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The Presence of an S3 Is Associated with an Increased Rate of Adverse Cardiac Events
The 11th Annual Scientific Meeting this study. Results: Left ventricular ejection fraction was significantly increased with spironolactone and furosemide (baseline: 34.3 6 2.8%, spironolactone: 42.5 6 3.2%, furosemide: 43.1 6 3.3%, p ! 0.05) and plasma BNP level was significantly decreased with spironolactone and furosemide (baseline: 197.7 6 48.0 pg/ml, spironolactone: 98.3 6 22.7 pg/ml, furosemide: 78.4 6 14.8 pg/ml, p ! 0.05). On the other hand, serum insulin levels (baseline: 10.3 6 1.0 mU/ml, spironolactone: 5.7 6 0.8 mU/ml, furosemide: 10.9 6 1.2 mU/ml, p ! 0.05) and HOMA-IR (placebo: 2.8 6 0.4, spironolactone: 1.4 6 0.3, furosemide: 3.1 6 0.4, p ! 0.05) were significantly improved with spironolactone compared with baseline and furosemide, while fasting plasma glucose was not changed. Serum TNF-a level was decreased with spironolactone, not furosemide (baseline: 3.55 6 0.35 pg/ml, spironolactone: 2.12 6 0.28 pg/ ml, furosemide: 3.32 6 0.52 pg/ml, p ! 0.05). Conclusions: Spironolactone, not furosemide, improved insulin resistance and decreased serum TNF-a level in patients with CHF.
237 The Presence of an S3 Is Associated with an Increased Rate of Adverse Cardiac Events Alan Maisel1, W. Frank Peacock2, Paul Clopton1, Lori Daniels1, Sean Collins3; 1 Department of Cardiology, VA San Diego Medical Center, San Diego, CA; 2 Department of Emergency Medicine, The Cleveland Clinic, Cleveland, OH; 3 Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH, United Kingdom Introduction: The S3 heart sound has been reported to be a predictor of illness severity in patients presenting with acute decompensated heart failure. We sought to determine 90-day outcomes, associated with the presence of the cardiac S3, in patients presenting to the Emergency Department with acute dyspnea. Methods: Analysis of the multi-center Heard-It study database. This prospective trial enrolled patients presenting to the emergency department with dyspnea and undergoing S3 evaluation by Audicor (Inovise Inc, Portland, OR). A gold standard diagnosis was determined by 2 cardiologists, blinded to the S3 results, who reviewed all available data at the end of hospitalization. The endpoint of this analysis was defined as the composite of 90-day re-hospitalization rates and all cause mortality. Backward stepwise multiple logistic regression tested the prognostic utility of S3, BUN, creatinine, elevated troponin, initial systolic and diastolic BP, BNP O 100pg/ml, age, and gender. Results: There were 1077 eligible patients enrolled in this study. Overall, 589 (55%) were male, 477 (44%) white and 512 (48%) black, and 512 (48%) were older than 65 years. Prior diabetes, HF, and MI was reported by 367 (34%), 465 (43%), and 209 (19%), respectively. The initial BNP was O 100 pg/mL in 523 (49%). Of ECGs performed it was coded as abnormal in 75%, but was interpreted as having diagnostic ischemic findings (ST elevation) in only 2%. Troponin was elevated in only 7%. Of the total population, 452 (42%) received an adjudicated diagnosis of HF. The presence of an ED S3 heart sound was a significant independent predictor of adverse events. Conclusions: The presence of a cardiac S3 is an independent predictor of 90-day cardiac admission or all cause mortality.
HFSA
S143
Logistic Regression to predict 90-day cardiac admission or all cause mortality 95% CI Predictor Presence of S3 BUN BNP O 100pg/ml
p
Odds Ratio
Lower
Upper
0.021 0.006 ! 0.001
1.52 1.01 1.94
1.07 1.00 1.35
2.17 1.02 2.78
238 The Sensitivity and Specificity of the Cardiac S3 in the Emergency Diagnosis of Heart Failure W. Frank Peacock1, Paul Clopton2, Alan Maisel2, Lori Daniels2, Sean Collins3; 1 Department of Emergency Medicine, The Cleveland Clinic, Cleveland, OH; 2 Department of Cardiology, Veterans Affairs San Diego Medical Center, San Diego, CA; 3Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH Introduction: The diagnosis of Heart Failure (HF) in the Emergency Department (ED) is challenging, with error rates as high as 25% reported in contemporary studies. Few tests have high specificity in this environment. Our purpose was to determine the performance characteristics of the S3 heart sound in the ED evaluation of patients presenting with acute dyspnea. Methods: Multicenter prospective study of patients presenting to the ED with a primary complaint of dyspnea. Within 15 minutes of ED arrival, a blinded cardiac S3 was obtained using the Audicor device (Inovise Inc, Portland, OR). Simultaneously, the emergency phyisician indicated their diagnosis using all available data. The performance of the BNP level and S3 were compared to a gold standard final diagnosis adjudicated by 2 cardiologists blinded to the S3, using all data available at the end of hospitalization. Results: 1077 patients met all entry criteria; of these 487 (45%) were female, and (512) 48% black. There were high rates of co-existent disease, with the following reported: asthma 220 (20%), emphysema 296 (28%), diabetes 367 (34%), CHF 465 (43%), MI 209 (19%), and 119 (CVA 11%). Overall, 238 (22%) had an S3 detected, and 523 (49%) had a BNP O 100 pg/mL. A gold standard diagnosis of acute heart failure was diagnosed in 432 (40%). A chest x-ray (CXR), done in 998 (93%), was normal in 216 (22%). The most common CXR sign of HF was cardiomegaly in 398 (40%). Pneumonia and emphysema were found in 86 (9%) and 66 (7%), respectively. A cardiac echo, done in 276 (26%), was read as normal, systolic dysfunction, diastolic dysfunction, and both in 93 (34%), 112 (41%), 30 (11%), 17 (6%), respectively. The sensitivity and specificity of the cardiac S3 for a gold standard heart failure diagnosis, performed at 15 minutes after ED arrival, was 38 and 90%, respectively. This compared to a BNP level O 100 pg/mL, which had a sensitivity and specificity of 98 and 71%, respectively. Conclusions: The cardiac S3, measured within 15 minutes of arrival, is highly specific for the diagnosis of acute heart failure. Its use with BNP testing may improve early diagnostic accuracy in the emergency department.
