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Using automated clinical data to predict mortality of heart failure (HF) patients
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Journal of Cardiac Failure Vol. 10 No. 4 Suppl. 2004
295 Higher not Lower Systolic Blood Pressure is Independently Associated with Improved Survival in Heart Failure Tamara B. Horwich,1 Michele A. Hamilton,1 Gregg C. Fonarow1; 1Division of Cardiology, UCLA Medical Center, Los Angeles, CA Background: Increase in systolic blood pressure (SBP) is independently and incrementally associated with risk of developing of heart failure (HF). The relationship between SBP and prognosis in patients with pre-existing HF has not been systematically investigated. Methods: This study analyzed 1879 systolic HF patients (age 52 ⫾ 13, LVEF 22 ⫾ 7, 60% NYHA IV) referred to a single university center for HF management and heart transplant evaluation between 1983 and 2003. Blood pressure and other hemodynamic variables were prospectively recorded after implementation of HF medical therapy. Patients were analyzed by quartiles of SBP. Results: Patients with higher SBP were older, had significantly higher left ventricular ejection fraction (LVEF) and cardiac index, and lower pulmonary artery and pulmonary capillary wedge pressure (PCW). The higher SBP quartiles were associated with higher sodium, hemoglobin, and total cholesterol levels, history of hypertension and diabetes, and therapy with ACE inhibitor and statins. SBP quartiles were similar in terms of gender, coronary artery disease, BMI, beta-blocker therapy, and levels of TnI, BNP, and Cr. Higher quartiles of SBP were associated with significantly improved 1-yr survival (Figure). The hazard ratio for Q1 (SBP ⬍ 92 mmHg) relative to Q4 (SBP ⬎ 112 mmHg) was 2.48 (95% CI 1.79–3.43). After adjustment for sex, age, coronary artery disease, LVEF, ACE inhibitor use, PCW, and cardiac index, relative risk of death at 1 year per each 10 mmHg increase was 0.80 (p ⬍ 0.0001). Conclusions: Higher not lower SBP is associated with improved HF survival independent of ventricular function, invasive hemodynamic parameters, and other prognostic factors. The optimal, target SBP for HF patients requires further study.
297 Estimating the True Prevalence, Morbidity and Mortality of Peripartum Cardiomyopathy Lisa M. Mielniczuk,1 Davis Darryl,1 Birnie David1; 1Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Introduction: Peripartum cardiomyopathy (PPCM) is a potentially life threatening cardiomyopathy of unknown cause Data from tertiary referral centers have suggested mortality up to 50% however it is likely that these studies suffer from major selection bias. The true population prevalence and mortality from the condition is currently unknown. Objectives: This was a population based study designed to identify the patient demographics, prevalence, morbidity and mortality of PPCM in the United States. Methods: The National Hospital Discharge Survey, a nationally representative sample of discharge records from 1997–2001 was used for analysis. This data set contained information from 1.5 million patient discharges per annum. Results: 83 cases of PPCM were identified representing a prevalence rate of 4.18 cases per 10, 000 live births. The estimated mortality from PPCM was 1-2%. Patients with a discharge diagnosis of PPCM had a significantly greater mean age, 29.32 vs. 27.14 years (p ⫽ 0.005, 95%CI 1.07–3.29); and a greater incidence of hypertensive disorders in pregnancy (39% vs. 5.9%) when compared to national data of all pregnancies for the same time period. A major maternal morbidity index was determined by the coexistent diagnosis of respiratory failure/distress, ventricular tachycardia, cardiac arrest, death, or procedural requirements for any of intubation, invasive hemodynamic monitoring, intra-aortic balloon pump or coronary angiography. The overall prevalence of significant maternal morbidity associated with PPCM was 35%. Conclusions: This is the first population based study of PPCM, with an estimate of 4.18 cases per 10,000 live births in the United States for the years 1997–001. The estimated mortality rate of 1–2% is lower than data from previous cohort studies. Patients with PPCM are significantly older and have a higher incidence of hypertension in pregnancy compared to pregnant women without PPCM.
