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Geographic Variation in Trends and Disparities in Cardiovascular Mortality Related to Heart Failure in the United States, 2000-2017
The 23rd Annual Scientific Meeting HFSA 25§3, 34§3, 26§3, 34§4 kg/m2, respectively. Patients met ESC/HFA criteria for ID: serum ferritin <100 mg/L, or ferritin 100-299 mg/L and Tsat <20%. Low Hb for women and men were, <12 g/dL and <13 g/dL, respectively. Area under the receiver operating characteristic curve (AUC) and sensitivity and specificity indices were used to calculate the PPV for pV̇ O2 in identifying HFrEF demonstrating ID+Hb versus patients with no ID+norm Hb. Results: Group differences for age, LVEF, and sex were not significant. The pV̇ O2 indexed to body weight for non-obese no ID+norm Hb (19§6 mL/kg/min) was greater (P<0.0001 vs all) than non-obese ID+Hb, obese ID +Hb, and obese no ID+norm Hb (14§4, 12§2, and 15§5 mL/kg/min, respectively). For ID+Hb patients, pV̇ O2 did not differ between obese and non-obese (P>0.05). A PPV=92% and AUC=0.77 (P<0.0001) was associated with a pV̇ O2 cutoff = 16 mL/kg/ min in separating non-obese ID+Hb from non-obese no ID+norm Hb. A PPV=90% and AUC=0.85 (P<0.0001) was associated with a pV̇ O2 cutoff = 15 mL/kg/min in separating obese ID+Hb from non-obese no ID+norm Hb. The AUC (0.54, P=0.53) was negligible between non-obese ID+Hb and obese no ID+norm Hb. Lastly, the AUC was 0.65 (P=0.04) between obese ID+Hb and obese no ID+norm Hb. Conclusions: For HFrEF with normal Hb and no ID, obesity markedly limits pV̇ O2 to critical levels demonstrated by non-obese patients with ID+Hb. This is an important finding in demonstrating high BMI alone plays a powerful role in impairing pV̇ O2 in HFrEF. Secondary prevention should emphasize weight management therapy for patients with HFrEF.
243 Trends in Place of Cardiovascular Deaths Related to Heart Failure in the United States from 2003-2017 Sarah Chuzi1, Rebecca Molsberry1, Adeboye Ogunseitan1, Haider J. Warraich2, Jane Wilcox1, Kathleen L. Grady1, Clyde W. Yancy1, Sadiya S. Khan1; 1Northwestern University Feinberg School of Medicine, Chicago, IL; 2Duke University Medical Center, Durham, NC Objectives: While most patients would prefer to die at home, the majority of deaths among patients with HF still occur in medical facilities. Increased hospice utilization in the past decade for cardiovascular diseases (CVD) may have contributed to changing national trends in place of death for HF patients. Therefore, we sought to describe the distribution of and trends in location for CVD deaths among patients with HF between 2003 and 2017. Methods: HF-related CVD deaths were ascertained using the multiple cause of death files from the Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research data, which includes the underlying and contributing cause of death from all death certificates in the US. HF-related CVD deaths were identified whereby CVD (International Classification of Diseases, 10thRevision, I00-I78) was listed as underlying cause of death and HF (ICD-10 I50) was listed as contributing cause of death, or HF (ICD-10 I50) was listed as underlying cause of death from January 1, 2003 to December 31, 2017. We performed linear regression with place of death as dependent variable and time as independent variable and calculated odds ratios for sex and race. Findings: We identified 3,888,803 HF-related CVD deaths between 2003 and 2017 with 44% occurring in men, 9% in blacks, and 92% among individuals > age 65 years. From 2003 to 2017, proportion of deaths in hospice facilities and at home increased more than 40fold (0.2% to 8.2%; Ptrend< .001) and 1.5-fold (20.6% to 30.7%; Ptrend< .001), respectively (FIGURE), while modest decreases were noted in the proportion of deaths occurring in medical facilities (43.8% to 30.4%; Ptrend< .001) and nursing homes (31.3% to 26.0%; Ptrend< .001). The rate of increase in proportion of deaths at hospice facilities and at home were similar by sex and race, but odds of dying at home (odds ratio [OR] 1.53 [1.52, 1.54]) or in a hospice facility (OR 1.70 [1.67, 1.73]) versus a medical facility remained higher for whites compared with blacks in 2017. Conclusions: While the majority of patients who die of HF-related CVD are still dying in medical facilities, increases in the proportion of patients dying in hospice facilities and at home may reflect a greater focus on patient-centered care at the end of life. More research is needed to better understand preferred location of death, hospice utilization during home deaths, and disparities in location and preferred place of death among HF patients.