237 The Presence of an S3 Is Associated with an Increased Rate of Adverse Cardiac Events Alan Maisel1, W. Frank Peacock2, Paul Clopton1, Lori Daniels1, Sean Collins3; 1 Department of Cardiology, VA San Diego Medical Center, San Diego, CA; 2 Department of Emergency Medicine, The Cleveland Clinic, Cleveland, OH; 3 Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH, United Kingdom Introduction: The S3 heart sound has been reported to be a predictor of illness severity in patients presenting with acute decompensated heart failure. We sought to determine 90-day outcomes, associated with the presence of the cardiac S3, in patients presenting to the Emergency Department with acute dyspnea. Methods: Analysis of the multi-center Heard-It study database. This prospective trial enrolled patients presenting to the emergency department with dyspnea and undergoing S3 evaluation by Audicor (Inovise Inc, Portland, OR). A gold standard diagnosis was determined by 2 cardiologists, blinded to the S3 results, who reviewed all available data at the end of hospitalization. The endpoint of this analysis was defined as the composite of 90-day re-hospitalization rates and all cause mortality. Backward stepwise multiple logistic regression tested the prognostic utility of S3, BUN, creatinine, elevated troponin, initial systolic and diastolic BP, BNP O 100pg/ml, age, and gender. Results: There were 1077 eligible patients enrolled in this study. Overall, 589 (55%) were male, 477 (44%) white and 512 (48%) black, and 512 (48%) were older than 65 years. Prior diabetes, HF, and MI was reported by 367 (34%), 465 (43%), and 209 (19%), respectively. The initial BNP was O 100 pg/mL in 523 (49%). Of ECGs performed it was coded as abnormal in 75%, but was interpreted as having diagnostic ischemic findings (ST elevation) in only 2%. Troponin was elevated in only 7%. Of the total population, 452 (42%) received an adjudicated diagnosis of HF. The presence of an ED S3 heart sound was a significant independent predictor of adverse events. Conclusions: The presence of a cardiac S3 is an independent predictor of 90-day cardiac admission or all cause mortality.
HFSA
S143
Logistic Regression to predict 90-day cardiac admission or all cause mortality 95% CI Predictor Presence of S3 BUN BNP O 100pg/ml
p
Odds Ratio
Lower
Upper
0.021 0.006 ! 0.001
1.52 1.01 1.94
1.07 1.00 1.35
2.17 1.02 2.78
238 The Sensitivity and Specificity of the Cardiac S3 in the Emergency Diagnosis of Heart Failure W. Frank Peacock1, Paul Clopton2, Alan Maisel2, Lori Daniels2, Sean Collins3; 1 Department of Emergency Medicine, The Cleveland Clinic, Cleveland, OH; 2 Department of Cardiology, Veterans Affairs San Diego Medical Center, San Diego, CA; 3Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH Introduction: The diagnosis of Heart Failure (HF) in the Emergency Department (ED) is challenging, with error rates as high as 25% reported in contemporary studies. Few tests have high specificity in this environment. Our purpose was to determine the performance characteristics of the S3 heart sound in the ED evaluation of patients presenting with acute dyspnea. Methods: Multicenter prospective study of patients presenting to the ED with a primary complaint of dyspnea. Within 15 minutes of ED arrival, a blinded cardiac S3 was obtained using the Audicor device (Inovise Inc, Portland, OR). Simultaneously, the emergency phyisician indicated their diagnosis using all available data. The performance of the BNP level and S3 were compared to a gold standard final diagnosis adjudicated by 2 cardiologists blinded to the S3, using all data available at the end of hospitalization. Results: 1077 patients met all entry criteria; of these 487 (45%) were female, and (512) 48% black. There were high rates of co-existent disease, with the following reported: asthma 220 (20%), emphysema 296 (28%), diabetes 367 (34%), CHF 465 (43%), MI 209 (19%), and 119 (CVA 11%). Overall, 238 (22%) had an S3 detected, and 523 (49%) had a BNP O 100 pg/mL. A gold standard diagnosis of acute heart failure was diagnosed in 432 (40%). A chest x-ray (CXR), done in 998 (93%), was normal in 216 (22%). The most common CXR sign of HF was cardiomegaly in 398 (40%). Pneumonia and emphysema were found in 86 (9%) and 66 (7%), respectively. A cardiac echo, done in 276 (26%), was read as normal, systolic dysfunction, diastolic dysfunction, and both in 93 (34%), 112 (41%), 30 (11%), 17 (6%), respectively. The sensitivity and specificity of the cardiac S3 for a gold standard heart failure diagnosis, performed at 15 minutes after ED arrival, was 38 and 90%, respectively. This compared to a BNP level O 100 pg/mL, which had a sensitivity and specificity of 98 and 71%, respectively. Conclusions: The cardiac S3, measured within 15 minutes of arrival, is highly specific for the diagnosis of acute heart failure. Its use with BNP testing may improve early diagnostic accuracy in the emergency department.