- Email: [email protected]
The prognostic value of serum chemistries in decompensated heart failure
68
Journal of Cardiac Failure Vol. 5 No. 3 Suppl. 1 1999
Outcomes 252
253
Neuropsychological Sequelae of Heart Transplant Patients Stephen Phlaum, Thomas J. Donohue; Saint Louis University, St. Louis, MO
Prognostic Value of Lung Function Tests in Patients with Mild to Severe Heart Failure Pompilio Faggiano, 1 Antonio D'Aloia, a Anna Gualeni, t Marco Pagani, 3 Luca Bontempi, a Amerigo Giordano3; ~Cardiology, S.Orsola Hospital, Brescia, Italy, 2Cardiology, Spedali Civili, Brescia, Italy, 3Cardiac Rehabilitation, S. Maugeri Foundation, Gussago, Italy
Objective: To investigate the cognitive abilities of individuals with symptomatic end-stage cardiomyopathy, and evaluate improvement in cognitive abilities associated with improved cardiopulmonary performance following cardiac transplantation. Background: Diffuse cognitive defects are common among patients with a& vanced cardiac failure impacting on quality of life and medical compliance. Reversibility of these defects with correction of the cardiac failure may influence quality of life and patient selection for heart transplantation. Methods: Neuropsychological and psychological measures were obtained from 76 patients who completed preoperative cardiopulmonary and hemodynamic evaluation, and were matched with postoperative data from 25 patients who subsequently underwent orthotopic heart transplantation. Neuropsychological measures included the Wechsler Adult Intelligence Scales (WAIS), Wechsler Memory Scales (WMS), Trail Making Test Parts A & B and the Mini Mental State Exam (MMSE). Psychological measures incorporated the Symptom Check List-90 Revised (SCL-90-R). The Psychological Adjustment to Illness Scale: Self-Report (PAIS-SR) and the Beck Depression and Anxiety Scale (BDI/BAI) Results: Comparison of pre- and post-operative cognitive psychological scores at six months and one year showed significant improvement in the areas of IQ (p=0.008), memory (P=0.001), attention and concentration, depression (p=0.0001), anxiety (p=0.002), psychological distress, and psychosocial adjustment to illness (p-0.013). Conelusinm Data from this study clearly shows these deficits to be reversible on correction of the underlying congestive heart failure. Documentation of a patient's specific cognitive abilities and limitations can provide the information necessary to design alternative teaching strategies based on the patient's cognitive strengths. These tailored teaching strategies should foster independence, compliance, and improve quality of life.
Several abnormalities of pulmonary function have been described in patients (pts) with congestive heart failure (CHF). Particularly, a reduction in forced vital capacity (FVC) and/or in the alveolar-capillary diffusing capacity to carbon monoxide (DLCO) are relatively common in CHF pts and appear to be related to an abnormal hemodynamic profile and a poor exercise capacity. Aim of this study was to evaluate the prognostic value of these parameters in a group of CHF pts. We measured lung function tests (FVC and DLCO were expressed as percentage of predicted value) in 147 pts with mild to severe CHF (NYHA class IMV, mean age 59-+9 yrs, LVEF 23-+7%). Follow-up duration was two years; the combined end-point was death or transplantation. Results: Cox regression analysis showed that FVC% was significantly related to one-year survival, while DLCO% was related to one-year and two-year survival. FVC% was 91+_18% in endpoint free survivors at 12 months, compared to 80-+18% (p<0.005) in the others pts. DLCO% was 75-+22% in one-year survivors compared to 6 6 +_ 18% (p<0.05) in pts dead or transplanted at one-year, and it was 76-+22% versus 67-+ 19% at two-year (p<0.05). According to the value of DLCO%, pts were subdivided in three groups: Group 1 (35 pts) had a DLCO >85%, Group 2 (65 pts) had a DLCO of 61-85% and Group 3 (47) had a DLCO £ 60%: one-year survival was 88%, 66% and 64%, respectively (p<0.05) and two-year survival was 74%, 58% and 45%, respectively (p<0.05). Finally, both FVC and DLCO were significantly correlated with puhnonary artery systolic pressure, pulmonary artery wedge pressure and peak oxygen uptake. In conclusion, in pts with mild to severe heart failure some Iung function tests, such as FVC and DLCO, correlate with the abnormalities of the hemodynamic profile and exercise tolerance and predict one- and two-year outcome.