298 296 Statins Are Associated with Improved Survival in Advanced Heart Failure Irrespective of Total Cholesterol Levels Tamara B. Horwich,1 W. Robb MacLellan,1 Gregg C. Fonarow1; 1Division of Cardiology, UCLA Medical Center, Los Angeles, CA Background: Recent evidence suggests that HMG CoA reductase inhibitors (statins) are associated with improved survival in patients with advanced heart failure (HF) of ischemic and non-ischemic etiologies. The interaction between total cholesterol (TC) levels and statin-associated survival improvements in HF patients has not been well studied. Methods: We analyzed data on 473 patients with systolic HF of multiple etiologies [age 53 ⫾ 12, LVEF 24 ⫾ 7, 49% CAD] seen at a single university center between 2000 and 2003 for HF management and transplant evaluation. TC levels were determined at time of initial referral and medication usage was tracked at initial and follow-up visits. Patients were divided into two groups based on the median TC level of 162 mg/dL (TC162 and TC ⬎ 162). Effects of statin usage on mortality or need for urgent heart transplantation (UTx) were determined for each TC group. Results: Fifty-four percent of patients (n ⫽ 256) were treated with statins. Left ventricular ejection fraction (LVEF) and levels of TC, LDL and HDL cholesterol, and triglycerides were similar in patients who were treated and not treated with statins. Patients on statins were more likely to have CAD, HTN, DM. In the total cohort, statin treatment was associated with a significant 1-year survival advantage compared to patients not on statins (81% vs 67%, HR 0.50 95% CI 0.34 – 0.73, p ⫽ 0.0002). Statin therapy was associated with better 1-year outcomes in patients with TC both above and below the median. One-year survival rates for treated vs untreated patients for TC162 and TC ⬎ 162 were 72% vs 57% and 90% vs 79%, respectively. Univariate and risk- adjusted (sex, age, CAD, LVEF, BMI, HTN, and DM) hazard ratios for death or UTx are depicted in the Figure. Conclusions: Although lower TC is associated with worse prognosis in advanced HF, statins are associated with improved prognosis irrespective of TC levels. Further investigation into mechanisms of statin benefit in HF, as well as prospective trials for confirmation of benefit, are warranted.
Using Automated Clinical Data to Predict Mortality of Heart Failure (HF) Patients Ying Tabak, R.S. Johannes; Research, Cardinal Health, Marlboro, MA Introduction: Research models predicting mortality in HF have not been widely adopted due to the high cost of chart abstraction. A cost effective clinical model is crucial to large-scale implementations of quantitative decision support. Objective: Develop and validate a mortality model based on admission severity using automated laboratory data (LAB) and supplementing with UB92 for demographics, discharge status, and comorbidities. The significance of vital signs (VS) and altered mental status (AMS), which were not automated, was also analyzed. Methods: A model was derived from 23,606 HF discharges (1084 deaths) across 44 hospitals that exported lab data to the Atlas system in 2000–01. Values on admission were used. Levels of LAB and VS were crafted per medical literature and empiric examination. Comobidities were identified using 6th digit ICD-9 coding. Age, sex, LAB, comorbidity, VS & AMS were entered into logistic regressions in sequential blocks. ROC curves assessed predictive accuracy and Bootstrapping validated the model internally. Manually abstracted data (n ⫽ 108,142, 4924 deaths) from 183 hospitals validated the model externally. Results are presented as Odds Ratios & 95% confidence intervals. Results: The median age was 76 (74 ⫾ 13) and mortality was 5.3%. Significant predictors included BUN ⬎70 mg/dl (2.5, 2.0-3.3), albumin ⬍ 2.4 g/dl (2.2, 1.6-2.9), troponin I ⬎ 1 ng/ml or CKMB ⬎ 9 ng/ml (2.2, 1.8–2.7), Na ⬍ 130 mEq/dl (1.7, 1.4–2.1), total bilirubin ⬎ 1.4 mg/dl (1.6, 1.2–1.9), pH arterial⬍7.3 (1.5, 1.2–1.9), creatinine ⬎ 2 mg/ dl (1.3, 1.1–1.6), WBC ⬎10.9k/mm3 (1.2, 1.0–1.4), previous AMI, cancer, and COPD, systolic BP⬍90 mmHg (2.4, 1.9–2.9), pulse ⬎ 119/min (1.6, 1.3–1.9), temperature ⬍ 95 Fº or ⬎ 101 Fº (1.6, 1.3–1.9), and diastolic BP ⬍ 59 mmHg (1.7, 1.4–2.0), and AMS (6.4, 5.0–8.2). The cumulative ROCs for age, LAB, comorbidity, and VS & AMS blocks were .60, .76, .77, and .82 respectively. The final ROCs for the derivative and validation models were .82 & .81 respectively. Conclusions: LAB provides objective precise measures of acute pathophysiological conditions. Variables indicating renal dysfunction, hypoalbumenia, and cardiac ischemia constitute high risk. VS & AMS add significant predictive power to the model and should be automated. Chronic diseases are significant but add little to the model fitting. Pathophysiological variables commonly measured on admission are adequate to generate a parsimonious and clinically plausible model with excellent discrimination. Mainly based on automated clinical data, this model is cost effective to implement on a large-scale for HF disease management and outcome reporting.
