S132 Journal of Cardiac Failure Vol. 12 No. 6 Suppl. 2006 439 The Utility of Impedence Cardiography in Assessment of Hemodynamics in Patients with Left and Right Heart Dysfunction: Fact Versus Fiction Robert L. Scott1, David E. Steidley1, Sergei Shatillo1, Anne-Marie Wenzel1, Jennifer Spadafore1, Francisco A. Arabia; 1Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ Heart failure is a major cause of hospitalizations, morbidity and mortality in the United States. While we have clear guidelines regarding the care and management of left heart dysfunction, there is much less clarity regarding the treatment or much less the surveillance of patients with right heart dysfunction due to pulmonary hypertension. Impedence Cardiography (ICG) has been established as a reliable tool in the measurement of non-invasive cardiac output in patients with left heart failure. Our goal was to assess the efficacy of ICG in the evaluation of patients with pulmonary hypertension and preserved left ventricular function. Methods: We retrospectively evaluated several demographic and clinical variables in 11 patients with either left heart failure (CHF) or right heart dysfunction due to pulmonary hypertension (PH) referred for right heart catheterization. Immediately following the right heart catheterization, an Impedence Cardiography analysis was done using the BIOZ Device by Cardiodynamics. Results: The cardiac output and index measured by right heart catheterization correlated with the ICG cardiac output and cardiac index respectively among both the patients with CHF and PH. Both the BMI and left ventricular ejection fraction was significanlty greater in the PH patients compared to the CHF patients. Also, the systolic pulmonary artery pressure was significantly higher in the PH patients (62 6 18 mmHg) compared to the CHF patients (37 6 12 mmHg) p 5 0.02. Inferences: Given that the Cardiac Output can be a better correlate of pulmonary vascular resistance and response to treatment in pulmonary hypertension patients, perhaps the ICG analysis may provide a non-invasive measure for assessment of response to therapy. Left heart dysfunction(CHF) patients compared to patients with pulmonary hypertension (PH) Patient studied CHF n 5 7 PH n 5 4
BMI
TPG
LVEF
25 6 5 38 6 8*
863 19 6 7*
23 6 9 60 6 12*
TPG 5 Transpulmonary gradient in Wood Units; *depicts p ! 0.05. ICG versus Swan cardiac output and index Swan C.O. Swan C.I. ICG C.O. ICG C.I.
4.7 2.4 4.5 2.5
6 6 6 6
1.4 0.9 1.2 0.7
C.O. 5 cardiac output L/min, C.I. 5 cardiac index L/min/M2.
440 Heart Failure Management among the Advanced Elderly, Age Should Not Be a Factor in Guiding Therapy Robert L. Scott1, David E. Steidley1, Anne-Marie Wenzel1, Lori A. Wood1, Donna L. Durocher1; 1Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, AZ Background: Heart failure is devastating disease that is a major cause of morbidity and mortality in the United States. Despite the fact that the prevalence of heart failure increases with age, the advanced elderly, greater than 84 years of age, are rarely included in most heart failure trials. This is particularly troublesome given that as a society we people are living longer. Furthermore, there is some question as to how well standard heart failure therapy is tolerated among the advanced elderly. Our goal was to define the key clinical and demographic variables among advanced elderly patients with heart failure. Method: In our retrospective analysis we identified a cohort of 47 advanced elderly patients age $ 84 years followed in our heart failure clinic. All included patients had to be seen at least twice in the calendar year. The variables evaluated included: etiology of heart failure, marital status, frequency of in-patient hospitalization for acute decompensated heart failure, serum creatinine, hemoglobin, left and right ventricular dimensions, NYHA class and the utilization of beta-blocker and ACE-inhibitor/ARB therapy. Results: The mean age of our cohort was 87 6 3 years. The mean ejection fraction was 39 6 14% and the mean NYHA class was 2.7 6 0.8. The utilization of beta-blocker and ACE-inhibitor/ARB therapy in our cohort was 75% and 78% respectively. Coronary artery disease (ICM) was the etiology of heart failure in 30 patients, 2 had hypertrophic cardiomyopathy (HCM) and the
remainder had non-ischemic dilated cardiomyopathy (DCM). When we compared the ICM patients with the DCM patients there was more anemia, renal dysfunction and a higher NYHA class among the ICM patients. The ejection fraction among the ACE-Inhibitor/ARB treated patients 39 6 12% was significantly higher compared with the ACE intolerant patients 27 6 12%. The estimated right ventricular systolic pressure was significantly lower among patients treated with beta-blocker therapy (41 6 12 mmHg) compared to those not on beta-blockers (50 6 13 mmHg). Inferences: Our analysis makes the case that standard heart failure therapy should be used in all patients regardless of age. Also, screening for renal dysfunction and anemia is important in elderly patients with coronary artery disease in order to enhance quality of care. Etiology of CHF Among Advanced Elderly
DCM ICM
Creatinine
Hemoglobin
NYHA Class
1.2 6 0.4 1.7 6 0.7*
13.3 6 1.9 12.3 6 1.3*
2.3 6 0.9 2.9 6 0.7*
*denotes p ! 0.05.
441 What Do Heart Failure Patients Expect from Implantable Defibrillators? Garrick C. Stewart1, Joanne Weintraub1, Marc J. Semigran2, Kimberly Brooks1, Janice Camuso1, Sui Tsang1, Susan Anello1, Catherine Eramo1, Viviane Nguyen1, Eldrin F. Lewis1, Anju Nohria1, Akshay S. Desai1, Michael M. Givertz1, Lynne Warner Stevenson1; 1Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA; 2Division of Cardiology, Massachusetts General Hospital, Boston, MA Introduction: Broader indications for implantable cardioverter-defibrillators (ICDs) in primary prevention of sudden death may impact over one million patients with heart failure (HF) though many will die of causes not preventable by ICDs. We examined patient perceptions about the effect of ICDs on survival and circumstances under which defibrillation might be inactivated. Hypothesis: HF patients often overestimate the impact of ICDs on survival. Methods: 104 patients with LVEF ! 35% and symptomatic HF but without prior VT/VF, cardiac arrest, or syncope were chosen from two HF referral centers to approximate the SCD-HeFT population in which ICDs saved 7.2 lives per 100 during 5 years. Consent was obtained prior to a questionnaire which asked patients to estimate the lives saved by ICDs, their own life expectancy, and when they might consider turning off such a device. Results: Of 104 patients, 65% had an ICD, 71% were male, 35% had ischemic disease, 52% had HF O 5yrs, and 37% were NYHA Class III. Mean LVEF was 21%, and peak VO2 14 ml/kg/min. Asked about life expectancy, 51% anticipated living O 10yrs and 26% O 20yrs. As for magnitude of benefit, 54% thought ICDs would save $ 50 lives per 100 over 5 years (Figure), and 52% thought it would save their own life. Expectations were no different between patients with and without ICD. For device inactivation, 75% of ICD recipients knew it could be easily programmed off, compared to 38% without ICD. Despite this, 70% of recipients would keep the ICD on if dying of cancer, 55% would keep it on even if receiving daily shocks, and none would turn the device off for constant dyspnea at rest. Conclusion: HF patients overestimate their own survival and ICD impact. ICD recipients express reluctance to inactivate their device even if faced with lethal illness or debilitating symptoms. HF patient education should include specific discussion about the limitations of ICDs in the primary prevention setting.