Twenty-first century heart failure deaths

S118

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

375 Cardiac Resynchronization Failures: The Lateral Chest X Ray Identifies Patients Who Benefit from a New LV Lead Position Seth J. Worley,1 Douglas C. Gohn,1 Tanya M. Smith1; 1Cardiology, Lancaster Heart Foundation, Lancaster, PA

373 Treatments for Acute Decompensated Heart Failure Have Significant International Variations: An Analysis of the Randomized Interventions with Tezosentan (RITZ-1) Trial John R. Teerlink,1 John G.F. Cleland,2 Barry M. Massie,1 Dan Tzivoni,3 Aline Frey,4 on behalf of the RITZ-1 Investigators; 1Cardiology, San Francisco VAMC/UCSF, San Francisco, CA; 2Cardiology, Castle Hill Hospital, Kingston Upon Hull, United Kingdom; 3Cardiology, Zedek Medical Center, Jerusalem, Israel; 4Actelion Pharmaceuticals LTD, Allschwil, Switzerland Background: Despite its role as a leading cause for hospitalization, no currently available therapy for acute decompensated heart failure (ADHF) has been evaluated in a large international trial, and no therapy has been demonstrated to improve morbidity or mortality. In the absence of clinical trial evidence or guidelines upon which to base therapeutic decisions, regional and international differences in practice can be quite significant. Methods: RITZ-1 was the largest international (9 countries) ADHF trial evaluating the efficacy of the dual receptor endothelin antagonist, tezosentan, enrolling 669 patients admitted with dyspnea at rest or minimal exertion requiring intravenous therapy. All patients met identical inclusion criteria; we investigated regional [USA (n ⫽ 227), European Union (EU; n ⫽ 196), Israel (n ⫽ 246)] differences in the therapies of the ADHF patients enrolled in RITZ-1. Results: There were marked international differences among the baseline therapies of the RITZ-1 patients, with greater use of aspirin, ACEi/ ARB, beta blockers and statins in Israel compared to the other regions. Hydralazine and metolazone were much more frequently used in the US. Intravenous vasoactive therapies also varied greatly among regions (%patients in region treated with drug; EU/ Israel/ US): Nitrates: 26/22/1; Dobutamine: 10/4/9: Dopamine: 4/ 11/3; Milrinone: 0/0/8. In the US centers, positive inotropes were used in 95% of the patients receiving intravenous vasoactive therapy, compared to 35% in EU and 40% in Israel. Conclusions: Despite identical entry criteria, there are marked regional differences in the selection of therapies for patients with ADHF in the RITZ-1 trial. These disparities may be explained by variations in patient characteristics or by the nature of participating centers (transplant/referral in the US vs more community based in other countries), or they may reflect differing attitudes about the utility of treatments. Other studies have also suggested a predilection among US investigators for positive inotropes. Given the multiple studies that suggest increased risk and limited benefit with these agents, there is an imperative need for agents that improve cardiac output without increasing mortality.

374 Twenty-First Century Heart Failure Deaths Jeffrey J. Teuteberg,1 Eldrin F. Lewis,1 Anju Nohria,1 Sui W. Tsang,1 James C. Fang,1 Michael Givertz,1 John A. Jarcho,1 Gilbert H. Mudge,1 Kenneth L. Baughman,1 Lynne W. Stevenson1; 1Medicine, Brigham and Women’s Hospital, Boston, MA Objective: As new therapies for heart failure (HF) delay progression and increase survival, the end stages of HF require redefinition. Methods: Patients followed by the cardiomyopathy (CM) service with an ejection fraction (EF) of less than or equal to 35% who died between1/1/00 and 9/1/03 were analyzed. Results: There were 176 deaths (mean age 60 years, HF duration 5.0 years, in the HF program 1.9 years, hypertension in 37% and diabetes in 38%). Mean EF was 20% and diastolic dimension 6.8 centimeters. HF was ischemic in 55%, of whom 70% had prior bypass. Medications upon last admission included ACE inhibitors or angiotensin blockers in 62%, betablockers in 34%, and loop diuretics in 90% (mean dose: torsemide 228 mg/day, furosemide 171 mg/day). The prevalence of implantable defibrillators was 37% (38% in ischemic CM and 38% in nonischemic CM). In the 6 months prior to death, 92% of the patients were NYHA class III or IV, 72% were hospitalized at least once, 70% had a creatinine ⬎ 2.0, and 52% had a sodium ⬍ 130. As compared to their last known values, the degree of hyponatremia and renal insufficiency were significantly worse in the six months preceding death. Laboratories Sodium (mmol/L) BUN (mg/dL) Creatinine (mg/dL) Hematocrit (%)

Last Known

Worst in past 6 months

p-value

135 62.4 2.3 35.2

128 88.1 3.2 29.9

⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001

There were 78 (44%) deaths in the hospital and 18 (10%) in hospice. During terminal hospitalization (mean 17.1 days, range 1–116), 45% of patients died in intensive care, 60% had been intubated, 15% had and intra-aortic balloon pump, 21% had received dialysis, 47% had received intravenous antibiotics, and an average of 2.5 inotropic agents. Comfort care was initiated on the day of death in 40% and within 2 days or less in 72%. Conclusions: Most deaths in a contemporary HF referral population are preceded by hospitalizations and are heralded by hyponatremia and chronic renal insufficiency in the weeks before death, frequently as severe in patients dying at home as in the hospital. The terminal hospitalization is long, with high intensity interventions and a late focus on comfort measures.

