Independent Predictor Of Heart Failure Research Articles

Abstract 16726: Association of Renin-angiotensin System Inhibitors With Reduced Adverse Cardiac Events in Patients With Ischemic Mitral Regurgitation After Acute Myocardial Infarction

Background: Ischemic mitral regurgitation (IMR) portends a poor prognosis during long-term follow-up and has been identified as an independent predictor of heart failure (HF) and reduced long-term survival. Renin-angiotensin system inhibitors (RASI) including angiotensin-converting enzyme inhibitors (ACEI) and angiotensin-receptor blockers (ARB) may improve prognosis in patients with IMR after acute myocardial infarction (AMI). The purpose of this study was to investigate the association of RASI with the incidence of adverse cardiac events in patients with IMR after AMI. Methods: We screened 867 consecutive patients admitted for AMI and underwent emergency coronary angiography between January 2000 and December 2008. A total of 388 patients who were diagnosed to have mild or greater MR evaluated by transthoracic echocardiography within 2 weeks after the onset were enrolled. Results: The mean age was 67±11 years and 297 patients (77%) were men. A total of 297 patients (77%) received RASI before hospital discharge. Patients without RASI were older and more likely to have higher creatinine level compared with patients with RASI. Left ventricular ejection fraction, peak CPK level, prevalence of prior MI were comparable between the two groups. The mean follow-up period was 5.4±3.4 years. During the follow-up, 22 cardiac deaths and 39 HF events occurred. Kaplan-Meier analysis revealed that freedom from cardiac death and HF was significantly higher in patients with RASI than in those without RASI (p<0.001 and p=0.001, respectively). After adjustment with the inverse probability treatment weighting, Cox regression analysis showed a significant beneficial effect of RASI therapy in reducing cardiac death (hazard ratio [HR]: 0.20; p<0.001) and HF (HR: 0.41; p=0.008). Conclusions: RASI was associated with a lower incidence of adverse cardiac events in patients with IMR after AMI.

Echocardiographic Predictors of Heart Failure in Hypertrophic Cardiomyopathy Secondary to Hypertension

On Echocardiography (Echo), hypertension (HTN) is known to manifest as variable degrees and patterns of LV hypertrophy (hypertensive hypertrophic cardiomyopathy) in association with divergent degree of systolic, diastolic dysfunction, left sided chamber and aortic enlargement; However, Echo predictors of heart failure (HF) in hypertensive hypertrophic cardiomyopathy (HTN HCM) has not been well studied. Identifying the independent Echo predictors of HF in HTN HCM. From Echo laboratory, we identified 300 consecutive patients with LV hypertrophy (LVH) (100 each of mild, moderate and severe LVH). We excluded 82 LVH patients of non-hypertensive etiology. Control group included 100 age-matched subjects with no LVH. We examined patients’ demographics, comorbidities including a history of HF, EKG, laboratory values, and Echo variables including but not limited to chamber size, LV mass, LVH phenotype, LV diastolic function, LV EF and mitral annular systolic velocity by tissue Doppler imaging (S’), a surrogate marker of LV long axis (longitudinal) systolic function. Above variables were compared between the subjects of HTN HCM with HF from those without HF by using X2 and ANOVA. Multivariable regression analysis (MVA) was performed to identify the independent predictors. Among HTN HCM, 28% (n=62), 36% (n=78) and 36% (n=78) had mild, moderate and severe degree of LVH respectively. 57% (n=125) were females with a mean age of 59 ± 14 years. 39% (n=85) had HF among which 82 % had HFpEF (heart failure with preserved EF, >50%), 14 % had HFrEF (HF with reduced EF, <40%) and 4 % were HFbEF (HF with borderline EF, 40-50%). When HTN HCM with and without HF groups were compared, a significant difference was noted among 2 out of 14 Echo (diastolic dysfunction and S’) and 4 of 16 clinical parameters (Tobacco abuse, Methamphetamine use, Coronary artery disease, Chronic kidney disease). Of note, there was no difference noted in LVH phenotype and LVEF between the groups of HF and no HF. On MVA, advanced LV diastolic dysfunction (moderate to severe) and impaired longitudinal LV systolic function (S’ ≤6cm/sec) were noted to be the only independent predictors of HF among all the variables (Figure 1). HFpEF is the predominant form of HF in HTN HCM. Impaired longitudinal LV systolic function and advanced diastolic dysfunction on Echo are the independent predictors of HF in HTN HCM. These markers can provide guidance in HF management of HTN HCM.