254
255
Which Heart Failure Patients Respond Best to a Multidisciplinary Disease Management Approach? Barbara J. Riegel, ~ Beverly Carlson, 2 Dale Glaser, 2 Peter Hoagland2; tSchool of Nursing, San Diego State University, San Diego, CA, 2Clinical Research Department, Sharp HealthCare, San Diego, CA
The Prognostic Value of Serum Chemistries in Decompensated Heart Failure Kishore J. Harjai, MehuI Shah, Tansel Turgut, Eduardo Nunez; Ochsner Medical Institutions, New Orleans, LA
Disease management (DM) has been shown to be effective although we remain uncertain regarding which HF patients will benefit most from these types of approaches. The purpose of this study was to identify the characteristics of a HF population in which multidisciplinary DM is most effective. 240 hospitalized HF patients completed the quasi-experimental study. Participants were matched on functional status, comorbidity, and age; half (n=120) were assigned to the intervention and half (n = 120) to the usual care group. The sample was elderly (72.6,SD=11.35 yrs), female (55%), married (48.6%), high school educated, poor, and functionally compromised (43.8% class III). The DM intervention involved nurses, physicians, pharmacists, dieticians, and social workers supporting and educating the patients for 6 months after hospital discharge. Acute care resource use (hospital admissions, length of stay, direct costs [HF and total]) was measured at 6 months. Health-related quality of life (HRQL) (health perceptions, Minnesota Living w/ HF Questionnaire and time trade-off) was measured at baseline and 14 weeks (100.13,SD=26.7 days). Descriptive statistics, ANOVA, mixed-model analyses were used to assess the usefulness of functional status, comorbidity, and age in identifying groups in which the intervention was effective. It was most effective in the class II patients; total costs decreased 68% and HF costs decreased 29% when compared to the class I1 usual care group. Comorbidity (moderate levels) and age (>75 yrs) identified subgroups of responsive class III and IV intervention patients. In class I intervention patients, however, total costs were 288% higher and HF costs increased 14 fold in comparison to class I patients in the usual care group. Overall QOL improved in the class IV intervention patients (F= 10.03, df= 1,17, p=.006) but it worsened in the class I intervention patients (F:6.75, df=l,38, p - . 0 1 ) over time and in comparison to the usual care group. Functional status, comorbidity, and age are useful for identifying subgroups for HF patients in whom a multidisciplinary DM approach can decrease acute care resource use and improve HRQL.
Background: Serum chemistries are routinely measured in patients hospitalized for symptomatic heart failure (HF). However, their prognostic value with regard to clinical outcomes is unclear. Methods: In 563 consecutive hospitalizations for symptomatic HF we sought a correlation between admission serum chemistries [serum levels of sodium, potassium, chloride, carbon dioxide, anion gap, creatinine (Cr), blood urea nitrogen (BUN), and BUN/Cr ratio] and short-term clinical outcomes (i.e. 30 day incidence of readmission for HF, all-cause mortality, and composite end-point of readmission or mortality.) Serum chemistry variables which had a univariate relation (p < 0.10) with the study outcomes were tested in multivariate analysis (after adjustment for age, gender, CAD, ejection fraction, & ACE-inhibitor use) for an association with the outcomes. Results: Patients were a mean age of 69 years; 65% were white, and 55% were male. Known CAD was present in 40%. Death and readmission occurred in 29 and 79 patients respectively. BUN, Cr, and BUN/Cr, but not the other chemistry variables, correlated in univariate analysis with each of the 3 clinical outcomes. Significant multivariate correlates of clinical outcomes are shown in the table.
Clinical Outcome Readmission Death Death or readmission
Correlates
Odds ratio (95% CI)
Cr > 1.5 m ~ d l BUN/Cr BUN/Cr
2.53 (1.46-4.46) 1.10" (1.04-1.15) 1.04" ( 1.004-1.078)
* Represents OR for each 1 unit increase in BUN/Cr ratio
Conclusions: In patients hospitalized for decompensated heart failure, serum chemistries measured at the time of admission have significant, independent, prognostic value with regard to short-term clinical outcomes. Indicators of 'pre-renal' and renal compromise increase the likelihood of poor outcome within 30-days after hospitalization.