Figure 1. Trends in Location of HF-Related Deaths.
S91
244 Longer-Term Survivors of Light Chain Cardiac Amyloidosis Joseph P. Donnelly, Andrej Gabrovsek, Faiz Anwer, Jason Valent, Christy Samaras, Jerry Estep, W.H. Wilson Tang, Mazen Hanna; Cleveland Clinic Foundation, Cleveland, OH Introduction: Heart failure (HF) due to light chain (AL) cardiac amyloidosis (CA) is often considered to have a bleak prognosis with a median untreated survival of less than 6 months. A prognostic staging system has been developed by the Mayo Clinic utilizing NT-proBNP, troponin T, and the difference in free light chains (dFLC). Median survival of the two most advanced stages are 14 months for stage III, and 5.8 months for Stage IV. Advances in anti-plasma cell therapies have improved patient survival, most notably combination therapy using proteasome inhibitors (PI). We describe patients who presented with AL-CA at our institution who have survived for at least 3 years. Methods: This is a retrospective review of patients with AL-CA seen between July 1997 and March 2016 at the Cleveland Clinic. Diagnosis of AL-CA was established via endomyocardial biopsy or extracardiac biopsy plus cardiac imaging in addition to evaluation with cardiac biomarkers. Results: Of 303 patients with AL-CA, 82 (27%) survived for 3 years or longer. Average age at diagnosis for this cohort was 62 §11 years and 61% of patients were male. In patients with available testing for Mayo staging (n = 45), 5 were Stage I, 12 were Stage II, 19 were Stage III, and 9 were Stage IV. 22 patients experienced exceptionally remarkable long-term survival (greater than 94 months). These long-term survivors tended to be younger, with an average age of 58 §11 years, and 68% had multi-organ involvement of AL. Conclusions: AL-CA is an aggressive disease that requires early diagnosis and treatment. More than one quarter of our patient population have a survival greater than 3 years. Of the 82-patient cohort who had survival greater than 3 years, two-thirds of patients who had data available for staging (28/45) presented with advanced Stage III or IV disease. 22 patients (7% of the overall cohort) survived nearly 8 years or more. Patients with AL-CA should be promptly treated with the help of an experienced multidisciplinary team using appropriately selected regimens, as this experience demonstrates that long-term survival can be achieved even for patients who present with more advanced disease.