Risk factors for heart failure during pregnancy among Chinese women with cardiac disease

ObjectiveTo identify risk factors for heart failure (HF) during pregnancy among women with pre-existing cardiac disease. MethodsA retrospective review was conducted of pregnant women with cardiac disease who attended Shanghai Obstetrical Cardiology Intensive Care Center, China, for delivery between January 1, 1993, and December 31, 2013. Independent predictors of HF were identified by logistic regression analysis. ResultsAmong 1086 pregnant women with cardiac disease, 116 (10.7%) developed HF. In multivariate analysis, HF was associated with left ventricular systolic dysfunction (odds ratio [OR] 13.16, 95% confidence interval [CI] 3.62–47.80; P<0.001), history of HF before pregnancy (OR 11.66, 95% CI 5.83–23.33; P<0.001), twin pregnancy (OR 11.63, 95% CI 4.10–32.99; P<0.001), sinus tachycardia (OR 4.60, 95% CI 2.77–7.62; P<0.001), New York Heart Association functional class higher than II (OR 3.36, 95% CI 1.11–10.25; P=0.033), and severe pulmonary arterial hypertension (OR 1.40, 95% CI 1.10–1.78; P=0.007). ConclusionWomen with cardiac disease who wish to become pregnant should be guided by risk factors for HF. Those who do conceive should be closely monitored during pregnancy to improve outcomes and reduce maternal mortality and morbidity.

Risk stratification for the development of heart failure after acute coronary syndrome at the time of hospital discharge: Predictive ability of GRACE risk score

BackgroundDespite encouraging declines in the incidence of heart failure (HF) complicating acute coronary syndrome (ACS), it remains a common problem with high mortality. Being able to identify patients at high risk of HF after ACS would have great clinical and economic impact. With this study, we assessed the usefulness of the GRACE score to predict HF after an ACS. MethodsWe studied 4137 consecutive patients discharged with diagnosis of ACS. We analyzed HF incidence, timing, and association with the follow-up mortality. Cox proportional hazards modeling was performed to assess the accuracy of the GRACE risk score to predict HF admissions in follow-up (median 3.1 years). ResultsA total of 433 patients (10.5%) developed HF. GRACE score was an independent predictor of HF after ACS [hazard ratio (HR) 1.02, 95% confidence interval (CI): 1.01–1.03, p<0.001]. A risk gradient for the development of HF with GRACE risk score was shown: high- and moderate-GRACE risk groups have been linked to a sixfold and twofold increased risk of HF. This risk gradient was maintained in patients with and without prior history of HF, in ST elevation myocardial infarction and non-ST elevation myocardial infarction groups, and in patients with depressed and preserved left ventricular ejection fraction. The development of HF was associated with high mortality (54.5% vs 13.4%; HR=4.48; 95% CI: 3.84–5.24; p<0.001). After adjusting for GRACE risk score, HF development resulted as an independent predictor of mortality. ConclusionGRACE risk score has been shown to provide clinically relevant stratification of follow-up HF admission risk at the time of hospital discharge in patients with ACS.

Abstract 13882: Impact of Ischemic Mitral Regurgitation on Long-Term Prognosis in Patients With Acute Myocardial Infarction After Primary Percutaneous Coronary Intervention

Introduction: Ischemic mitral regurgitation (IMR) portends a poor prognosis during long-term follow-up and has been identified as an independent predictor of heart failure (HF) and reduced long-term survival. Despite the poor prognosis with chronic IMR, few studies report the impact of IMR on long-term prognosis in patients with acute myocardial infarction (AMI) who underwent primary percutaneous coronary intervention (PCI). Methods: We studied 674 consecutive patients with AMI from 2000 to 2006 who underwent emergent coronary angiography and primary PCI, and who were assessed by transthoracic echocardiography during index hospitalization. Primary outcomes were cardiac death and the development of HF during follow-up. Results: The mean age of the study patients was 65±12 years and 534 patients (79%) were men. Sixty patients (9%) had moderate or severe MR before hospital discharge. Patients with moderate or severe MR were older, more frequently non-smoker, and more likely to have Killip class ≥2, lower ejection fraction, larger left ventricular end-diastolic volume, compared with patients with no or mild MR. During the mean follow-up period of 5.7±3.6 years, 35 cardiac deaths and 53 episodes of HF occurred. Kaplan-Meier analysis revealed that patients with moderate or severe MR had significantly increased risk for cardiac death (P&lt;0.001), and HF (P&lt;0.001), compared with patients with no or mild MR. Multivariate analysis revealed that moderate or severe MR was the significant predictor of the development of cardiac death (P&lt;0.001), and the development of HF (P=0.006), independently of age, gender, history of MI, Killip class ≥2, initial TIMI flow≤1, peak CPK level, ejection fraction. Conclusions: Moderate or severe IMR detected early after AMI was independently associated with adverse cardiac events during long-term follow-up in patients with AMI after primary PCI.

