Systolic Versus Diastolic Dysfunction in Congestive Heart Failure Patients

S108 Journal of Cardiac Failure Vol. 12 No. 6 Suppl. 2006 354 Systolic Versus Diastolic Dysfunction in Congestive Heart Failure Patients Anuj R. Shah1, Igor Mamkin1, Da-dong Lee2, Jeff Mather2, Francis Kiernan2, Raymond McKay2; 1Internal Medicine, University of Connecticut; Hartford Hospital, Hartford, CT; 2Cardiology, Hartford Hospital, Hartford, CT Background: Ejection Fraction (EF) remains one of the most important predictor and determinant of the natural history of congestive heart failure (CHF) patients. There are few head to head data comparing systolic (EF !50%) versus diastolic (EF O50%) heart failure in real clinical setting. Methods: We evaluated 542 consecutive patients admitted to our large tertiary care center with the diagnoses of CHF exacerbation. The patients with age O18 years were seleced. Clinical, demographic and diagnostic varaibles were compared between patients with EF #50% vs. O50%. In-patient mortality was compared between the two groups. Results: Patients with lower EF (total 112 pateints) were older, more likely to be female, had more incidence of atrial fibrillation, valvular heart disease and acute renal failure. These patients had less incidence of myocardial infarction, revascularization and ischemic heart disease. There were less likely to be on beta-blockers, ACE-inhibitors and digoxin. They had lower mean serum BNP and troponin levels at the time of admissions. They had higher frequency of hospitalization in previous 6 months. They had higher frequency of ICD and Bi-Ventricular pacemakers. (All p values #0.05) Both groups had comparable frequencies of presenting symptoms (dyspnea, fatigue, edema), signs on examination (JVP, S3, S4, rales, murmurs, hepatomegaly, edema), similar incidence of diabetes, anemia, hypertension, stroke, peripheral vascular disease. They had comparable mean BUN, Creatinine, HbA1C, serum cholesterol profiles. They had similar use of ARB, antiarrhythmics, Antiplatelets, cholesterol-lowering medications, diuretics, nitrates, anti-coagulants, Niseritide and pressors. Both groups had similar incidence of pacemakers, Intra-aortic balloon pumps, EP studies, mechanical ventilation, right heart catheterizations and ventricular assist device placements. Both group had comparable in-patient mortality rates. (All p 5 NS). Conclusion: Although patients with systolic and diastolic dysfunctions have different comorbidites, the in-patient mortality remained similar in our single-center experience.

when not performed on day one of the hospitalization, LOS is prolonged suggesting that patient selection occurs during an acute HF hospitalization. Further research is required to evaluate the reliability and validity of MCO administrative databases and their utility for quality assessment and outcomes measurement in device therapy.

356 What Factors Increase Anxiety and Depression in Advanced Heart Failure? Alvina Ter-Galstanyan1, Lorraine S. Evangelista1, Debra K. Moser2, Terry Lennie2, Marla DeJong2, Misook Chung2, Gregg C. Fonarow3; 1School of Nursing, UCLA, LA, CA; 2School of Nursing, UK, Lexington, KY; 3School of Nursing, UPenn, Philadelphia, PA; 4School of Medicine, UCLA, LA, CA Background: For many individuals, the diagnosis of heart failure (HF) provides a great emotional challenge that may lead to anxiety and depression, thus jeopardizing their overall mental health and ultimately may contribute to morbidity and mortality. Further research on determinants of anxiety and depression in this population is needed to provide insight on potential approaches for minimizing anxiety and depression.We examined the incidence of anxiety and depression in a cohort of advanced systolic HF patients and tested the hypothesis that perceived control, financial stability, and emotional support (i.e., presence of someone in whom to confide) is associated with the development of anxiety and depression. Methods: Data were collected from 241 patients from a single HF clinic using the Brief Symptom Inventory-Anxiety, the Patient Health Questionnaire Depression Scale, and the Control Attitude Scale to report anxiety, depression, and perceived control scores, respectively. To measure financial stability and emotional support, patients were asked: 1) how well their household income allowed them to make ends meet, and 2) whether they had someone in whom to confide. Results: Patients were age, 56.7 6 13.0 years, male (70%), Caucasian (70%), retired (75%), and married (81%), NYHA Class III (53.9%) with mean LVEF, 31.2 6 5.4) In all, 38.2% of the patients scored above the normative level for anxiety, and 19.9%, above the normative level for depression. In a multivariate analysis, perceived control (odds ratio [OR] 5 .890; 95% confidence interval [CI] 5 .827 -.957, p 5 .002) and depression (OR 5 1.229; 95% CI 5 1.143e1.321, p ! .001) were independent predictors of anxiety. Perceived control (OR 5 .892; 95% CI 5 .814-.977, p 5 .014), financial stability (OR 5 2.511; 95% CI 5 1.345e4.688, p 5 .004),emotional support (OR 5 .921; 95% CI 5 .873-.972, p 5 .003), and anxiety (OR 5 1.842; 95% CI 5 1.298e2.614, p 5 .001) were independent predictors of depression. Conclusion: Our findings indicate that measures of perceived control, financial stability, and emotional support are associated with anxiety and depression in HF patients. Because patient perceptions of control and financial and emotional support are related to dysphorias known to influence morbidity and mortality, regular assessment of patient concerns and providing access to appropriate services and treatment should be considered.

