Independent Predictor Of Heart Failure Research Articles

Valor pronóstico del péptido natriurético cerebral en el síndrome coronario agudo sin elevación del segmento ST

The B-type natriuretic peptide (BNP) has recently emerged as a prognostic marker in acute coronary syndromes (ACS). This role is based on results from randomized trials and other high selected population studies. The aim of this study was to determine the prognostic value of BNP in unselected patients with non-ST-elevated-ACS. BNP plasma concentrations were measured in 100 consecutive patients admitted in 2007 with non-ST-elevated-ACS, taking as cut-off value 80pg/ml (high BNP levels on 48% of patients). After one year-of follow-up, 21 major adverse cardiovascular events occurred: 12 ACS, 7 hospitalizations for heart failure and 2 sudden cardiac deaths. No relationship was found between BNP levels and events on follow-up. BNP >80pg/ml was the only independent predictor of heart failure and death. No relationship was found between high levels of BNP and coronary events during the follow-up. BNP was an independent predictor of heart failure and mortality in unselected patients with non-ST-elevated-ACS.

The Prognostic Significance of Bundle Branch Block in High‐Risk Chronic Stable Vascular Disease Patients: A Report from the HOPE Trial

The prognostic significance of left and right bundle branch block (LBBB and RRBB) in patients with chronic stable cardiovascular (CV) disease is not well characterized and was evaluated in the Heart Outcomes Prevention Evaluation (HOPE) study cohort. Observational analysis of data prospectively collected in the HOPE trial. HOPE was a multicenter, international trial, which evaluated ramipril and vitamin E in 9,541 patients aged > or = 55 years with CV disease or diabetes with > or = 1 CV risk factor(s) but without heart failure (HF) or known left ventricular systolic dysfunction. Follow-up extended for a median of 4.5 years. Electrocardiograms were obtained at baseline in all study participants and were read centrally. Major CV events (defined as CV death, myocardial infarction, or stroke), heart failure, CV death, all-cause death, and sudden death. Baseline LBBB was present in 246 (2.6%) patients and was associated with increased risk for major CV events (HR = 1.54; 95% CI, 1.18-2.02), CV death (HR 2.29; 95% CI, 1.63-3.20), heart failure (HR 2.99; 95% CI, 2.31-3.87), sudden death (HR 3.17; 95% CI, 2.13-4.73), and all-cause death (HR = 2.10; 95% CI, 1.59-2.77). In multivariate models, LBBB remained an independent predictor of heart failure, sudden death, CV death, and all-cause death (P < or = 0.002 for all). Baseline RBBB was present in 428 (4.5%) of patients and was not associated with increased CV risk. In patients with stable chronic CV disease, LBBB but not RBBB is an independent predictor of heart failure, sudden death, CV death, and all-cause death.

Long‐term prognosis of medically treated patients with functional mitral regurgitation and left ventricular dysfunction

To assess long-term prognosis in patients with functional mitral regurgitation (FMR) and left ventricular (LV) dysfunction, receiving current standard pharmacological therapy. We prospectively enrolled 404 consecutive patients (mean age 70.2 +/- 10 years) with ischaemic (76.5%) and non-ischaemic (23.5%) LV dysfunction (ejection fraction 34.4 +/- 10.8%) and at least mild MR. Results are reported at 4 years' follow-up. Survival free of all-cause mortality was 53% and cardiac death was 74%. Survival free of all-cause mortality was 50% (95% CI 35-72) for patients with moderate MR, 49% (95% CI 27-65) for severe MR, and 64% (95% CI 47-78) for mild MR (P = 0.03). Survival free of cardiac death was 57% (95% CI 38-74) for patients with moderate MR, 55% (95% CI 30-77) for severe MR, and 94% (95% CI 59-98) for mild MR (P = 0.003). Moderate-to-severe MR [relative risk (RR) 2.7, 95% CI 1.2-6.1, P = 0.003] was an independent predictor of cardiac death but not of all-cause mortality. Survival free of heart failure (HF) was 32%. Survival free of HF was 20% (95% CI 17-35) for patients with moderate MR, 18% (95% CI 15-32) for severe MR, and 62% (95% CI 45-72) for mild MR (P = 0.0001). Moderate-to-severe MR (RR 3.2, 95% CI 1.9-5.2, P = 0.0001) was an independent predictor of HF. The mortality and morbidity of patients with LV dysfunction and FMR remain high despite current standard pharmacological therapy. Moderate-to-severe MR is an independent predictor of cardiac death and HF.