245 Geographic Variation in Trends and Disparities in Cardiovascular Mortality Related to Heart Failure in the United States, 2000-2017 Peter Glynn, Rebecca Molsberry, Nilay S. Shah, Clyde W. Yancy, Donald M. LloydJones, Mercedes Carnethon, Sadiya S. Khan; Northwestern University, Chicago, IL Introduction: Over the past several decades, significant advances in the management of heart failure (HF) have led to dramatic declines in cardiovascular (CV) mortality among patients with HF. However, it is unknown whether these improvements were consistent across geographic regions. Therefore we sought to describe recent trends in HF-related CV mortality at the regional and state level. Hypothesis: Significant geographic variation exists in trends of HF-related CV mortality and have led to widening disparities. Methods: HF-related CV mortality rates from 2000 to 2017 were determined using the Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research when CVD (I00-I78) was listed as the underlying cause of death and HF (I50) was listed as a contributing cause of death. Mortality rates were age-adjusted using the 2000 US standard population, and ageadjusted mortality rates (AAMR) were examined by census region and by state. Within regions, AAMR were quantified for each race-sex group. We used JoinPoint Regression to identify the inflection point in AAMR trends and linear regression to quantify annual rate of change in AAMR. Results: AAMR for HF-related CV mortality experienced an inflection point in 2011. AAMR declined consistently prior to 2011 and increased between 2011 and 2017 across all 4 regions. Annual increases in AAMR per 100,000 after 2011 were greatest in the Midwest (b=1.14 [95% CI 0.75, 1.53]), indicating an increase of 1.14 deaths per 100,000 per year. In the South annual AAMR increase was 0.96 per 100,000 per year (0.66, 1.26) followed by the West (0.72 [0.05, 1.39]) and Northeast (0.35 [0.03, 0.68]). In each region, HF-related CV AAMR were highest among black men. In addition, the steepest rate of annual change in AAMR occurred in black men (Midwest 2.45 [1.03,3.87], South 3.79 [2.61,4.96], West 3.65 [2.41,4.88], and Northeast 1.29 [0.69,1.90]) from 2011 to 2017. HF-related CV AAMR varied widely for all states (FIGURE) with the greatest burden focused in Mississippi, Utah, and Idaho in 2017. Conclusions: Wide geographic variation exists
S92 Journal of Cardiac Failure Vol. 25 No. 8S August 2019 in HF-related CV mortality rates with highest rates and greatest increases observed in the South and Midwest. Black men in each region have the highest HF-related CV mortality rates and saw the greatest increases between 2011 and 2017. Urgent action is needed to focus public health efforts on modifiable risk exposures in regions and subgroups with greatest burden of HF.
identify and screen 167 potentially eligible publications through the databases. Based on our inclusion and exclusion criteria, 2 studies for a total of 558 patients were included in this analysis: one (1) prospective cohort study and (1) one retrospective cohort study. Conclusion: Non-ischemic cardiomyopathy was the leading cause of heart failure and women are predominantly affected with the caveat of not having any catheterization laboratory in the country as a diagnostic tool. Tailored multilevel interventions are needed to decrease health disparities and help in the diagnosis, classification and management of heart failure in poor resource settings like Haiti.
Incidence and prevalence of HF in studies. n: number of patients (%) Type of study
Country, Region
Malbranche prospective et al study Kwan et al. retrospective study
246 Increased eGFR Variability is Observed in Patients with HFrEF Compared to no HF or HFpEF in the Setting of Chronic Kidney Disease Aaron M. Hein1, Julia J. Scialla1,2, Linda K. Shaw2, Karen Chiswell2, Patrick H. Pun1,2, Robert J. Mentz1,2; 1Duke University Medical Center, Durham, NC; 2Duke Clinical Research Institute, Durham, NC Introduction: Patients with chronic kidney disease (CKD) with increased variability in estimated glomerular filtration rate (eGFR) have increased mortality compared to those with a stable eGFR trend. In those with CKD and heart failure (HF) with reduced (HFrEF) or preserved ejection fraction (HFpEF), who experience distinct hemodynamic and neurohormonal fluctuations, eGFR variability has not been characterized. Understanding of eGFR variability in these patients may help better understand a vulnerable population with poor outcomes. Hypothesis: eGFR variability is increased in patients with CKD and either HFrEF or HFpEF relative to patients without HF, and those with HFrEF will experience the greatest eGFR variability. Methods: A retrospective analysis of the Duke Databank for Cardiovascular Disease included participants with left ventricular ejection fraction (LVEF) data undergoing left heart catheterization from 2003-2013 with an eGFR<60 mL/min/1.73m2 as determined by the CKD-EPI equation. eGFR variability for the subsequent 24-month period was determined as the residual standard deviation (SD) from the regression line of eGFR versus time fit. eGFR variability was calculated for each individual participant who had at least 3 outpatient creatinine values, with any 2 of those