Pulmonary Hypertension, Normal Ejection Fraction and Elevated Pulmonary Capillary Wedge Pressure: Idiopathic Pulmonary Arterial Hypertension or Diastolic Heart Failure?

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

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359

Pulmonary Hypertension, Normal Ejection Fraction and Elevated Pulmonary Capillary Wedge Pressure: Idiopathic Pulmonary Arterial Hypertension or Diastolic Heart Failure? Brian P. Shapiro,1 Michael D. McGoon,1 Margaret M. Redfield1; 1Mayo Heart Failure Clinic and Mayo Pulmonary Hypertension Clinic, Mayo Clinic College of Medicine, Rochester, MN

Nesiritide Is Safe for CHF Patients with Renal Insufficiency: Retrospective Results from the Follow up Serial Infusions of Nesiritide (FUSION) Trial Clyde W. Yancy1; 1Department of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX

Background: Left heart disease is the most common cause of pulmonary hypertension (PH). In patients (pts) with PH and no systolic dysfunction or mitral valve disease, an elevated pulmonary capillary wedge pressure (PCWP) may indicate pulmonary veno-occlusive disease (PVOD), that the PH is causing diastolic dysfunction (ventricular interdependence) or that the pt has diastolic heart failure (DHF) with secondary PH. Objective: To determine the prevalence of elevated PCWP among pts considered to have idiopathic pulmonary arterial hypertension (IPAH) and gain insight into the mechanism. Methods: Consecutive pts evaluated at the Mayo PH Clinic who had normal (ⱖ 50%) ejection fraction, no left valve disease and no other etiology for PH who were considered to have IPAH (n ⫽ 218) underwent right heart catheterization. Clinical, hemodynamic and echocardiographic parameters were compared in those with normal PCWP (n ⫽ 156, 51% male) or elevated (ⱖ 15 mmHg) PCWP (n ⫽ 62, 21% male). Results: See table. Pts with elevated PCWP were older, more often female, had less severe symptoms, and had higher systemic systolic and right atrial pressures. Pulmonary systolic pressure tended to be higher while pulmonary arteriolar resistance tended to be lower. The severity of right ventricular (RV) dysfunction (RV index of myocardial performance; RIMP) was similar. Only 1 pt was thought to have PVOD. Conclusions: While diastolic dysfunction secondary to ventricular interdependence may occur in PH, the degree of RV dysfunction was similar in the two groups. The older age, female predominance and higher systemic pressures in the elevated PCWP group is consistent with the clinical profile of pts with DHF. As IPAH is a diagnosis of exclusion, DHF with secondary PH should be considered when PCWP is elevated, particularly in elderly females. We speculate that elderly pts with DHF may be predisposed to PH due to age-related vascular stiffening.

Age (yrs) (%ⱖ65yrs) NYHA class RIMP (RV Index of myocardial performance) PCWP (mmHg) Right atrial P (mmHg) Cardiac index (l/min/m2) Systemic systolic P (mmHg) Pulmonary systolic P (mmHg) Pulmonary arteriolar resistance (Wood units*m2)