Early Ventricular Remodeling and Dysfunction in Obese Children and Adolescents

Obesity is an independent predictor of heart failure in adults. Obese individuals have increased hemodynamic load and neuro-hormonal activation that contribute, but cannot entirely explain the reported changes in ventricular structure and function leading to heart failure. There are intrinsic alterations in the myocardium that are independent of load. Insulin resistance promotes alterations in myocardial substrate metabolism that may play a role in the pathogenesis of decreased myocardial efficiency and cardiac dysfunction in obese individuals. The prevalence of obesity in childhood and adolescence has increased significantly over the last decade. Obese children and adolescents have left ventricular remodeling that transpires into adulthood, and subclinical systolic and diastolic dysfunction despite normal conventional parameters of ventricular function. These findings suggest that obesity has an early impact in the cardiovascular health of obese adolescents. Life-style modifications causing weight loss can reverse the ventricular dysfunction observed in this young population and must be strongly encouraged.

Analysis of Left Atrial Performance in Patients with Type 2 Diabetes Mellitus without Overt Cardiac Disease and Inducible Ischemia: High Prevalence of Increased Systolic Force Related to Enhanced Left Ventricular Systolic Longitudinal Function

In patients with chronic pressure overload, higher left atrial systolic force (LASF) is associated with high-risk cardiovascular (CV) phenotype, with increased left ventricular (LV) mass, concentric hypertrophy, and diastolic dysfunction. In hypertension and aortic stenosis, LASF predicts increased rate of CV events independent of traditional risk factors. Moreover, LASF is an independent predictor of heart failure in diabetic and nondiabetic patients. Limited data are available about LASF and its relationship with LV systolic function in type 2 diabetes mellitus (T2DM). We used baseline clinic and echocardiographic data from 333 patients recruited in the SHORTWAVE study evaluating LV and left atrial performance in T2DM patients without cardiac disease. LASF was calculated by Manning's method and defined high when exceeded 16 Kdynes (90th percentile of LASF found in 120 healthy subjects used as controls). Mean LASF was 15.8 Â ± 9.4 Kdynes/cm(2) and showed a close positive correlation with peak mitral annular systolic velocity (function of LV longitudinal fibers), independent of E/E', age, systolic blood pressure, heart rate, and concentric geometry (multiple R = 0.57, P < 0.0001). Such independent correlation (tested in patients with and without concomitant hypertension) was confirmed at multiple logistic regression analysis where patients were dichotomized for having high (119 = 36%) or normal LASF. High LASF is present in one third of T2DM patients without overt cardiac disease and is positively and independently related to an increased LV longitudinal shortening function, suggesting a close interaction between LV systolic and diastolic function.

Heart failure in octogenarians with acute coronary syndrome: the EURHOBOP study in Portugal