outpatient creatinine values at least 3 months apart. HFrEF was defined as LVEF<40% with NYHA class II-IV symptoms, and HFpEF was defined as LVEF>40% with NYHA II-IV symptoms. Patients with no history of HF or NYHA class I symptoms were the comparator group. Associations between eGFR variability, HF phenotype, and pre-selected covariates such as age, race, and sex were analyzed using multivariable regression. Results: 4707 participants met study criteria. The median (IQR) eGFR was 45.5 (33.7, 55.3) mL/min/1.73m2, and a median of 9 (6, 15) eGFR measurements per participant were used to determine variability, resulting in a median residual SD of 6.2 (3.9, 9.2). After adjustment for covariates, the presence of HFrEF (n=1024, 22%) was associated with increased eGFR variability (b=2.03, 95% CI 1.69-2.36, p<.0001) compared to the absence of HF (n=2776, 59%), and with increased variability compared to HFpEF (n=907, 19%) (b=1.73, 95% CI 1.31-2.15, p<.0001). Patients with HFpEF had numerically increased eGFR variability relative to the absence of HF that did not meet the pre-specified threshold for statistical significance (b=0.30, 95% CI -0.05-0.65, p=0.10). Conclusions: In patients with CKD, patients with HFrEF have elevated eGFR variability compared to those without HF and those with HFpEF. Further study to better understand any effects of eGFR variability on clinical outcomes in these HF populations is warranted.
247 Heart Failure, a Growing Global Health Concern: A Systematic Review of the Epidemiology in a Poor Resource Setting Country, Haiti Michel Ibrahim1, Sandrine Lebrun2; 1Boston Medical Center, Boston, MA; 2Lenox Hill Hospital, Boston, NY Background: The epidemiology of HF (Heart Failure) has been extensively researched in the western world, its incidence and prevalence in the developing world has not been well characterized. Haiti is a one of the poorest countries in the western hemisphere and notably with a total 4 cardiologists for a population of 8 million. We report a systematic review of the evidence on the incidence and prevalence of Heart Failure and their etiologies in Haiti over the last 20 years. Our goal is to strengthen current knowledge on the epidemiology of HF in a resource poor setting. This will be helpful in making further recommendations regarding future investigations in the development of a more effective tailored approach to Haiti’s population that can very well serve in other similar settings. Methods: A systematic review in accordance with PRISMA guidelines was performed. The literature search was carried up until January 9, 2018, referring to PubMed, Medline and EMBASE. Results: We could
All Sample Setting subgroups size Male
Port-au-Prince, Urban all Haiti patients Mirebalais, Rural all Haiti patients
247 311
Female
n: 93 (37.7%) n:125 (40.2%)
n:154 (62.4%) n:186 (59.8%)
Outcomes table
Malbranche et al. Kwan et al.
Total patients
Mortality (%)
30 day re-admission
Lost to follow up
247 311
50 (20.2%) 37 (11.2%)
7(2.8%) 18(6.6%)
32 0
248 Characteristics of Incident Heart Failure over 11 Years in Korea: Analysis from National Health Insurance Database Chan Joo Lee1, Jung-Woo Son2, Jinseub Hwang3, Jaewon Oh1, Seok-Min Kang1, Dong-Ju Choi4, Byung-Su Yoo2; 1Yonsei University College of Medicine, Seoul, Republic of Korea; 2Yonsei University, Wonju College of Medicine, Wonju, Republic of Korea; 3Daegu University, Daegu, Republic of Korea; 4Seoul National University College of Medicine, Seongnam, Republic of Korea Background: We assume that the prevalence of HF in Korea as well as western country is increasing because of mainly rapid aging of the population. However, there are limited studies on the prevalence through long-term period. The purpose of this study was to analyze the epidemiology of heart failure and to better understand comorbidities and risk factors in Korea. Methods: The study used data from 2002 to 2014 of the National Health Insurance Service that covers most Korean citizens. Heart failure was defined with International Classification of Diseases 10th revision codes. Primary outcome was composite of all-cause death and re-hospitalization due to heart failure. Multivariable Cox-regression analysis was performed to find the factors affecting the primary outcome. Results: The prevalence of heart failure was 1.42% in 2004 and steadily increased to 1.98% in 2014. From 2004 to 2014, 3,445,256 patients with heart failure occurred. The incidence of heart failure was 6.1/ 1000 person-years in 2004 and remained at similar levels, reaching 5.4/1000 personyears in 2014. In 2014, the prevalence of HF was 7.6% in subjects aged 75 years or older, while it was 7.5% and 3.6% in those aged 65-74 years and 55-64 years, respectively. The nationwide prevalence of HF in subjects aged 75 years or older increased approximately 1.3-fold, from 2002 to 2014. The factors that increase the risk of death and readmission for these patients were age, diabetes, history of MI, cerebral infarction, chronic kidney disease, and chronic liver disease. Conclusion: This study is valuable in that it describes the epidemiology of heart failure using a big-sized Korean national data. Our study shows an increase in the prevalence and provides basic clinical information of HF in Korea during decades.
