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Predictors of Mortality in African Americans Hospitalized with Systolic Heart Failure
The 13th Annual Scientific Meeting CI 5 1.70-5.71, p50.0002) when both were elevated than either alone. Stratification by both N-ANP and ET-1 better discriminated deaths from WHF as opposed to other causes of death (c50.61; 95% CI 5 0.52-0.70, p!0.0001) than either N-ANP or ET1 level alone. Conclusions: Simultaneous profiling using both N-ANP and ET-1 better predicted different modes of death in HF pts than either N-ANP or ET-1 alone; this strategy might be helpful in selecting pts with higher risk for SD or deaths from WHF to whom more intensive treatments can be targeted.
306 New Heart Failure Score Predicts Outcomes in Heart Failure Patients Konstadina Darsaklis, Sophia Farooki, Viviane Nguyen, Nadia Giannetti; Cardiology, McGill University Health Center - Royal Victoria Hospital, Montreal, QC, Canada Introduction: Heart failure patients are at risk of adverse cardiac events. Because heart failure is a heterogenous disease, a comprehensive assessment of these patients, inclusive of history, physical exam, and laboratory investigations, may best predict adverse outcomes. The McGill Heart Failure Score (MHFS) is a comprehensive assessment comprised of 3 sections (table 1). Items in each section are graded on a scale from 0 (no symptoms) to 3 (severe symptoms). All three sections are summed for a total possible maximum score of 48. Hypothesis: We hypothesize that the MHFS can accurately predict adverse outcomes in heart failure patients at 1 year follow-up. Methods: Patients at the Royal Victoria Hospital’s Heart Failure Clinic were recruited into this prospective observational study. Baseline evaluation included MHFS and NYHA assessment. Primary outcomes recorded at follow-up included i) ER visits !24 hours for CHF, ii) hospital admissions for CHF, iii) death and iv) heart transplant. A total MHFS cutoff of 10 was chosen. Outcomes and NYHA classes in patients above and below the cutoff of 10 were compared. Results: Eighty patients with abnormal ejection fractions were recruited. Forty-four patients had a total score !10. Their mean NYHA class was 1.68 6 0.52 and their average EF was 24.5%. Six out of 44 patients had a primary outcome event. The percentages of patients with adverse events were 2.3%, 4.5%, 6.8%, and 0% for outcomes i through iv, respectively. Thirty-six patients had a total score O10. Their mean NYHA class was 2.11 6 0.52 and their average EF was 29.8%. Seventeen patients out of 36 had a primary outcome event. The percentages of patients with adverse events were 2.8%, 25%, 16.7%, and 2.8% for outcomes i through iv, respectively. There were significantly more patients who had adverse events in the cohort with a total score O10 (p!0.001), despite similar NYHA classes. Conclusion: In heart failure patients, a McGill Heart Failure Score O10 predicts a worse cardiac prognosis, within the next year. This may be a more reliable predictor than NYHA classification at initial evaluation. Further validation in a larger sample size is warranted. The McGill Heart Failure Score History
Physician Evaluation
Laboratory
Dyspnea walking 2m on flat surface Dyspnea climbing 1 flight of stairs Dyspnea lying flat Lack of energy Difficulty completing daily tasks
Adjustment of diuretic (last month) Systolic blood pressure
Urea
Leg edema Pulmonary rales Adjustment of diuretics today
Sodium Albumin Bilirubin
HFSA
(n51172)(P50.924). The mean number of inpatient days was 13.6 (SD527.0) in the exercise training group compared to 15.0 (SD531.4) days in usual care (P50.21). Additional measures of medical resource use, including urgent care visits, outpatient visits and procedures, home IV therapy, skilled nursing and rehabilitative care were similar between groups, with the exception of trends indicating that fewer patients in the exercise training group underwent high-cost inpatient procedures including heart transplant and/or placement of a left ventricular assist device (n544 [3.7%] vs. n531 [2.7%], P50.14). Total direct medical costs were estimated at $50,857 (SD581,488) in the exercise training group and $56,177 (SD592,749) in the usual care group (95% CI for difference: $-12,755 to $1547). Direct cost of exercise training was estimated at $1006 (SD5337): $632 for supervised training and $374 for home-based training. Conclusions: Exercise training had little systematic impact on medical resource use overall, but the cost of exercise training may have been offset through a reduction in high-cost procedures.