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355 Biventricular Pacemaker Placement in Clinical Practice: Insights from a Managed Care Organization Database Jason Swindle1, Mark A. Schnitzler1, Zainal Hussain1, Steven Takemoto1, Thomas E. Burroughs1, Paul J. Hauptman1; 1Center for Outcomes Research, Department of Medicine, Saint Louis University School of Medicine, St. Louis, MO Background: The implantation of biventricular pacemakers with ICD (CRT-D) or without (CRT-P) has increased significantly in volume over a short period of time. However, there are scant data available regarding patient selection and peri-procedural risks in non-clinical trial settings. Methods: Using administrative claims data from a large Managed Care Organization (MCO) in a moderately sized Midwestern state, during the period Jan 1, 2003 to Mar 31, 2005, we identified cases using CPT (33224, 33225) and ICD-9 (0.50-0.54) procedure codes to examine (1) the length of stay (LOS) after device implantation and (2) the development of subsequent complications during the index hospitalization using CPT complication, ICD-9 E and other ICD-9 procedure codes such as revision, replacement or removal of lead or device. We attempted to limit the analyses to primary implants by restricting the population to patients who did not have a device code in the prior 30 days. Case finding was also limited by intentional exclusion of all generic pacemaker CPT codes. Results: 124 patients (mean age 70.3 6 12.1 years, 73.4% male) had CRT devices placed. Comorbidities were common including COPD (46.8%), diabetes (43.5%), depression (16.9%) and renal failure (16.1%). Most devices were placed on day 1 (n 5 109, 88%) suggesting that these implantations were elective; mean LOS was 3.04 days versus 11.5 days when the device was placed after the first hospital day. Post procedural device-related complications occurred in 18.5% at a mean of 3.53 days. Conclusions: Identification of CRT device implantation in a MCO administrative database may be limited by miscoding; difficulty distinguishing upgrade from primary implantation; and lack of well defined codes for complications. Most current device recipients appear to have the implantation performed on an elective basis;

B-Type Natriuretic Peptide: A Predictor for Length of Hospital Stay and 180Day Mortality in Patients with Congestive Heart Failure Anjali Bhagra1, Gautam Kumar1, Lekshmi Vaidyanathan2, Chitra J. Varadachari2, Wyatt W. Decker2, Raquel M. Schears2, Latha G. Stead2; 1Internal Medicine, Mayo Clinic, Rochester, MN; 2Emergency Medicine, Mayo Clinic, Rochester, MN Introduction: Measurement of B-type natriuretic peptide (BNP) level may be useful for the identification of high-risk patients presenting to the Emergency department with congestive heart failure (CHF). Hypothesis: Serum BNP is useful to predict hospital length of stay and 180 day mortality after ED presentation for CHF. Methods: Study population: This study was conducted at St Mary’s Hospital, a tertiary care academic medical center, affiliated with Mayo Clinic, in Rochester, MN. It was approved by the Institutional Review Board. The study cohort consisted of 388 consecutive patients who presented with CHF and had serum BNP drawn at the time of ED presentation. Primary end points were length of hospitalization and 180 day mortality. Laboratory analysis: Serum BNP was measured on the Beckman Coulter DXI 800. The assay (Biosite Incorporated) was performed as a 2-site immunoenzymatic sandwich assay. The sample was added to a reaction vessel with mouse monoclonal antihuman BNP antibody-alkaline phosphatase conjugate and paramagnetic particles coated with mouse monoclonal antihuman BNP antibody. (BNP in human plasma binds to the immobilized anti-BNP on the solid phase, while the mouse anti-BNP conjugate reacts specifically with bound BNP). The chemiluminescent substrate Lumi-Phos* 530 was then added to the reaction vessel and light generated by the reaction measured. The light production is directly proportional to the concentration of BNP in the sample. The amount of analyte in the sample is determined from a stored, multi-point calibration curve. Statistical analysis: Correlations of BNP to mortality at 180 days and overall hospital length of stay were performed using JMP software. Results: Serum BNP levels were significantly associated with increased risk of death at 180 days. (Chi-square test, p ! 0.001). This was true for both men and women. The serum BNP showed an overall trend toward significance with regard to increased hospital length of stay (ANOVA, p 5 0.0904). When this was broken down by gender, it appears that it is the men who drive this association (p 5 0.024). The reason for this gender difference remains to be investigated. Conclusion: Higher admission serum BNP correlates with increased 180 day mortality and length of hospitalization in patients presenting with congestive heart failure.