Introduction: Octogenarians with Acute Coronary Syndrome (ACS) are at risk of developing Heart Failure (HF). Our purpose was to identify clinical conditions that could predict HF development during hospitalization, and to evaluate its impact on in-hospital mortality. Methods: We studied a sample of 3009 cases of ACS from 10 Portuguese public hospitals, consecutively discharged within each hospital in 2009. The discharge notes and electronic/paper medical files were retrospectively reviewed by trained data extractors according to a standard protocol. For the present analysis patients were stratified according to age (< or ≥ 80 years) and compared regarding HF incidence (Killip2) as well as its predictors. Logistic regression analysis was performed to identify independent predictors of HF and, additionally, in-hospital death. Results: The very old group comprised 21.4% (n=645) of all ACS patients and 56.3% were women (versus 27.2% in the younger group; p<0.001) with a mean age of 84.7 years. This group was more likely to have an NSTEMI (59.3% vs 51.2%; p=0.003). During hospitalization, the very old group had more complications, namely new onset of atrial fibrillation (15.8% vs 7.5%; p<0.001) and cardiac (28.4% vs 17.1%; p<0.001) or renal failure (RF), (18.9% vs 6.4%; p<0.001). The very old group was more likely to have Left Ventricular Systolic Dysfunction (LVSD) (26.0% vs 19.7%; p=0.006) and to die in the hospital (16.7% vs 5.3%; p<0.001). In multivariate logistic regression, acute RF (OR 2.39; 95% CI 1.45-3.94, in comparison with no RF), LVSD (OR 2.37; 95% CI 1.47-3.81) as well as severe anemia (OR 1.97; 95% CI 1.16-3.35) were associated with higher in-hospital HF in the older. In the younger, the strongest determinants of developing HF were also RF (chronic: OR 1.40; 95% CI 1.04-1.87; acute: OR 3.00; 95% CI 2.01-4.48), LVSD (OR 4.94; 95% CI 3.77-6.48), severe anemia (OR 1.63; 95% CI 1.10-2.41) and atrial fibrillation (OR 1.92; 95% CI 1.33-2.78). In addition, the development of HF was associated with a higher in-hospital mortality only in younger group with STEMI, adjusted for sex, diabetes, previous coronary heart disease, acute and or chronic RF (OR 1.94; 95% CI 1.01-3.72). Conclusion: The very old group had a higher risk of HF. RF, LVSD and severe anemia were associated with HF at all ages. Atrial fibrillation had a strong effect on HF only in the younger. Higher mortality was associated with heart failure only in the younger group. HF after an ACS in the very old has a different clinical meaning than in younger patients and warrants a specific approach for improved.

Abstract 56: Change in Midlife Fitness is an Independent Predictor of Heart Failure in Older Age

Background: Low mid-life fitness is associated with increased risk for heart failure (HF) events decades later. However, the association between changes in mid-life fitness and heart failure risk has not been studied. Methods: We included 9050 subjects (15% Females, mean age 48 years) with no prior cardiovascular disease who underwent two cardiorespiratory fitness measurements approximately 8 years apart. Fitness was estimated in metabolic equivalents (METs) according to Balke treadmill time, with low fitness defined as the lowest quintile of fitness and high fitness defined as quintiles 2-5. Change in fitness was defined categorically according to fitness quintiles (see figure legend) and continuously as the change in METs between the two examinations. Baseline data from the CCLS were matched with Medicare administrative claims data from the Center for Medicare and Medicaid Services. Hospitalization for HF was determined from Medicare claims files. The association between change in fitness and HF hospitalization was assessed by applying a proportional hazard recurrent events model to the failure time data and adjusted for traditional risk factors. Results: After 60,635 person years of Medicare follow up, we observed 242 hospitalizations for HF. Compared to individuals with persistently low fitness levels in middle-age, individuals who increased their fitness levels had a lower rate of HF hospitalization (0.88 vs. 0.64%/year). After multivariable adjustment for baseline fitness level and other risk factors, each 1 MET increase in middle age fitness was associated with 5% less risk for HF hospitalization in later life [HR 0.95 (0.93-0.97) per MET]. Conclusion: Change in mid-life fitness is associated with HF risk in older age. These findings suggest that the heart failure risk related to low fitness may be modifiable with exercise training.

