Renal Function Modulates the ‘Obesity Paradox’ in Heart Failure with Preserved Systolic Function

S86 Journal of Cardiac Failure Vol. 14 No. 6S Suppl. 2008

Outcomes 276

HFPSF mortality (30 and 180 days)

Diastolic Dysfunction (DD) Is a Useful Marker to Risk Stratify Patients with Frequent COPD Exacerbations and Normal Left Ventricular Ejection Fraction (LVEF) Ghassan Abu Said2, Gulshan Sharma3, Enrique Tuero1, Wissam Khalife1, Oscar Paniagua1, Alejandro Barbagelata1; 1Cardiology Dep., University of Texas Medical Branch, Galveston, TX; 2Internal Medicine Dep., University of Texas Medical Branch, Galveston, TX; 3Pulmonary and Critical Care Dep., University of Texas Medical Branch, Galveston, TX Introduction: Chronic Obstructive Pulmonary Disease (COPD) exacerbation is a frequent cause of hospital admissions in the US.COPD may contribute to DD secondarily to a chronic increase in RV volume and pressure, septal shift towards the LV, and increased thoracic pressure causing impaired LV filling.We studied whether DD is a risk factor for increased morbidity in pts with COPD and LVEF O 40 %. Methods: Retrospective review of pts hospitalized with primary discharge diagnosis of COPD exacerbation between 1/2002e12/2007 was done. Pts with acute coronary syndrome,arrhythmia,congenital heart disease,hypertrophic or dilated cardiomyopathy,moderate or severe valvular disease, pneumonia, + blood or sputum cultures, pulmonary embolism,acute renal failure,lung cancer were excluded. DD was defined as reduced E/A ratio and impaired relaxation on transthoracic echocardiogram (TTE). Of 1080 pts hospitalized with COPD exacerbations,549 met the inclusion criteria with LVEF O 40 % .We present below the preliminary results based on review of medical records of 98 pts, 49 with DD and 49 without DD. Results: Our preliminary results showed that pts with DD had increased length of stay (mean 5 4.35 days,95 % CI 3.90e4.80,SD 1.48) as compared to pts without DD (mean 5 3.48 95 % CI 3.03e3.93,SD 1.36) {P! 0.0078}. Patients with DD had more frequent exacerbations within a 2 year period, a mean of 2.4 vs. 1.8 exacerbations as compared to the no DD group (P O 0.05). The odds ratio for O1 day of hospitalization for DD vs. no DD group was 1.39; [95% CI 0.74e2.63]. Table1. Length of Stay in patients hospitalized for COPD exacerbation with and without diastolic dysfunction Diastolic dysfunction No diastolic dysfunction P value 5 Length of Stay (days) 4.35 6 1.77 (n 5 49) 3.48 6 1.34 (n 5 49) Length of Stay-age 4.4 6 2 (n 5 36) 3.5 6 1.3 (n 5 36) adjusted (days)

0.0078 0.029

Conclusions: Our preliminary data showed that COPD pts with DD had longer length of stay and more frequent hospitalization with COPD exacerbation. These findings suggest that DD as surrogate of increased LV filling pressures may contribute to COPD exacerbation and warrant a screening TTE in pts with recurrent COPD exacerbations.

277 Renal Function Modulates the ‘Obesity Paradox’ in Heart Failure with Preserved Systolic Function Scott L. Hummel1, Todd M. Koelling1; 1University of Michigan, Ann Arbor, MI Introduction: Heart failure (HF) mortality decreases as body mass index (BMI) increases, a phenomenon termed the ‘obesity paradox.’ Patients with preserved systolic function HF (HFPSF) are predominantly obese. Renal failure is common in HFPSF and markedly increases the risk of death. Potential interaction effects between the obesity paradox and renal function have not been explored in HFPSF. Hypothesis: Obesity does not decrease mortality in HFPSF patients with overt renal disease. Methods: We used data from the Mid-Michigan GAP-HF study, which tracked 1,500 HFPSF (EF $ 40%) patients admitted to 14 Michigan community hospitals in 2002e2004. We defined obesity as BMI $30 kg/m2 and estimated the MDRD glomerular filtration rate (eGFR). We calculated 30-day and one year EFFECT scores; this validated model uses admission clinical data to predict mortality in HF