Journal of Cardiac Failure Vol. 5 No. 3 Suppl. 1 1999
Outcomes 252
253
Neuropsychological Sequelae of Heart Transplant Patients Stephen Phlaum, Thomas J. Donohue; Saint Louis University, St. Louis, MO
Prognostic Value of Lung Function Tests in Patients with Mild to Severe Heart Failure Pompilio Faggiano, 1 Antonio D'Aloia, a Anna Gualeni, t Marco Pagani, 3 Luca Bontempi, a Amerigo Giordano3; ~Cardiology, S.Orsola Hospital, Brescia, Italy, 2Cardiology, Spedali Civili, Brescia, Italy, 3Cardiac Rehabilitation, S. Maugeri Foundation, Gussago, Italy
Objective: To investigate the cognitive abilities of individuals with symptomatic end-stage cardiomyopathy, and evaluate improvement in cognitive abilities associated with improved cardiopulmonary performance following cardiac transplantation. Background: Diffuse cognitive defects are common among patients with a& vanced cardiac failure impacting on quality of life and medical compliance. Reversibility of these defects with correction of the cardiac failure may influence quality of life and patient selection for heart transplantation. Methods: Neuropsychological and psychological measures were obtained from 76 patients who completed preoperative cardiopulmonary and hemodynamic evaluation, and were matched with postoperative data from 25 patients who subsequently underwent orthotopic heart transplantation. Neuropsychological measures included the Wechsler Adult Intelligence Scales (WAIS), Wechsler Memory Scales (WMS), Trail Making Test Parts A & B and the Mini Mental State Exam (MMSE). Psychological measures incorporated the Symptom Check List-90 Revised (SCL-90-R). The Psychological Adjustment to Illness Scale: Self-Report (PAIS-SR) and the Beck Depression and Anxiety Scale (BDI/BAI) Results: Comparison of pre- and post-operative cognitive psychological scores at six months and one year showed significant improvement in the areas of IQ (p=0.008), memory (P=0.001), attention and concentration, depression (p=0.0001), anxiety (p=0.002), psychological distress, and psychosocial adjustment to illness (p-0.013). Conelusinm Data from this study clearly shows these deficits to be reversible on correction of the underlying congestive heart failure. Documentation of a patient's specific cognitive abilities and limitations can provide the information necessary to design alternative teaching strategies based on the patient's cognitive strengths. These tailored teaching strategies should foster independence, compliance, and improve quality of life.
Several abnormalities of pulmonary function have been described in patients (pts) with congestive heart failure (CHF). Particularly, a reduction in forced vital capacity (FVC) and/or in the alveolar-capillary diffusing capacity to carbon monoxide (DLCO) are relatively common in CHF pts and appear to be related to an abnormal hemodynamic profile and a poor exercise capacity. Aim of this study was to evaluate the prognostic value of these parameters in a group of CHF pts. We measured lung function tests (FVC and DLCO were expressed as percentage of predicted value) in 147 pts with mild to severe CHF (NYHA class IMV, mean age 59-+9 yrs, LVEF 23-+7%). Follow-up duration was two years; the combined end-point was death or transplantation. Results: Cox regression analysis showed that FVC% was significantly related to one-year survival, while DLCO% was related to one-year and two-year survival. FVC% was 91+_18% in endpoint free survivors at 12 months, compared to 80-+18% (p<0.005) in the others pts. DLCO% was 75-+22% in one-year survivors compared to 6 6 +_ 18% (p<0.05) in pts dead or transplanted at one-year, and it was 76-+22% versus 67-+ 19% at two-year (p<0.05). According to the value of DLCO%, pts were subdivided in three groups: Group 1 (35 pts) had a DLCO >85%, Group 2 (65 pts) had a DLCO of 61-85% and Group 3 (47) had a DLCO £ 60%: one-year survival was 88%, 66% and 64%, respectively (p<0.05) and two-year survival was 74%, 58% and 45%, respectively (p<0.05). Finally, both FVC and DLCO were significantly correlated with puhnonary artery systolic pressure, pulmonary artery wedge pressure and peak oxygen uptake. In conclusion, in pts with mild to severe heart failure some Iung function tests, such as FVC and DLCO, correlate with the abnormalities of the hemodynamic profile and exercise tolerance and predict one- and two-year outcome.