243 Trends in Place of Cardiovascular Deaths Related to Heart Failure in the United States from 2003-2017 Sarah Chuzi1, Rebecca Molsberry1, Adeboye Ogunseitan1, Haider J. Warraich2, Jane Wilcox1, Kathleen L. Grady1, Clyde W. Yancy1, Sadiya S. Khan1; 1Northwestern University Feinberg School of Medicine, Chicago, IL; 2Duke University Medical Center, Durham, NC Objectives: While most patients would prefer to die at home, the majority of deaths among patients with HF still occur in medical facilities. Increased hospice utilization in the past decade for cardiovascular diseases (CVD) may have contributed to changing national trends in place of death for HF patients. Therefore, we sought to describe the distribution of and trends in location for CVD deaths among patients with HF between 2003 and 2017. Methods: HF-related CVD deaths were ascertained using the multiple cause of death files from the Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research data, which includes the underlying and contributing cause of death from all death certificates in the US. HF-related CVD deaths were identified whereby CVD (International Classification of Diseases, 10thRevision, I00-I78) was listed as underlying cause of death and HF (ICD-10 I50) was listed as contributing cause of death, or HF (ICD-10 I50) was listed as underlying cause of death from January 1, 2003 to December 31, 2017. We performed linear regression with place of death as dependent variable and time as independent variable and calculated odds ratios for sex and race. Findings: We identified 3,888,803 HF-related CVD deaths between 2003 and 2017 with 44% occurring in men, 9% in blacks, and 92% among individuals > age 65 years. From 2003 to 2017, proportion of deaths in hospice facilities and at home increased more than 40fold (0.2% to 8.2%; Ptrend< .001) and 1.5-fold (20.6% to 30.7%; Ptrend< .001), respectively (FIGURE), while modest decreases were noted in the proportion of deaths occurring in medical facilities (43.8% to 30.4%; Ptrend< .001) and nursing homes (31.3% to 26.0%; Ptrend< .001). The rate of increase in proportion of deaths at hospice facilities and at home were similar by sex and race, but odds of dying at home (odds ratio [OR] 1.53 [1.52, 1.54]) or in a hospice facility (OR 1.70 [1.67, 1.73]) versus a medical facility remained higher for whites compared with blacks in 2017. Conclusions: While the majority of patients who die of HF-related CVD are still dying in medical facilities, increases in the proportion of patients dying in hospice facilities and at home may reflect a greater focus on patient-centered care at the end of life. More research is needed to better understand preferred location of death, hospice utilization during home deaths, and disparities in location and preferred place of death among HF patients.
Figure 1. Trends in Location of HF-Related Deaths.