308 Predictors of Mortality in African Americans Hospitalized with Systolic Heart Failure Jareer Farah1, Hammam D. Zmily1, Sandip Zalawadiya1, Omaima Ali1, Suleiman Daifallah1, Jalal K. Ghali2; 1Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, MI; 2Cardiology, Detroit Medical Center, Detroit, MI Introduction: Predictors of mortality in systolic heart failure (HF) have not been well characterized in African Americans. Methods: We studied 312 patients hospitalized with systolic HF in urban hospital between Jan and May-2007. Mortality was the primary outcome. We analyzed variables like clinical characteristics, co-morbidities, and laboratory findings. Multi-variate logistic regression analysis was constructed which included all statistically significant variables (p-value # 0.05). Results: The mean age was 61.7 6 16.7. Males were 56.7%. Sixty eight patients (21.8%) died. They were older (70.5 6 16.9 vs 59.3 6 15.9, p50.000), female gender (51.5% vs 41.0%, p50.123), had lower BMI (28.0 6 8.1 vs 30.6 6 8.9, p50.027), lower admission SBP (139.5 6 34.5 vs150.7 6 33.6, p50.016), and admission DBP (80.1 6 18.1 vs 91.4 6 23.1, p50.000). They were more likely to have PVD (16.2% vs 6.6% p50.013), ischemic HF (54.4% vs 37.7%, p50.013), wall motion abnormalities on echocardiogram (47.1% vs 30.7%, p50.012), lower serum calcium on discharge (8.4 6 0.9 vs 8.7 6 0.6 , p5 0.003), to have serum bicarbonate level of O28meq/dl on discharge (48.5% vs 34.0%, p50.029), GFR !60 on discharge (55.9% vs 41.8%, p50.039), had higher MCV on admission (88.7 6 9.9 vs 87.4 6 7.4, p50.233), higher MCV on discharge (89.1 6 9.4 vs 87.6 6 7.2, p50.163) and higher RDW on admission (16.6 6 2.1 vs 15.9 6 2.0, p50.011) and on discharge (16.9 6 2.5 vs 15.7 6 1.9, p50.000). They were less likely to have new onset HF (5.9% vs 16.0%, p50.025), or be discharged on ACEI (52.9% vs 67.2%, p50.030). Multivariate logistic regression analysis for mortality is shown below.