High PCWP

Normal PCWP

p value

60 ⫾ 14 (45%) 2.82 ⫾ 0.63 0.66 ⫾ 0.27

48 ⫾ 15 (15%) 3.05 ⫾ 0.70 0.72 ⫾ 0.24

⬍0.0001 0.03 0.19

20 ⫾ 5 16 ⫾ 6 2.38 ⫾ 0.77 144 ⫾ 32 89 ⫾ 19 18.2 ⫾ 9.4

9⫾3 11 ⫾ 7 2.44 ⫾ 0.76 132 ⫾ 21 84 ⫾ 20 20.3 ⫾ 8.8

⬍0.0001 ⬍0.0001 0.58 0.002 0.07 0.13

358 Does the Gender Gap Still Persist after Myocardial Infarction? Treatments and Outcomes in VALIANT E. J. Velazquez,9 M. Moreira,2 J. L. Rouleau,3 K. Swedberg,4 J. Kvasnicka,5 J. A. MarinNeto,6 C. Manes,7 M. A. Pfeffer,8 J. J. V. McMurray1; 1Department of Cardiology, Western Infirmary, Glasgow, United Kingdom; 2Leuven Coordinating Center, Leuven, Belgium; 3Montreal Heart Institute, Montreal, Canada; 4Sahlgrenska University HospitalOstra, Goteborg, Sweden; 5University Hospital, Hradec Kralove, Czech Republic; 6 University of Sao Paulo, Ribeirao Preto, Brazil; 7University G. d’Annunzio-Chieti, Chieti, Italy; 8Brigham and Women’s Hospital, Boston, MA; 9Department of Medicine, Duke University Medical Center/Duke Clinical Research Institute, Durham, NC Purpose: Previously women were shown to receive inferior treatment and have worse outcomes than men after acute myocardial infarction (MI). We examined whether this “gender gap” persists in the VALsartan In Acute myocardial iNfarcTion (VALIANT) trial. Methods: VALIANT enrolled 14,703 patients (31% women) with left ventricular systolic dysfunction (LVSD), heart failure (HF), or both 12 hours to 10 days post-MI (median 4.9 days). The independent effect of gender on all-cause death, cardiovascular (CV) death, or hospitalization for HF and a broader composite CV endpoint (CV death, MI, hospitalization for HF, stroke, or resuscitated sudden death) over the 3 years after randomization was examined using multivariable (MV) modelling. Results: Women were older than men (69.3 yrs vs 62.8 yrs; P ⬍ 0.0001), had more co-morbidity, and less often received standard drug therapy or coronary procedures (Table). Three-year mortality rates were: women 23.2%, men 17.8%. Substantially more women developed HF. CV death or HF hospitalization was: women 34%, men 24%; in the MV model, gender was an independent predictor of this outcome (HR 1.13; 95% CI 1.04–1.22) but not of overall death. Composite CV endpoint rates were: women 38.7%, men 30.1% (HR 1.12; 1.04–1.20). Conclusions: Significant differences in the treatment of men and women persist after MI. The risk for HF remains higher in women and the effect of gender on CV morbidity requires further investigation. Characteristic (%) Killip class ⱖ2 Median LVEF History (%) Angina HF Hypertension Diabetes mellitus Treatment of MI (%) Thrombolysis Primary PCI Beta-blocker Statin

Men (n ⫽ 10,133)

Women (n ⫽ 4570)

P

69.2 34.0

78.1 34.0

⬍0.0001 0.0003

37.9 12.6 49.4 19.9

43.7 19.6 68.3 30.2

⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001

37.8 16.4 71.7 35.3

29.3 11.2 67.4 31.5

⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001

LVEF, left ventricular ejection fraction; HF, heart failure; MI, myocardial infarction; PCI, percutaneous coronary intervention.