Outcomes After Acute Myocardial Infarction in HIV-Infected Patients

Background— We aimed to assess in-hospital case fatality and 1-year prognosis in HIV-infected patients with acute myocardial infarction. Methods and Results— From the PMSI (Program de Medicalisation des Systèmes d’informatique) database, data from 277 303 consecutive acute myocardial infarction patients hospitalized from January 1, 2005, to December 31, 2009, were analyzed. Surviving patients were followed up for 1 year after discharge. HIV-infected patients were compared with uninfected patients. Among the cohort, HIV-infected patients (n=608) accounted for 0.22%. All-cause hospital and 1-year mortality rates were lower in the HIV-infected group than in uninfected patients (3.1% versus 8.1% [ P &lt;0.001] and 1.4% versus 5.5% [ P &lt;0.001], respectively). From the database, we then analyzed a cohort derived from a matching procedure, with 1 HIV patient matched with 2 patients without HIV, based on age and sex (n=1824). Ischemic cardiomyopathy was more frequent in the HIV group (7.6% versus 4.2%, P =0.003). Hospitalization and 1-year mortality rates were similar in the 2 groups (3.1% versus 2.1% [ P =0.168] and 1.4% versus 1.7% [ P =0.642], respectively). However, at 12 months, hospitalizations for episodes of heart failure were significantly more frequent in HIV-infected than in uninfected patients (3.3% versus 1.4%, respectively; P =0.020). HIV infection, diabetes mellitus, history of ischemic cardiomyopathy, and undergoing percutaneous coronary intervention were associated in univariate analysis with occurrence of heart failure. By multivariable analysis, HIV infection (odds ratio 2.82, 95% confidence interval 1.32–6.01), diabetes mellitus, and undergoing percutaneous coronary intervention remained independent predictors of heart failure. Conclusions— The present study demonstrates that after acute myocardial infarction, HIV status influences long-term risk, although the short-term risk in HIV patients is comparable to that in uninfected patients.

Is Serum Uric Acid Level an Independent Predictor of Heart Failure Among Patients With Coronary Artery Disease?

Uric acid (UA) is elevated in patients with the metabolic syndrome, and there is a possible association with coronary events. Its association with future risk of heart failure (HF) is not clear. Our objective was to evaluate the association between levels of UA and risk of HF in patients with stable coronary artery disease (CAD). Serum UA is associated with HF in CAD patients. A retrospective cohort analysis among 2939 participants of the bezafibrate infarction prevention study, assessing long-term risk of HF incidence over an 8-year of follow-up in relation to baseline UA. Among patients with high levels of UA, there was a larger proportion of men, systolic hypertension, diabetes mellitus, metabolic syndrome, elevated total cholesterol, chronic renal failure, and previous coronary revascularization procedures. The rate of myocardial infarction during the follow-up was 10.9%, 10.3%, and 11.6% in the 1st, 2nd and 3rd tertiles of UA, respectively (P = 0.68). Age-adjusted hazard ratios for HF were 1.16 (95% confidence interval [CI]: 0.94-1.45) and 1.28 (95% CI: 1.04-1.59) in the 2nd and 3rd tertiles, respectively, as compared to the 1st tertile. After adjusting for multiple confounders and myocardial infarction, the hazard ratio for developing HF was 1.18 (95% CI: 0.95-1.47) and 1.25 (95% CI: 1.00-1.56) in the 2nd and 3rd tertiles of UA levels, respectively. UA levels are associated with future risk of HF in patients with stable CAD, but this association is attenuated after adjusting for traditional CAD risk factors.

Association of serum angiopoietin-1, angiopoietin-2 and angiopoietin-2 to angiopoietin-1 ratio with heart failure in patients with acute myocardial infarction

The aim of the present study was to investigate the association of the serum angiopoietin (Ang)-1 and Ang-2 levels and the Ang-2 to Ang-1 ratio (Ang-2/Ang-1) with heart failure (HF) in patients with acute myocardial infarction (AMI) during hospitalization. The serum Ang-1 and Ang-2 levels of the AMI patients were measured at admission to hospital. The correlations between serum Ang-1, Ang-2 and Ang-2/Ang-1 with HF were examined. Among 103 patients, 20 developed HF during hospitalization. The serum Ang-2 level and Ang-2/Ang-1 were found to be significantly higher in the patients with HF than in the patients without HF (2,203.1±122.0 vs. 2,102.3±114.4 pg/ml, P=0.001 and 11.4±1.6×10−2 vs. 10.6±1.1×10−2, P=0.007, respectively). Serum Ang-2 level and Ang-2/Ang-1 were negatively correlated with left ventricular ejection fraction (LVEF; r=−0.352, P<0.001 and r=−0.365, P<0.001, respectively) and positively correlated with the natural logarithm of the level of N-terminal pro-B-type natriuretic peptide (LnNT-proBNP, r=0.367, P<0.001 and r=0.304, P=0.003, respectively) and peak cardiac troponin T (cTnT, r=0.421, P<0.001 and r=0.278, P=0.009, respectively). However, the serum Ang-1 level was not found to correlate significantly with LVEF (r= 0.194, P= 0.05), LnNT-proBNP (r=−0.116, P=0.266) or peak cTnT (r=−0.056, P=0.607). In multivariable logistic regression analysis, Ang-2 (P=0.031), Ang-2/Ang-1 (P=0.018) and NT-proBNP (P=0.001) were revealed to be independently associated with HF. The present study reveals that Ang-2 levels and Ang-2/Ang-1 are independent predictors of HF in AMI patients during hospitalization.

