), use of beta blockers, and use of ACE inhibitors. Results: The prevalence of anemia in the entire population was 29%. See table for demographics. The final model included age (HR ⫽ 1.04, p ⫽ .023), ejection fraction ⬍25% (HR ⫽ 2.71, p ⫽ .002), African-American race (HR ⫽ 1.21, p ⫽ .576), and anemia (HR ⫽ 2.55, p ⫽ .002, 95% CI 1.40–4.67). There was no significant difference in mean creatinine clearance between the two cohorts.The median annual income was $11,300 for each cohort. Conclusions: Anemia was common in rural indigent systolic heart failure patients followed in a disease managemant model. The anemia cohort contained significantly more African-Americans as compared to the non-anemic cohort. Anemia was strongly associated with mortality in a younger, rural indigent heart failure population, even when patients were enrolled in a disease management program receiving both Ace inhibitors and beta blockers. Demographics of Anemic and Non-Anemic Groups Covariates Mean Age (years) % female % African-American Mean QRS duration (msec) Mean ejection fraction (%) % EF ⬍ 25% NYHA I & II NYHA III & IV % on Ace inhibitors % on Beta blockers

Anemia (n ⫽ 96)

Non Anemia (n ⫽ 232)

p value

59.5 25 41 117.6 26.7 36 66 34 92 92

57.5 31 30 115.2 25.9 41 67 33 93 95

0.146 0.150 0.038 0.531 0.399 0.458 0.342 0.342 0.199 0.402

314 Elevated B-Type Natriuretic Peptide (BNP) in the Absence of Heart Failure Predicts Future Mortality Carrie B. Chapman1, Nancy K. Sweitzer1; 1Heart Failure Program, University of Wisconsin Hospital and Clinics, Madison, WI Introduction: B-type natriuretic peptide (BNP) is a hormone released from the ventricles in response to stretch or pressure elevation, and has gained utility as a test for heart failure (HF). BNP levels may be elevated (⬎100 pg/ml) in conditions other than HF. Elevated BNP is a marker of increased mortality in chronic HF and after myocardial infarction (MI). We hypothesized that elevated BNP would predict poor outcome even in patients without HF or MI. Methods: We performed a retrospective chart review of 400 patients with acute symptoms in whom BNP was measured. A subset of 123 patients was determined not to have heart failure as the etiology of symptoms, using clinical and echocardiographic data. Predictors of elevated BNP and clinically significant outcomes were assessed at 2 years using Chi square analysis. Results: Of 123 non-HF patients identified, 71 had an elevated BNP (⬎100). High and low BNP groups were similar, however patients with histories of atrial fibrillation (afib) or chronic kidney disease were significantly more likely to have an elevated BNP (p ⬍ 0.05). Significant univariate predictors of high BNP at the time of acute presentation were sepsis, afib and other arrhythmias (p ⬍ 0.05) (Table 1). After two years, 54% of the non-HF patients with an elevated BNP had died compared to 29% of patients with a normal BNP (p ⬍ 0.01). All other outcomes, including new HF, were not significantly different (Table 2). Conclusions: Elevated BNP is a strong predictor of mortality, even in patients without evident heart disease. There are multiple conditions which may increase serum BNP other than heart failure. In our small sample size BNP did not predict future development of heart failure or other overt cardiac disease. Clinical Predictors of Elevated BNP Diagnosis Pulmonary Disease (Restrictive, Obstructive, Pneumonia, Effusion, Pulmonary HTN) Sepsis Renal Insufficiency Atrial Fibrillation/Arrythmias

BNP ⬍ 100 pg/ml (N ⫽ 52)

BNP ⬎ 100 pg/ml (N ⫽ 71)

p-value

33 (63%)

47 (66%)

0.753

1 (2%) 3 (6%) 0 (0%)

8 (11%) 9 (13%) 8 (11%)

0.049 0.203 0.012

Outcomes After Two Years

313 What Is the Prevalence and Impact of Anemia on Survival in Indigent Systolic Heart Failure Patients Receiving Standard Medical Therapy? Lee M. Arcement1, Ron Horswell2, Kathy Hebert1; 1Cardiology, Chabert Medical Center, Houma, LA; 2Epidemiology, LSU School of Public Health, New Orleans, LA Background: Previous studies have shown an association between anemia and mortality in patients with heart failure. One question not addressed in these studies is the anemia-mortality relationship within a heart failure population enrolled in a disease

Outcome Death Cardiovascular Endpoints (Atrial Fibrillation, Stroke/TIA, MI, HF) Nursing Home/Hospice Re-Hospitalization

BNP ⬍ 100 pg/ml (N ⫽ 52)

BNP ⬎ 100 pg/ml (N ⫽ 71)

p-value

15 (29%) 8 (15%)

38 (54%) 14 (20%)

0.006 0.536

8 (15%) 24 (46%)

13 (18%) 34 (48%)

0.671 0.841