Creatinine
Recent EF
307 Cost of Exercise Training and Its Impact on Medical Resource Use and Costs: Results of HF-ACTION Shelby D. Reed1, David J. Whellan2, Yanhong Li1, Joelle Y. Friedman1, Ileana L. Pina3, Sharon J. Settles1, Linda Davidson-Ray1, Johanna Johnson1, Lawton S. Cooper4, Christopher M. O’Connor1, Kevin A. Schulman1; 1Duke Clinical Research Institute, Durham, NC; 2Thomas Jefferson University, Philadelphia, PA; 3 Case Western Reserve University School of Medicine, Cleveland, OH; 4National Heart Lung and Blood Institute, Bethesda, MD Introduction: HF-ACTION demonstrated modest clinical benefits with exercise training in heart failure patients. Hypothesis: Exercise training reduces medical resource use and direct medical costs. Methods: Between April 2003 and February 2007, HF-ACTION randomized 2331 patients with NYHA Class II-IV heart failure with reduced ejection fraction to usual care plus exercise training, consisting of 36 supervised sessions followed by home-based training, versus usual care alone. Throughout the trial, extensive data on medical resource use and hospital bills were collected to estimate direct medical costs. Intervention-related costs were estimated using patient-level data from the trial, administrative records, and published unit costs. Costs were reported in 2008 US dollars. Counts of hospitalizations and inpatient days were compared using negative binomial regression models. Confidence intervals for cost differences were derived using nonparametric bootstrapping. Results: Mean follow-up was 2.5 years in both groups. There were 2297 hospitalizations in the exercise training group (n51159) and 2332 in the usual care group
S93
Variable Age Presence of diastolic dysfunction Wall motion abnormality Discharge RDW Discharge MCV Discharge serum sodium bicarbonate Discharge Calcium
Odds Ratio
P value
1.04 0.44 1.97 1.36 1.04 2.06 0.65
0.000 0.043 0.033 0.000 0.025 0.022 0.044
Confidence Interval 1.02-1.06 0.20-0.97 1.06-3.68 1.17-1.59 1.01-1.09 1.11-3.83 0.43-0.99
Conclusion: Novel predictors of mortality in African Americans were identified including higher discharge MCV, RDW, serum sodium bicarbonate and lower serum calcium levels. Additional studies are needed to define the role of these factors.
309 Prediction of Congestive Heart Failure as Adverse Outcome of Non-STElevation Myocardial Infarction Lukasz R. Kiljanek, Pramil Cheriyath; Department of Medicine, PinnacleHealth Systems, Harrisburg Hospital, Harrisburg, PA Background: Non ST segment elevation myocardial infarction (NSTEMI) as the initial presentation of coronary artery disease (CAD) often leads to development of congestive heart failure (CHF). The incidence of CHF after NSTEMI is about 4.9 %. Our objective is to create prediction model for developing CHF as an adverse outcome of NSTEMI using Random Forest tool. Methods: The database was collected 20022004 for the CRUSADE registry (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes). Mean age of patients was 61.8 years. Females were 41%, 83% were Caucasians, 30% had diabetes and 22% of the patients had signs of CHF at initial presentation. To analyze the dataset, we used the Random Forest (RF) machine learning algorithm. Results: Mean AUC for the model was 0.95 with sensitivity of 86 %, specificity of 91%, and positive predictive value of 60%
306 New Heart Failure Score Predicts Outcomes in Heart Failure Patients Konstadina Darsaklis, Sophia Farooki, Viviane Nguyen, Nadia Giannetti; Cardiology, McGill University Health Center - Royal Victoria Hospital, Montreal, QC, Canada Introduction: Heart failure patients are at risk of adverse cardiac events. Because heart failure is a heterogenous disease, a comprehensive assessment of these patients, inclusive of history, physical exam, and laboratory investigations, may best predict adverse outcomes. The McGill Heart Failure Score (MHFS) is a comprehensive assessment comprised of 3 sections (table 1). Items in each section are graded on a scale from 0 (no symptoms) to 3 (severe symptoms). All three sections are summed for a total possible maximum score of 48. Hypothesis: We hypothesize that the MHFS can accurately predict adverse outcomes in heart failure patients at 1 year follow-up. Methods: Patients at the Royal Victoria Hospital’s Heart Failure Clinic were recruited into this prospective observational study. Baseline evaluation included MHFS and NYHA assessment. Primary outcomes recorded at follow-up included i) ER visits !24 hours for CHF, ii) hospital admissions for CHF, iii) death and iv) heart transplant. A total MHFS cutoff