Heart fAilure Prevalence and Predictors in TurkeY (HAPPY) Çalışması

The aim of this study was to determine the prevalence of heart failure (HF) in adult residents of Turkey based on echocardiography and N-terminal B type natriuretic factor. 4650 randomly selected residents aged ≥ 35 years were enrolled. Height, weight, waist and hip circumference, and blood pressure measurements were taken, and a 12-lead ECG was performed. Advanced age, hypertension (HT), diabetes mellitus (DM), obesity, and chronic renal failure (CRF) were assessed. History of any heart disease, any abnormal ECG, or an NT-proBNP ≥ 120 pg/mL was accepted as echocardiography indication. Patients with systolic and/or diastolic dysfunction, or NT-proBNP ≥ 2000 pg/mL were classified as having HF if their functional capacity was NYHA ≥ Class II, and were classified as having asymptomatic left ventricular dysfunction (ASVD) if their functional capacity was NYHA <Class I. The absolute and estimated prevalences were 2.9% and 6.9% for HF, and 4.8% and 7.9% for ASVD, respectively. Advanced age, male gender, history of heart disease, HT and CRF were independent predictors of HF. In patients with ejection fraction (EF) <50%, HF prevalence was higher in men, while HF prevalences were higher in women when EF ≥ 50%. In global sum, HF and ALVD prevalence were similar in male and females. The prevalences of HF and ASVD are higher in Turkey when compared with western countries, despite a younger Turkish population. The established predictors of HF are valid for Turkey as well. There is a significant ASVD population in Turkey with similar characteristics and risk factors to HF. Focusing on the early detection and treatment of ASVD may prevent the progression to HF, and therefore would decrease the prevalence of HF in Turkey.

A clinical risk score for heart failure in patients with type 2 diabetes and macrovascular disease: An analysis of the PROactive study

BackgroundDiabetes mellitus is associated with a high risk for heart failure, which is further increased in the presence of coronary heart disease. So far no clinical risk score for development of heart failure exists for patients with type 2 diabetes and macrovascular disease. MethodsIndependent clinical predictors for heart failure events were identified by Cox regression in a post-hoc analysis of the PROactive trial and were used for calculating a risk prediction score. Results233 of 4951 patients with available baseline data suffered a serious adverse heart failure event during a mean follow-up of 34.5 (±2.3) months. Age, renal dysfunction, diuretic use, HbA1c, duration of diabetes, LDL-cholesterol, heart rate, right and left bundle branch block, microalbuminuria, previous myocardial infarction and pioglitazone treatment were independent predictors of heart failure. The risk score showed a good calibration and moderate discrimination (AUC 0.75). Patients were accurately stratified with an actual risk of 1.0%, 3.2% and 9.7% in the bottom, middle and top tertile of the score, respectively, with corresponding hazard ratios of 3.5 (95% CI 2.0–6.2) and 10.5 (95% CI 6.3–17.6) for the middle and top tertile compared to the bottom tertile (both p<0.0001). The score stratified well in subgroups defined by pioglitazone treatment, prior myocardial infarction, obesity, poor glycemic control and microalbuminuria. ConclusionA risk score based on routinely assessed clinical variables proved a good stratification for future heart failure events in diabetic patients with macrovascular disease. Strategies targeting specific interventions and monitoring of high risk patients need further evaluation.