Univariable

EFFECT score (per 10 units) MDRD (ml/min/m2) Obesity (BMI $ 30) Hypertension Diabetes Obesity x MDRD

Multivariable

30 day

180 day

30 day

180 day

1.43* (1.31e1.56) .98* (.97-.99) .39* (.25-.60) 1.50 (.95e2.36) .79 (.54e1.15)

1.36* (1.27e1.45) .98* (.97-.99) .38* (.28-.51) 1.32 (.94e1.84) .80 (.62e1.05)

1.37* (1.24e1.52) 1.00 (.99e1.01) 1.35 (.51e3.62) 1.35 (.80e2.27) .85 (.54e1.33) .97y (.94-.99)

1.29* (1.20e1.39) 1.00 (.99e1.01) .85 (.43e1.69) 1.23 (.84e1.80) .86 (.62e1.18) .98y (.97e.99)

*p ! .001, yp ! .04 (OR, 95% CI)

inpatients. We assessed the effects of BMI, eGFR, and the EFFECT score on mortality at 30 and 180 days with logistic regression, controlling for hypertension and diabetes and including a second-order interaction term (obesity x eGFR). Results: The EFFECT model, eGFR, and obesity predicted mortality at 30 and 180 days. The interaction term was statistically significant and improved multivariable model fit. With this term included, 30- and 180-day mortality was significantly lower in obese patients only when eGFR was O30 ml/min/m2. Obesity was more protective as eGFR increased. Conclusions: Renal failure significantly modulated the obesity paradox in a large population of HFPSF patients. Further study is needed to understand the involved mechanisms.

278 The Development of Heart Failure in Diabetic Patients with Preclinical Diastolic Dysfunction: A Population Based Study Aaron M. From1, Margaret M. Redfield1, John C. Burnett1, Horng H. Chen1; 1 Cardiology, Mayo Clinic, Rochester, MN Background: Studies have reported a high prevalence of preclinical diastolic dysfunction among patients with diabetes mellitus (DM). However, there have been few studies to evaluate the outcomes of preclinical diastolic dysfunction in DM. The objective of our study is to determine if there is an association between diastolic dysfunction in DM patients and the subsequent development of heart failure (HF). Methods: We retrospectively identified all DM patients with a tissue Doppler assessment of diastolic function within the Olmsted County, MN population from September 2001 through June 2005. Patients with a diagnosis of HF prior to the echocardiogram were excluded as were patients with severe mitral or aortic valve regurgitation. Diastolic dysfunction was defined as a Doppler mitral E/e’ ratio $ 15 as previously described. The main outcome was the development of HF. Results: Overall, 1924 diabetic patients with a tissue Doppler echocardiographic assessment of diastolic function were identified of which 505 patients (26%) had diastolic dysfunction as defined above. Average time from echocardiogram to HF or latest follow-up was 2.52 6 1.77 years. Using Cox’s proportional hazard modeling we determined that for every 1 unit increase in the mitral E/e’ ratio the hazard of HF increases by 4% (HR 5 1.04, 95% CI 5 1.02e1.05; p ! 0.001) and that diastolic dysfunction was associated with the subsequent development of HF (HR 5 1.76, 95% CI 5 1.40e2.23; p ! 0.001) after adjustment for age, sex, body mass index, hypertension, coronary disease, ejection fraction, left atrial volume and deceleration time. Conclusion: This study confirms that preclinical diastolic dysfunction is prevalent in DM patients. More importantly, we demonstrated that an increase in the E/e’ ratio in DM patients is associated with the subsequent development of HF independent of hypertension, coronary disease or other echocardiographic parameters.

279 Symptom Severity, Attribution and Delay in Seeking Treatment for Heart Failure Kristen A. Sethares1; 1Adult and Child Nursing, University of Massachusetts Dartmouth, North Dartmouth, MA Problem: Self-care of heart failure (HF) requires numerous behavior changes in persons with HF, including actively recognizing, interpreting and treating symptoms. Failure to recognize and properly interpret HF symptoms can lead to delay in seeking treatment, worsened symptoms and ultimately costly hospitalizations. Few studies have explored symptom attribution and severity in relationship to delay in seeking treatment. Purpose: The purpose of this study was to describe symptom severity,