Introduction: Only 60% of patients respond to cardiac resynchronization therapy (CRT) despite successful LV lead placement. Placement of the LV lead on the lateral free wall (LFW) is important to the hemodynamic success of CRT. Placement of the LV lead on the anterior wall may cause hemodynamic deterioration. On lateral CXR (LCXR) the RV lead is located anterior. The LCXR identifies the anterior vs. posterior location of the LV lead relative to the RV lead. Hypothesis: Anterior LV lead placement can be identified on LCXR by measuring the separation between the RV lead and the LV lead. CRT non responders (NR) with anterior LV lead placement will benefit clinically from repositioning of the LV lead more posterior. Methods: An AP and lateral chest x-ray was included in the systematic evaluation of all CRT patients 4 to 6 months post implant. In general, it was noted that patients with posterior lead placement on LCXR responded well where patients with anterior lead placement, close to the RV lead, tended to respond less favorably. Based on our preliminary observations, we compared the RV-LV lead tip separation on LCXR of CRT responders (R) to NR. In 15 CRT NR where the LV lead was in close proximity to the RV it was replaced with a posterior LV lead. Results: The distance between the tips of the RV and LV leads were measured on the LCXR of 15 non-responding CRT patients and compared to R. The RV-LV lead tip separation was ⬍8.0cm for NR and 10.5–13cm for R. In 10 patients, the LV lead arrived anterior near the RV lead despite initial placement in a lateral wall target vein. In 5 patients the LV lead reached the anterior wall through the anterior cardiac vein. All patients underwent placement of a new LV lead more posterior; 8 patients in the same vein, 7 in a new vein. There was no improvement in two NR at 4 months despite 10.5cm RV-LV tip separation on lateral CXR. Thirteen patients improved by at least one CHF class and experienced reduction in creatinine, diuretic dose and or outpatient drug infusion. In 8 patients the clinical response was profound and immediate. Conclusion: The LCXR identifies CRT NR who may benefit from a new (more posterior) LV lead position. The LCXR of NR patients should be reviewed by the implanting physician for LV lead placement. The anterior position of the LV lead as defined by the separation measured between lead tips of the RV and LV lead on lateral CXR is more important than into which vein the lead was placed. Posterior LW lead placement increases the separation seen on lateral CXR and improves the results of resynchronization.

376 Identification of Emergency Department Patients with Decompensated Heart Failure at Low Risk for Adverse Events and Prolonged Hospitalization Deborah B. Diercks,1 J. Douglas Kirk,1 W. Franklin Peacock,2 Jim Edward Weber3; 1 Emergency Medicine, University of California, Davis Medical Center, Sacramento, CA; 2Emergency Medicine, The Cleveland Clinic, Cleveland, OH; 3Emergency Medicine, University of Michigan, Ann Arbor, MI Background: The use of observation units (OU) to manage emergency department (ED) congestive heart failure (CHF) patients (pts) is cost effective for those at low risk for adverse events. However the definition of low risk is ill defined. Objective: To identify CHF pts at low risk for adverse events and therefore suitable for an OU protocol. Methods: Prospective convenience sample of all CHF pts presenting to a tertiary care medical center ED during 2004. Eligible pts had a final ED or inpatient diagnosis of CHF based on billing codes. Low risk was defined as a length of stay ⬍ 24 hours without any composite adverse events (recurrent myocardial infarction, death, or rehospitalization during the 30 day follow-up period). Follow-up was completed by telephone contact and medical record review. Pt demographics and past medical history was based on self-report and medical record review. Electrocardiograms were interpreted by the treating physician for the presence or absence of ischemia or infarction (iECG). A univariate analysis evaluating association with low risk criteria was performed on the following variables: gender, age ⬎ 70, race, insurance status, history of diabetes, hypertension, CHF, renal insufficiency, coronary artery disease, ejection fraction ⬍40%, systolic blood pressure ⬎160 mmHg (SBP ⬎160), no iECG, creatinine ⬍ 2.5 mg/dl, BUN ⬍60 mg/dl, initial normal troponin I (TnI) level, hematocrit ⬎ 30 mg/dl, sodium ⬎136 mEq/dl, no pulmonary edema on chest radiography, and initial pulse oximetry ⬎90%. Significant variables (p ⬍ 0.05) were entered into a multivariate analysis. Only pts with 30 day follow-up or adverse events were included in the analysis. Results: Of 538 potential pts, 499 met the inclusion criteria. The mean age was 61 (SD15), and 233 (46%) were women. There were 133 (27%) defined as low risk. The significant variables from the univariate analysis, SBP ⬎ 160, no iECG, and TnI level, were entered into a multivariate analysis. Independent predictors of low risk were SBP ⬎160 (OR 1.8, 95% CI 1.15-2.7) and a normal initial TnI (OR 14.7, 95% CI 1.9-105). Follow-up was complete in 499/538 pts. No differences were noted between pts with or without follow-up. Conclusion: The initial blood pressure and TnI level can be utilized identify pts at low risk for prolonged hospitalization and adverse events. Early risk stratification will help physicians determine appropriate hospitalization strategies and potentially allow a greater number of pts to benefit from an OU protocol.