Diabetic Retinopathy is Associated With Impaired Left Ventricular Relaxation

Background Diabetic retinopathy (DR) is an independent predictor of heart failure (HF) in patients with diabetes mellitus (DM). However, it is unclear how DR is related to the development of HF. We hypothesized that DR is associated with left ventricular (LV) diastolic dysfunction, which is well recognized to subsequently result in HF. Methods and Results Data were collected in 63 consecutive patients with DM and LV ejection fraction (EF) ≥50%. Patients were excluded if they had HF diagnosed according to the modified Framingham criteria. Doppler echocardiographic indices including peak early-diastolic mitral annular movement velocity (E′) were obtained in each patient.We also assessed the diastolic index of echocardiographic color kinesis (CK-DI), which proportionally decreases with LV relaxation abnormality independently of LV filling pressure, as recently published. The DM patients were divided into groups without (DM-N; n = 30) and with (DM-DR; n = 33) DR. Age, gender, LV end-diastolic dimension, EF, E/A ratio of the transmitral flow velocity curves, E′, and E/E′ were not different between DM-N and DM-DR. However, CK-DI was significantly lower in DM-DR than DM-N. Conclusions DR is associated with LV diastolic dysfunction, and this may at least in part explain the increased incidence of HF in DM patients with DR.

The Evaluation What Cause Heart Failure in the Patient Has Paroxysmal Atrial Fibrillation with Preserved Systolic Function

Background: Atrial fibrillation (AF) sometimes cause heart failure (HF) even if a patient has preserved left ventricular (LV) systolic function, but there is unclear what factor lead to heart failure. Methods and Results: From 2008 Sep to 2010 Sep, 180 patients with AF divide decompensate group (DECO, n=33) is led into NYHA III or IV HF and not decompensate group (NOR, n=147) is otherwise. We exclude under ejection fraction (EF) 55%, adaptation of valvular disease. Data are described consecutively DECO and NOR. Age is 75.3±9.5, 65.1±12.6 (p<0.0001). Male gender is 45.5% and 71.4% (p=0.004). Hypertension is 93.9%, 59.9% (p=0.0002). Hypertrophic cardiomyopathy is 33.3% and 12.9% (p=0.0045). Ischemic heart disease is 21.2% and 6.8% (p=0.01). Chronic kidney disease is 21.2% and 8.2% (p=0.028). Left atrial diameter is 43.3±7.9 mm and 39.1±6.0 mm (p=0.0008). The e′ is 5.1±1.6 cm/s and 7.2±2.1 cm/s (p<0.0001). E/e′ is 19.0±12.0 and 11.2±4.5 (p<0.0001). Heart rate on attack is 136±20 bpm and 121±37 bpm (p=0.052). Diabetes mellitus, stroke, valvular disease, medications, LV diastolic diameter, LV systolic diameter, EF, and E/A have no significant difference. Multivariable logistic regression analysis shows that E/e′ and age have relative risks 1.138 (95%CI, 1.026–1.261) and 1.069 (95%CI, 1.008–1.133), respectively. Conclusion: E/e′ and age are independent predictors of HF when patient fall into paroxysmal AF with preserved systolic function.

The prevalence and outcome of hypertension in patients with acute coronary syndrome in six Middle-Eastern countries

Aims. The aim was to report the prevalence and significance of hypertension (HTN) in patients with acute coronary syndrome (ACS). Methods and major findings. Over a 6-month period in 2007, 8171 consecutive patients (49.4% hypertensive and 50.6% non-hypertensive) presenting with ACS were enrolled in a prospective, multicenter study from six Middle Eastern adjacent countries. Patients with HTN were older (59.2 vs 53.1 years, p<0.001), and more likely to be female (34% vs 14.4%, p<0.001) when compared with patients without HTN. Patients with HTN were also more likely to have diabetes mellitus, hyperlipidemia, cerebrovascular disease, prior history of coronary artery disease, peripheral artery disease but less likely to be cigarette smokers. At admission, HTN patients had higher Killip class, heart rate and GRACE risk scoring. In-hospital mortality was higher in hypertensive patients with ST-elevation myocardial infarction (STEMI) but not in patients with non-STEMI or unstable angina. The incidence of heart failure complications was significantly higher among patients with HTN in overall ACS type (OR = 1.2, 95% CI 1.001–1.338, p= 0.04). Main conclusion. In this large cohort of patients with ACS, HTN was an independent predictor of heart failure and was associated with an increased rate of in-hospital mortality in STEMI only.