of 10 was chosen. Outcomes and NYHA classes in patients above and below the cutoff of 10 were compared. Results: Eighty patients with abnormal ejection fractions were recruited. Forty-four patients had a total score !10. Their mean NYHA class was 1.68 6 0.52 and their average EF was 24.5%. Six out of 44 patients had a primary outcome event. The percentages of patients with adverse events were 2.3%, 4.5%, 6.8%, and 0% for outcomes i through iv, respectively. Thirty-six patients had a total score O10. Their mean NYHA class was 2.11 6 0.52 and their average EF was 29.8%. Seventeen patients out of 36 had a primary outcome event. The percentages of patients with adverse events were 2.8%, 25%, 16.7%, and 2.8% for outcomes i through iv, respectively. There were significantly more patients who had adverse events in the cohort with a total score O10 (p!0.001), despite similar NYHA classes. Conclusion: In heart failure patients, a McGill Heart Failure Score O10 predicts a worse cardiac prognosis, within the next year. This may be a more reliable predictor than NYHA classification at initial evaluation. Further validation in a larger sample size is warranted. The McGill Heart Failure Score History
Physician Evaluation
Laboratory
Dyspnea walking 2m on flat surface Dyspnea climbing 1 flight of stairs Dyspnea lying flat Lack of energy Difficulty completing daily tasks
Adjustment of diuretic (last month) Systolic blood pressure
Urea
Leg edema Pulmonary rales Adjustment of diuretics today
Sodium Albumin Bilirubin
HFSA
(n51172)(P50.924). The mean number of inpatient days was 13.6 (SD527.0) in the exercise training group compared to 15.0 (SD531.4) days in usual care (P50.21). Additional measures of medical resource use, including urgent care visits, outpatient visits and procedures, home IV therapy, skilled nursing and rehabilitative care were similar between groups, with the exception of trends indicating that fewer patients in the exercise training group underwent high-cost inpatient procedures including heart transplant and/or placement of a left ventricular assist device (n544 [3.7%] vs. n531 [2.7%], P50.14). Total direct medical costs were estimated at $50,857 (SD581,488) in the exercise training group and $56,177 (SD592,749) in the usual care group (95% CI for difference: $-12,755 to $1547). Direct cost of exercise training was estimated at $1006 (SD5337): $632 for supervised training and $374 for home-based training. Conclusions: Exercise training had little systematic impact on medical resource use overall, but the cost of exercise training may have been offset through a reduction in high-cost procedures.
308 Predictors of Mortality in African Americans Hospitalized with Systolic Heart Failure Jareer Farah1, Hammam D. Zmily1, Sandip Zalawadiya1, Omaima Ali1, Suleiman Daifallah1, Jalal K. Ghali2; 1Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, MI; 2Cardiology, Detroit Medical Center, Detroit, MI Introduction: Predictors of mortality in systolic heart failure (HF) have not been well characterized in African Americans. Methods: We studied 312 patients hospitalized with systolic HF in urban hospital between Jan and May-2007. Mortality was the primary outcome. We analyzed variables like clinical characteristics, co-morbidities, and laboratory findings. Multi-variate logistic regression analysis was constructed which included all statistically significant variables (p-value # 0.05). Results: The mean age was 61.7 6 16.7. Males were 56.7%. Sixty eight patients (21.8%) died. They were older (70.5 6 16.9 vs 59.3 6 15.9, p50.000), female gender (51.5% vs 41.0%, p50.123), had lower BMI (28.0 6 8.1 vs 30.6 6 8.9, p50.027), lower admission SBP (139.5 6 34.5 vs150.7 6 33.6, p50.016), and admission DBP (80.1 6 18.1 vs 91.4 6 23.1, p50.000). They were more likely to have PVD (16.2% vs 6.6% p50.013), ischemic HF (54.4% vs 37.7%, p50.013), wall motion abnormalities on echocardiogram (47.1% vs 30.7%, p50.012), lower serum calcium on discharge (8.4 6 0.9 vs 8.7 6 0.6 , p5 0.003), to have serum bicarbonate level of O28meq/dl on discharge (48.5% vs 34.0%, p50.029), GFR !60 on discharge (55.9% vs 41.8%, p50.039), had higher MCV on admission (88.7 6 9.9 vs 87.4 6 7.4, p50.233), higher MCV on discharge (89.1 6 9.4 vs 87.6 6 7.2, p50.163) and higher RDW on admission (16.6 6 2.1 vs 15.9 6 2.0, p50.011) and on discharge (16.9 6 2.5 vs 15.7 6 1.9, p50.000). They were less likely to have new onset HF (5.9% vs 16.0%, p50.025), or be discharged on ACEI (52.9% vs 67.2%, p50.030). Multivariate logistic regression analysis for mortality is shown below.