S91
244 Longer-Term Survivors of Light Chain Cardiac Amyloidosis Joseph P. Donnelly, Andrej Gabrovsek, Faiz Anwer, Jason Valent, Christy Samaras, Jerry Estep, W.H. Wilson Tang, Mazen Hanna; Cleveland Clinic Foundation, Cleveland, OH Introduction: Heart failure (HF) due to light chain (AL) cardiac amyloidosis (CA) is often considered to have a bleak prognosis with a median untreated survival of less than 6 months. A prognostic staging system has been developed by the Mayo Clinic utilizing NT-proBNP, troponin T, and the difference in free light chains (dFLC). Median survival of the two most advanced stages are 14 months for stage III, and 5.8 months for Stage IV. Advances in anti-plasma cell therapies have improved patient survival, most notably combination therapy using proteasome inhibitors (PI). We describe patients who presented with AL-CA at our institution who have survived for at least 3 years. Methods: This is a retrospective review of patients with AL-CA seen between July 1997 and March 2016 at the Cleveland Clinic. Diagnosis of AL-CA was established via endomyocardial biopsy or extracardiac biopsy plus cardiac imaging in addition to evaluation with cardiac biomarkers. Results: Of 303 patients with AL-CA, 82 (27%) survived for 3 years or longer. Average age at diagnosis for this cohort was 62 §11 years and 61% of patients were male. In patients with available testing for Mayo staging (n = 45), 5 were Stage I, 12 were Stage II, 19 were Stage III, and 9 were Stage IV. 22 patients experienced exceptionally remarkable long-term survival (greater than 94 months). These long-term survivors tended to be younger, with an average age of 58 §11 years, and 68% had multi-organ involvement of AL. Conclusions: AL-CA is an aggressive disease that requires early diagnosis and treatment. More than one quarter of our patient population have a survival greater than 3 years. Of the 82-patient cohort who had survival greater than 3 years, two-thirds of patients who had data available for staging (28/45) presented with advanced Stage III or IV disease. 22 patients (7% of the overall cohort) survived nearly 8 years or more. Patients with AL-CA should be promptly treated with the help of an experienced multidisciplinary team using appropriately selected regimens, as this experience demonstrates that long-term survival can be achieved even for patients who present with more advanced disease.
245 Geographic Variation in Trends and Disparities in Cardiovascular Mortality Related to Heart Failure in the United States, 2000-2017 Peter Glynn, Rebecca Molsberry, Nilay S. Shah, Clyde W. Yancy, Donald M. LloydJones, Mercedes Carnethon, Sadiya S. Khan; Northwestern University, Chicago, IL Introduction: Over the past several decades, significant advances in the management of heart failure (HF) have led to dramatic declines in cardiovascular (CV) mortality among patients with HF. However, it is unknown whether these improvements were consistent across geographic regions. Therefore we sought to describe recent trends in HF-related CV mortality at the regional and state level. Hypothesis: Significant geographic variation exists in trends of HF-related CV mortality and have led to widening disparities. Methods: HF-related CV mortality rates from 2000 to 2017 were determined using the Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research when CVD (I00-I78) was listed as the underlying cause of death and HF (I50) was listed as a contributing cause of death. Mortality rates were age-adjusted using the 2000 US standard population, and ageadjusted mortality rates (AAMR) were examined by census region and by state. Within regions, AAMR were quantified for each race-sex group. We used JoinPoint Regression to identify the inflection point in AAMR trends and linear regression to quantify annual rate of change in AAMR. Results: AAMR for HF-related CV mortality experienced an inflection point in 2011. AAMR declined consistently prior to 2011 and increased between 2011 and 2017 across all 4 regions. Annual increases in AAMR per 100,000 after 2011 were greatest in the Midwest (b=1.14 [95% CI 0.75, 1.53]), indicating an increase of 1.14 deaths per 100,000 per year. In the South annual AAMR increase was 0.96 per 100,000 per year (0.66, 1.26) followed by the West (0.72 [0.05, 1.39]) and Northeast (0.35 [0.03, 0.68]). In each region, HF-related CV AAMR were highest among black men. In addition, the steepest rate of annual change in AAMR occurred in black men (Midwest 2.45 [1.03,3.87], South 3.79 [2.61,4.96], West 3.65 [2.41,4.88], and Northeast 1.29 [0.69,1.90]) from 2011 to 2017. HF-related CV AAMR varied widely for all states (FIGURE) with the greatest burden focused in Mississippi, Utah, and Idaho in 2017. Conclusions: Wide geographic variation exists
S92 Journal of Cardiac Failure Vol. 25 No. 8S August 2019 in HF-related CV mortality rates with highest rates and greatest increases observed in the South and Midwest. Black men in each region have the highest HF-related CV mortality rates and saw the greatest increases between 2011 and 2017. Urgent action is needed to focus public health efforts on modifiable risk exposures in regions and subgroups with greatest burden of HF.