The relationship between intermittent left bundle-branch block and slow coronary flow in a patient presenting with acute coronary syndrome

Coronary slow flow phenomenon (CSFP) is characterized by delayed opacification of coronary vessels in a normal coronary angiogram. The incidence of CSFP is reportedly 1% among patients undergoing coronary angiography, and is more prevalent in patients presenting with acute coronary syndromes (ACS). Over 80% of patients with CSFP experience recurrent chest pain. A relationship between CSFP and ventricular arrhythmias has also been reported. Left bundle-branch block (LBBB) is a strong, independent predictor of heart failure, sudden cardiac death, cardiovascular death, and all-cause death. New onset LBBB has also been shown to be prognostic for patients with ACS, and should be considered in risk stratification to identify high-risk patients. We report intermittent LBBB associated with CSFP in a patient presenting with ACS. We propose that LBBB may be a result of coronary ischemia secondary to CSFP in left anterior descending coronary artery and that intermittent LBBB may have a prognostic role for detecting coronary ischemia.

Diabetes, Glycemic Control, and New-Onset Heart Failure in Patients With Stable Coronary Artery Disease

OBJECTIVEDiabetes is a predictor of both coronary artery disease (CAD) and heart failure. It is unknown to what extent the association between diabetes and heart failure is influenced by other risk factors for heart failure.RESEARCH DESIGN AND METHODSWe evaluated the association of diabetes and A1C with incident heart failure in outpatients with stable CAD and no history of heart failure (average follow-up 4.1 years).RESULTSOf 839 participants, 200 had diabetes (23.8%). Compared with patients who did not have diabetes, those with diabetes had an increased risk of heart failure (hazard ratio [HR] 2.17 [95% CI 1.37–3.44]). Adjustment for risk factors for CAD (age, sex, race, smoking, physical inactivity, obesity, blood pressure, and LDL cholesterol), interim myocardial infarction, and myocardial ischemia did not alter the strength of the association between diabetes and heart failure. After inclusion also of other risk factors for heart failure (left ventricular ejection fraction, diastolic dysfunction, and C-reactive protein) and medication use, diabetes remained an independent predictor of heart failure (HR 3.34 [95% CI 1.65–6.76]; P = 0.001). Each 1% increase in A1C concentration was associated with a 36% increased HR of heart failure hospitalization (HR 1.36 [95% CI 1.17–1.58]).CONCLUSIONSIn patients with stable CAD who are free from heart failure at baseline, diabetes and glycemic control are independent risk factors for new-onset heart failure. The mechanisms by which diabetes and hyperglycemia lead to heart failure deserve further study, as the association is independent of baseline functional assessment of ischemia, systolic and diastolic function, and interim myocardial infarction.

Impact of untreated mild-to-moderate mitral regurgitation at the time of isolated aortic valve replacement on late adverse outcomes☆

The impact of untreated mild-to-moderate mitral regurgitation (MR) on patients undergoing isolated aortic valve replacement (AVR) is uncertain. The aim of this study is to investigate its long-term effects on outcomes. We retrospectively reviewed 193 consecutive patients undergoing isolated AVR between 1993 and 2007. The mean age of the study group was 64+/-12 years, 59% were male and the mean preoperative ejection fraction was 59+/-12%. The pathologic aetiology and degree of MR was determined on preoperative echocardiogram. Patients were stratified into preoperative no/trivial MR (group I; n=134) versus mild-to-moderate MR (group II; n=59). The aetiology of MR in group II was either organic (n=35, 60%) or functional (n=24, 41%). Survival and functional outcome were compared between the two groups and analyses for predictors of adverse events were performed by the Cox proportional hazard model. Operative mortality was 2.6% (n=5). In group II, mean degree of MR significantly decreased from 2.1+/-0.3 to 1.6+/-0.8 during the late period (p=0.003). The improvement in MR grade was more obvious in patients with functional aetiology. Although the actuarial survival was not significantly different between groups, freedom from re-admission for heart failure at 10 years was significantly lower in group II than in group I (23% vs 83%; p=0.002). Multivariate analysis demonstrated that independent predictors of heart failure were presence of mild-to-moderate MR (p=0.012, odds ratio (OR) 3.8) and left ventricular ejection fraction (p=0.004, OR 0.95). Despite the significant reduction after isolated AVR, preoperative mild-to-moderate MR is an independent risk factor impacting long-term functional outcome. Our results suggested that the concomitant mitral valve surgery for mild-to-moderate MR is warranted, especially in patients with reduced left ventricular function.