254
255
Which Heart Failure Patients Respond Best to a Multidisciplinary Disease Management Approach? Barbara J. Riegel, ~ Beverly Carlson, 2 Dale Glaser, 2 Peter Hoagland2; tSchool of Nursing, San Diego State University, San Diego, CA, 2Clinical Research Department, Sharp HealthCare, San Diego, CA
The Prognostic Value of Serum Chemistries in Decompensated Heart Failure Kishore J. Harjai, MehuI Shah, Tansel Turgut, Eduardo Nunez; Ochsner Medical Institutions, New Orleans, LA
Disease management (DM) has been shown to be effective although we remain uncertain regarding which HF patients will benefit most from these types of approaches. The purpose of this study was to identify the characteristics of a HF population in which multidisciplinary DM is most effective. 240 hospitalized HF patients completed the quasi-experimental study. Participants were matched on functional status, comorbidity, and age; half (n=120) were assigned to the intervention and half (n = 120) to the usual care group. The sample was elderly (72.6,SD=11.35 yrs), female (55%), married (48.6%), high school educated, poor, and functionally compromised (43.8% class III). The DM intervention involved nurses, physicians, pharmacists, dieticians, and social workers supporting and educating the patients for 6 months after hospital discharge. Acute care resource use (hospital admissions, length of stay, direct costs [HF and total]) was measured at 6 months. Health-related quality of life (HRQL) (health perceptions, Minnesota Living w/ HF Questionnaire and time trade-off) was measured at baseline and 14 weeks (100.13,SD=26.7 days). Descriptive statistics, ANOVA, mixed-model analyses were used to assess the usefulness of functional status, comorbidity, and age in identifying groups in which the intervention was effective. It was most effective in the class II patients; total costs decreased 68% and HF costs decreased 29% when compared to the class I1 usual care group. Comorbidity (moderate levels) and age (>75 yrs) identified subgroups of responsive class III and IV intervention patients. In class I intervention patients, however, total costs were 288% higher and HF costs increased 14 fold in comparison to class I patients in the usual care group. Overall QOL improved in the class IV intervention patients (F= 10.03, df= 1,17, p=.006) but it worsened in the class I intervention patients (F:6.75, df=l,38, p - . 0 1 ) over time and in comparison to the usual care group. Functional status, comorbidity, and age are useful for identifying subgroups for HF patients in whom a multidisciplinary DM approach can decrease acute care resource use and improve HRQL.
Background: Serum chemistries are routinely measured in patients hospitalized for symptomatic heart failure (HF). However, their prognostic value with regard to clinical outcomes is unclear. Methods: In 563 consecutive hospitalizations for symptomatic HF we sought a correlation between admission serum chemistries [serum levels of sodium, potassium, chloride, carbon dioxide, anion gap, creatinine (Cr), blood urea nitrogen (BUN), and BUN/Cr ratio] and short-term clinical outcomes (i.e. 30 day incidence of readmission for HF, all-cause mortality, and composite end-point of readmission or mortality.) Serum chemistry variables which had a univariate relation (p < 0.10) with the study outcomes were tested in multivariate analysis (after adjustment for age, gender, CAD, ejection fraction, & ACE-inhibitor use) for an association with the outcomes. Results: Patients were a mean age of 69 years; 65% were white, and 55% were male. Known CAD was present in 40%. Death and readmission occurred in 29 and 79 patients respectively. BUN, Cr, and BUN/Cr, but not the other chemistry variables, correlated in univariate analysis with each of the 3 clinical outcomes. Significant multivariate correlates of clinical outcomes are shown in the table.
Clinical Outcome Readmission Death Death or readmission
Correlates
Odds ratio (95% CI)
Cr > 1.5 m ~ d l BUN/Cr BUN/Cr
2.53 (1.46-4.46) 1.10" (1.04-1.15) 1.04" ( 1.004-1.078)
* Represents OR for each 1 unit increase in BUN/Cr ratio
Conclusions: In patients hospitalized for decompensated heart failure, serum chemistries measured at the time of admission have significant, independent, prognostic value with regard to short-term clinical outcomes. Indicators of 'pre-renal' and renal compromise increase the likelihood of poor outcome within 30-days after hospitalization.