Background: There is an unmet need for strategies to reduce hospitalization and improve quality of life for patients (pts) living with advanced congestive heart failure (CHF) who are at high risk for recurrent admission. The FUSION trial evaluated safety, tolerability, and clinical effects of serial outpatient infusions of nesiritide (weekly for 12 wks) in addition to standard care (SC) vs SC alone in high-risk CHF pts. This retrospective analysis evaluates nesiritide plus SC vs SC alone in the subset of FUSION pts with renal insufficiency (RI). Methods: In the open-label FUSION study, 210 pts were randomized to receive SC alone (IV inotropes not restricted) or nesiritide plus SC (nesiritide at 0.005 or 0.010 mcg/kg/min). Before randomization, pts were stratified for risk of morbidity and mortality based on 7 prospectively defined prognostic factors, one of which was baseline serum creatinine (SCr) ⬎ 2mg/ dL. Because creatinine clearance (CrCl) more accurately reflects renal function based on lean body mass, CrCl was calculated from SCr. A retrospective analysis was performed on the subset of 138 pts with RI (defined as highest CrCl ⬍ 60mL/min within 30 days of randomization). Results: Demographics and baseline measures, including SCr levels, were similar between groups. Cardiovascular adverse event rates were not significantly different between SC and nesiritide pts (respectively, any HF, 47% vs 40%; hypotension, 21% vs 27%). Although not significantly different, a smaller percentage of nesiritide pts had worsening renal function (SC vs nesiritide: ⬎ 0.5mg/dL increase in SCr , 44% vs 35%; SCr ⬎ 2.0 mg/dL , 14% vs 7%; and acute renal failure, 9% vs 5%). For SC vs nesiritide pts through week 12, 67% vs 42% had been hospitalized for any reason (p ⫽ 0.010), 35% vs 29% had been hospitalized for CHF (p ⫽ 0.56), and 14.6% vs 8.6% died (Kaplan-Meier estimates, p ⫽ 0.27). Through week 12, significantly fewer nesiritide pts died or were hospitalized (71% SC vs 42% nesiritide, p ⫽ 0.002), and nesiritide pts were alive and out of the hospital a median of 84 days vs 77 days for SC pts (p ⫽ 0.005). Conclusion: Outpatient infusions of nesiritide in pts with advanced CHF and RI are well tolerated. There was no evidence of worsening renal function in pts receiving nesiritide plus SC vs SC alone. Nesiritide added to SC may provide benefits over SC with or without IV inotropes, including fewer deaths and hospitalizations. A blinded, placebo-controlled trial is underway to confirm these findings in CHF pts with RI.

360 Assessment of the Impact of JCAHO-Required Inpatient Heart Failure Education: Evaluation of 1,331 Discharged Patients in a Multi-hospital System Laurie Burns,1 Holly L. Rimmasch,1 Dale G. Renlund,1 Colleen A. Roberts,1 Kismet D. Rasmusson,1 Jill A. Hall,1 Adam B. Wilcox,2 Paul D. Clayton2; 1Department of Cardiology, LDS Hospital, Salt Lake City, UT; 2Department of Medical Informatics, University of Utah School of Medicine, Salt Lake City, UT Background: Among the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) core measures for 2004 is a requirement to provide education to hospitalized heart failure patients. To assess the impact of standardized inpatient heart failure education in a multi-hospital system, the following study was conducted. Methods: In response to the JCAHO requirement, a standardized heart failure curriculum was developed and instituted in a multi-hospital, integrated healthcare delivery system. The curriculum, taught in one-on-one settings by nurses and reinforced by videotapes, facilitates patient understanding of heart failure medications, physical activity, measuring daily body weight, adherence to a low salt and restricted fluid diet, and fosters symptom recognition and response (MAWDS쑕). Assessment of the impact of the curriculum was performed by standardized telephone nurse interviews with patients with a primary diagnosis of heart failure discharged from six large urban hospitals. Results: 1,331 patients were interviewed, most of them (1299) within seven weeks after discharge from the hospital. Some of the patients were interviewed twice (590) within the same time period. Patient self-reported compliance with curriculum-suggested measures were as follows: Table 1. Patient Self Reported Compliance Curriculum Component Medications Activity Weigh Daily Diet and Fluid

Compliance 94% 88% 76% 58%

Interestingly, while the majority of patients (Table 2 were aware of the symptoms that should require urgent or semi-urgent provider follow-up, the telephone nurse interview prompted 29% to seek medical attention earlier than previously contemplated. Table 2. Patient Reported Symptom Awareness Curriculum Component Weight Change Light Headed Swelling

Awareness 76% 89% 98%

Conclusion: Even assuming patient self-reported compliance is accurate, the impact of inpatient heart failure education on patient behavior is sub-optimal. Educational measures beyond JCAHO’s inpatient requirements are needed. Ongoing outpatient educational opportunities are likely needed.