Creatinine
Recent EF
307 Cost of Exercise Training and Its Impact on Medical Resource Use and Costs: Results of HF-ACTION Shelby D. Reed1, David J. Whellan2, Yanhong Li1, Joelle Y. Friedman1, Ileana L. Pina3, Sharon J. Settles1, Linda Davidson-Ray1, Johanna Johnson1, Lawton S. Cooper4, Christopher M. O’Connor1, Kevin A. Schulman1; 1Duke Clinical Research Institute, Durham, NC; 2Thomas Jefferson University, Philadelphia, PA; 3 Case Western Reserve University School of Medicine, Cleveland, OH; 4National Heart Lung and Blood Institute, Bethesda, MD Introduction: HF-ACTION demonstrated modest clinical benefits with exercise training in heart failure patients. Hypothesis: Exercise training reduces medical resource use and direct medical costs. Methods: Between April 2003 and February 2007, HF-ACTION randomized 2331 patients with NYHA Class II-IV heart failure with reduced ejection fraction to usual care plus exercise training, consisting of 36 supervised sessions followed by home-based training, versus usual care alone. Throughout the trial, extensive data on medical resource use and hospital bills were collected to estimate direct medical costs. Intervention-related costs were estimated using patient-level data from the trial, administrative records, and published unit costs. Costs were reported in 2008 US dollars. Counts of hospitalizations and inpatient days were compared using negative binomial regression models. Confidence intervals for cost differences were derived using nonparametric bootstrapping. Results: Mean follow-up was 2.5 years in both groups. There were 2297 hospitalizations in the exercise training group (n51159) and 2332 in the usual care group
S93
Variable Age Presence of diastolic dysfunction Wall motion abnormality Discharge RDW Discharge MCV Discharge serum sodium bicarbonate Discharge Calcium
Odds Ratio
P value
1.04 0.44 1.97 1.36 1.04 2.06 0.65
0.000 0.043 0.033 0.000 0.025 0.022 0.044
Confidence Interval 1.02-1.06 0.20-0.97 1.06-3.68 1.17-1.59 1.01-1.09 1.11-3.83 0.43-0.99
Conclusion: Novel predictors of mortality in African Americans were identified including higher discharge MCV, RDW, serum sodium bicarbonate and lower serum calcium levels. Additional studies are needed to define the role of these factors.
309 Prediction of Congestive Heart Failure as Adverse Outcome of Non-STElevation Myocardial Infarction Lukasz R. Kiljanek, Pramil Cheriyath; Department of Medicine, PinnacleHealth Systems, Harrisburg Hospital, Harrisburg, PA Background: Non ST segment elevation myocardial infarction (NSTEMI) as the initial presentation of coronary artery disease (CAD) often leads to development of congestive heart failure (CHF). The incidence of CHF after NSTEMI is about 4.9 %. Our objective is to create prediction model for developing CHF as an adverse outcome of NSTEMI using Random Forest tool. Methods: The database was collected 20022004 for the CRUSADE registry (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes). Mean age of patients was 61.8 years. Females were 41%, 83% were Caucasians, 30% had diabetes and 22% of the patients had signs of CHF at initial presentation. To analyze the dataset, we used the Random Forest (RF) machine learning algorithm. Results: Mean AUC for the model was 0.95 with sensitivity of 86 %, specificity of 91%, and positive predictive value of 60%