Journal of Cardiac Failure Vol. 10 No. 4 Suppl. 2004
295 Higher not Lower Systolic Blood Pressure is Independently Associated with Improved Survival in Heart Failure Tamara B. Horwich,1 Michele A. Hamilton,1 Gregg C. Fonarow1; 1Division of Cardiology, UCLA Medical Center, Los Angeles, CA Background: Increase in systolic blood pressure (SBP) is independently and incrementally associated with risk of developing of heart failure (HF). The relationship between SBP and prognosis in patients with pre-existing HF has not been systematically investigated. Methods: This study analyzed 1879 systolic HF patients (age 52 ⫾ 13, LVEF 22 ⫾ 7, 60% NYHA IV) referred to a single university center for HF management and heart transplant evaluation between 1983 and 2003. Blood pressure and other hemodynamic variables were prospectively recorded after implementation of HF medical therapy. Patients were analyzed by quartiles of SBP. Results: Patients with higher SBP were older, had significantly higher left ventricular ejection fraction (LVEF) and cardiac index, and lower pulmonary artery and pulmonary capillary wedge pressure (PCW). The higher SBP quartiles were associated with higher sodium, hemoglobin, and total cholesterol levels, history of hypertension and diabetes, and therapy with ACE inhibitor and statins. SBP quartiles were similar in terms of gender, coronary artery disease, BMI, beta-blocker therapy, and levels of TnI, BNP, and Cr. Higher quartiles of SBP were associated with significantly improved 1-yr survival (Figure). The hazard ratio for Q1 (SBP ⬍ 92 mmHg) relative to Q4 (SBP ⬎ 112 mmHg) was 2.48 (95% CI 1.79–3.43). After adjustment for sex, age, coronary artery disease, LVEF, ACE inhibitor use, PCW, and cardiac index, relative risk of death at 1 year per each 10 mmHg increase was 0.80 (p ⬍ 0.0001). Conclusions: Higher not lower SBP is associated with improved HF survival independent of ventricular function, invasive hemodynamic parameters, and other prognostic factors. The optimal, target SBP for HF patients requires further study.
297 Estimating the True Prevalence, Morbidity and Mortality of Peripartum Cardiomyopathy Lisa M. Mielniczuk,1 Davis Darryl,1 Birnie David1; 1Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Introduction: Peripartum cardiomyopathy (PPCM) is a potentially life threatening cardiomyopathy of unknown cause Data from tertiary referral centers have suggested mortality up to 50% however it is likely that these studies suffer from major selection bias. The true population prevalence and mortality from the condition is currently unknown. Objectives: This was a population based study designed to identify the patient demographics, prevalence, morbidity and mortality of PPCM in the United States. Methods: The National Hospital Discharge Survey, a nationally representative sample of discharge records from 1997–2001 was used for analysis. This data set contained information from 1.5 million patient discharges per annum. Results: 83 cases of PPCM were identified representing a prevalence rate of 4.18 cases per 10, 000 live births. The estimated mortality from PPCM was 1-2%. Patients with a discharge diagnosis of PPCM had a significantly greater mean age, 29.32 vs. 27.14 years (p ⫽ 0.005, 95%CI 1.07–3.29); and a greater incidence of hypertensive disorders in pregnancy (39% vs. 5.9%) when compared to national data of all pregnancies for the same time period. A major maternal morbidity index was determined by the coexistent diagnosis of respiratory failure/distress, ventricular tachycardia, cardiac arrest, death, or procedural requirements for any of intubation, invasive hemodynamic monitoring, intra-aortic balloon pump or coronary angiography. The overall prevalence of significant maternal morbidity associated with PPCM was 35%. Conclusions: This is the first population based study of PPCM, with an estimate of 4.18 cases per 10,000 live births in the United States for the years 1997–001. The estimated mortality rate of 1–2% is lower than data from previous cohort studies. Patients with PPCM are significantly older and have a higher incidence of hypertension in pregnancy compared to pregnant women without PPCM.