identify and screen 167 potentially eligible publications through the databases. Based on our inclusion and exclusion criteria, 2 studies for a total of 558 patients were included in this analysis: one (1) prospective cohort study and (1) one retrospective cohort study. Conclusion: Non-ischemic cardiomyopathy was the leading cause of heart failure and women are predominantly affected with the caveat of not having any catheterization laboratory in the country as a diagnostic tool. Tailored multilevel interventions are needed to decrease health disparities and help in the diagnosis, classification and management of heart failure in poor resource settings like Haiti.
Incidence and prevalence of HF in studies. n: number of patients (%) Type of study
Country, Region
Malbranche prospective et al study Kwan et al. retrospective study
246 Increased eGFR Variability is Observed in Patients with HFrEF Compared to no HF or HFpEF in the Setting of Chronic Kidney Disease Aaron M. Hein1, Julia J. Scialla1,2, Linda K. Shaw2, Karen Chiswell2, Patrick H. Pun1,2, Robert J. Mentz1,2; 1Duke University Medical Center, Durham, NC; 2Duke Clinical Research Institute, Durham, NC Introduction: Patients with chronic kidney disease (CKD) with increased variability in estimated glomerular filtration rate (eGFR) have increased mortality compared to those with a stable eGFR trend. In those with CKD and heart failure (HF) with reduced (HFrEF) or preserved ejection fraction (HFpEF), who experience distinct hemodynamic and neurohormonal fluctuations, eGFR variability has not been characterized. Understanding of eGFR variability in these patients may help better understand a vulnerable population with poor outcomes. Hypothesis: eGFR variability is increased in patients with CKD and either HFrEF or HFpEF relative to patients without HF, and those with HFrEF will experience the greatest eGFR variability. Methods: A retrospective analysis of the Duke Databank for Cardiovascular Disease included participants with left ventricular ejection fraction (LVEF) data undergoing left heart catheterization from 2003-2013 with an eGFR<60 mL/min/1.73m2 as determined by the CKD-EPI equation. eGFR variability for the subsequent 24-month period was determined as the residual standard deviation (SD) from the regression line of eGFR versus time fit. eGFR variability was calculated for each individual participant who had at least 3 outpatient creatinine values, with any 2 of those outpatient creatinine values at least 3 months apart. HFrEF was defined as LVEF<40% with NYHA class II-IV symptoms, and HFpEF was defined as LVEF>40% with NYHA II-IV symptoms. Patients with no history of HF or NYHA class I symptoms were the comparator group. Associations between eGFR variability, HF phenotype, and pre-selected covariates such as age, race, and sex were analyzed using multivariable regression. Results: 4707 participants met study criteria. The median (IQR) eGFR was 45.5 (33.7, 55.3) mL/min/1.73m2, and a median of 9 (6, 15) eGFR measurements per participant were used to determine variability, resulting in a median residual SD of 6.2 (3.9, 9.2). After adjustment for covariates, the presence of HFrEF (n=1024, 22%) was associated with increased eGFR variability (b=2.03, 95% CI 1.69-2.36, p<.0001) compared to the absence of HF (n=2776, 59%), and with increased variability compared to HFpEF (n=907, 19%) (b=1.73, 95% CI 1.31-2.15, p<.0001). Patients with HFpEF had numerically increased eGFR variability relative to the absence of HF that did not meet the pre-specified threshold for statistical significance (b=0.30, 95% CI -0.05-0.65, p=0.10). Conclusions: In patients with CKD, patients with HFrEF have elevated eGFR variability compared to those without HF and those with HFpEF. Further study to better understand any effects of eGFR variability on clinical outcomes in these HF populations is warranted.
247 Heart Failure, a Growing Global Health Concern: A Systematic Review of the Epidemiology in a Poor Resource Setting Country, Haiti Michel Ibrahim1, Sandrine Lebrun2; 1Boston Medical Center, Boston, MA; 2Lenox Hill Hospital, Boston, NY Background: The epidemiology of HF (Heart Failure) has been extensively researched in the western world, its incidence and prevalence in the developing world has not been well characterized. Haiti is a one of the poorest countries in the western hemisphere and notably with a total 4 cardiologists for a population of 8 million. We report a systematic review of the evidence on the incidence and prevalence of Heart Failure and their etiologies in Haiti over the last 20 years. Our goal is to strengthen current knowledge on the epidemiology of HF in a resource poor setting. This will be helpful in making further recommendations regarding future investigations in the development of a more effective tailored approach to Haiti’s population that can very well serve in other similar settings. Methods: A systematic review in accordance with PRISMA guidelines was performed. The literature search was carried up until January 9, 2018, referring to PubMed, Medline and EMBASE. Results: We could
All Sample Setting subgroups size Male
Port-au-Prince, Urban all Haiti patients Mirebalais, Rural all Haiti patients
247 311
Female
n: 93 (37.7%) n:125 (40.2%)
n:154 (62.4%) n:186 (59.8%)
Outcomes table
Malbranche et al. Kwan et al.
Total patients
Mortality (%)
30 day re-admission
Lost to follow up
247 311
50 (20.2%) 37 (11.2%)
7(2.8%) 18(6.6%)
32 0
248 Characteristics of Incident Heart Failure over 11 Years in Korea: Analysis from National Health Insurance Database Chan Joo Lee1, Jung-Woo Son2, Jinseub Hwang3, Jaewon Oh1, Seok-Min Kang1, Dong-Ju Choi4, Byung-Su Yoo2; 1Yonsei University College of Medicine, Seoul, Republic of Korea; 2Yonsei University, Wonju College of Medicine, Wonju, Republic of Korea; 3Daegu University, Daegu, Republic of Korea; 4Seoul National University College of Medicine, Seongnam, Republic of Korea Background: We assume that the prevalence of HF in Korea as well as western country is increasing because of mainly rapid aging of the population. However, there are limited studies on the prevalence through long-term period. The purpose of this study was to analyze the epidemiology of heart failure and to better understand comorbidities and risk factors in Korea. Methods: The study used data from 2002 to 2014 of the National Health Insurance Service that covers most Korean citizens. Heart failure was defined with International Classification of Diseases 10th revision codes. Primary outcome was composite of all-cause death and re-hospitalization due to heart failure. Multivariable Cox-regression analysis was performed to find the factors affecting the primary outcome. Results: The prevalence of heart failure was 1.42% in 2004 and steadily increased to 1.98% in 2014. From 2004 to 2014, 3,445,256 patients with heart failure occurred. The incidence of heart failure was 6.1/ 1000 person-years in 2004 and remained at similar levels, reaching 5.4/1000 personyears in 2014. In 2014, the prevalence of HF was 7.6% in subjects aged 75 years or older, while it was 7.5% and 3.6% in those aged 65-74 years and 55-64 years, respectively. The nationwide prevalence of HF in subjects aged 75 years or older increased approximately 1.3-fold, from 2002 to 2014. The factors that increase the risk of death and readmission for these patients were age, diabetes, history of MI, cerebral infarction, chronic kidney disease, and chronic liver disease. Conclusion: This study is valuable in that it describes the epidemiology of heart failure using a big-sized Korean national data. Our study shows an increase in the prevalence and provides basic clinical information of HF in Korea during decades.