298 296 Statins Are Associated with Improved Survival in Advanced Heart Failure Irrespective of Total Cholesterol Levels Tamara B. Horwich,1 W. Robb MacLellan,1 Gregg C. Fonarow1; 1Division of Cardiology, UCLA Medical Center, Los Angeles, CA Background: Recent evidence suggests that HMG CoA reductase inhibitors (statins) are associated with improved survival in patients with advanced heart failure (HF) of ischemic and non-ischemic etiologies. The interaction between total cholesterol (TC) levels and statin-associated survival improvements in HF patients has not been well studied. Methods: We analyzed data on 473 patients with systolic HF of multiple etiologies [age 53 ⫾ 12, LVEF 24 ⫾ 7, 49% CAD] seen at a single university center between 2000 and 2003 for HF management and transplant evaluation. TC levels were determined at time of initial referral and medication usage was tracked at initial and follow-up visits. Patients were divided into two groups based on the median TC level of 162 mg/dL (TC162 and TC ⬎ 162). Effects of statin usage on mortality or need for urgent heart transplantation (UTx) were determined for each TC group. Results: Fifty-four percent of patients (n ⫽ 256) were treated with statins. Left ventricular ejection fraction (LVEF) and levels of TC, LDL and HDL cholesterol, and triglycerides were similar in patients who were treated and not treated with statins. Patients on statins were more likely to have CAD, HTN, DM. In the total cohort, statin treatment was associated with a significant 1-year survival advantage compared to patients not on statins (81% vs 67%, HR 0.50 95% CI 0.34 – 0.73, p ⫽ 0.0002). Statin therapy was associated with better 1-year outcomes in patients with TC both above and below the median. One-year survival rates for treated vs untreated patients for TC162 and TC ⬎ 162 were 72% vs 57% and 90% vs 79%, respectively. Univariate and risk- adjusted (sex, age, CAD, LVEF, BMI, HTN, and DM) hazard ratios for death or UTx are depicted in the Figure. Conclusions: Although lower TC is associated with worse prognosis in advanced HF, statins are associated with improved prognosis irrespective of TC levels. Further investigation into mechanisms of statin benefit in HF, as well as prospective trials for confirmation of benefit, are warranted.
Using Automated Clinical Data to Predict Mortality of Heart Failure (HF) Patients Ying Tabak, R.S. Johannes; Research, Cardinal Health, Marlboro, MA Introduction: Research models predicting mortality in HF have not been widely adopted due to the high cost of chart abstraction. A cost effective clinical model is crucial to large-scale implementations of quantitative decision support. Objective: Develop and validate a mortality model based on admission severity using automated laboratory data (LAB) and supplementing with UB92 for demographics, discharge status, and comorbidities. The significance of vital signs (VS) and altered mental status (AMS), which were not automated, was also analyzed. Methods: A model was derived from 23,606 HF discharges (1084 deaths) across 44 hospitals that exported lab data to the Atlas system in 2000–01. Values on admission were used. Levels of LAB and VS were crafted per medical literature and empiric examination. Comobidities were identified using 6th digit ICD-9 coding. Age, sex, LAB, comorbidity, VS & AMS were entered into logistic regressions in sequential blocks. ROC curves assessed predictive accuracy and Bootstrapping validated the model internally. Manually abstracted data (n ⫽ 108,142, 4924 deaths) from 183 hospitals validated the model externally. Results are presented as Odds Ratios & 95% confidence intervals. Results: The median age was 76 (74 ⫾ 13) and mortality was 5.3%. Significant predictors included BUN ⬎70 mg/dl (2.5, 2.0-3.3), albumin ⬍ 2.4 g/dl (2.2, 1.6-2.9), troponin I ⬎ 1 ng/ml or CKMB ⬎ 9 ng/ml (2.2, 1.8–2.7), Na ⬍ 130 mEq/dl (1.7, 1.4–2.1), total bilirubin ⬎ 1.4 mg/dl (1.6, 1.2–1.9), pH arterial⬍7.3 (1.5, 1.2–1.9), creatinine ⬎ 2 mg/ dl (1.3, 1.1–1.6), WBC ⬎10.9k/mm3 (1.2, 1.0–1.4), previous AMI, cancer, and COPD, systolic BP⬍90 mmHg (2.4, 1.9–2.9), pulse ⬎ 119/min (1.6, 1.3–1.9), temperature ⬍ 95 Fº or ⬎ 101 Fº (1.6, 1.3–1.9), and diastolic BP ⬍ 59 mmHg (1.7, 1.4–2.0), and AMS (6.4, 5.0–8.2). The cumulative ROCs for age, LAB, comorbidity, and VS & AMS blocks were .60, .76, .77, and .82 respectively. The final ROCs for the derivative and validation models were .82 & .81 respectively. Conclusions: LAB provides objective precise measures of acute pathophysiological conditions. Variables indicating renal dysfunction, hypoalbumenia, and cardiac ischemia constitute high risk. VS & AMS add significant predictive power to the model and should be automated. Chronic diseases are significant but add little to the model fitting. Pathophysiological variables commonly measured on admission are adequate to generate a parsimonious and clinically plausible model with excellent discrimination. Mainly based on automated clinical data, this model is cost effective to implement on a large-scale for HF disease management and outcome reporting.