Development of an Echocardiographic Risk‐Stratification Index to Predict Heart Failure in Patients With Stable Coronary Artery Disease: The Heart and Soul Study

Abstract. Objectives. We sought to determine which transthoracic echocardiographic (TTE) measurements most strongly predict heart failure (HF) and to develop an index for risk stratification in outpatients with coronary artery disease (CAD). Background. Many TTE measurements have been shown to be predictive of HF, and they might be useful if aggregated into a risk‐prediction index. Methods. We performed TTE in 1024 outpatients with stable CAD enrolled in the Heart and Soul study and followed them for 4.4 years. With Cox proportional hazard models, we evaluated the association of 15 TTE measurements with subsequent HF hospital stay. Those measurements that independently predicted HF were combined into an index. Variables were defined as normal or abnormal on the basis of dichotomous cutoffs determined from the American Society of Echocardiography. Abnormal variables in each measurement were assigned points on the basis of strength of association with HF. Results. Of the 15 variables, 5 measurements were independent predictors of HF: left ventricular mass index (LVMI), left atrial volume index (LAVI), mitral regurgitation (MR), left ventricular outflow tract velocity‐time integral (VTILVOT), and diastolic dysfunction (DD). In multivariate analysis, each of the 5 measurements independently predicted HF: LVMI &gt;90 g/m2 (hazard ratio [HR], 4.1; 95% confidence interval [CI], 2.3–7.2; P&lt;.0001); pseudo‐normal or restrictive DD (HR, 2.9; 95% CI, 1.8–4.5; P&lt;.0001); VTILVOT &lt;22 mm (HR, 2.2; 95% CI, 1.4–3.5; P=.0004); mild, moderate, or severe MR (HR, 1.8; 95% CI, 1.2–2.8; P=.009); and LAVI &gt;29 mL/m2 (HR, 1.6; 95% CI, 1.0–2.5; P&lt;.06). Combining these measurements, the Heart Failure Index ranged from 0 to 8, representing risk as follows: 3 points for LVMI, 2 points for DD, and 1 point for VTILVOT, MR, and LAVI. Among participants with 0 to 2 points: 4% had HF hospital stays (reference); 3 or 4 points: 10% (HR, 2.4; 95% CI, 1.3–4.4; P=.003); 5 or 6 points: 24% (HR, 6.2; 95% CI, 3.6–10.6; P&lt;.0001); 7 or 8 points: 48% (HR, 13.7; 95% CI, 7.2–25.9; P&lt;.0001). Conclusions. We identified 5 TTE measurements that independently predict HF in patients with stable CAD and combined them as an index that might be useful for risk stratification and serial observations.—Stevens SM, Farzaneh‐Far R, Na B, et al. Development of an echocardiographic risk‐stratification index to predict heart failure in patients with stable coronary artery disease: the Heart and Soul study. JACC Cardiovasc Imaging. 2009;2(1):21–23.

Development of an Echocardiographic Risk-Stratification Index to Predict Heart Failure in Patients With Stable Coronary Artery Disease: The Heart and Soul Study

We sought to determine which transthoracic echocardiographic (TTE) measurements most strongly predict heart failure (HF) and to develop an index for risk stratification in outpatients with coronary artery disease (CAD). Many TTE measurements have been shown to be predictive of HF, and they might be useful if aggregated into a risk-prediction index. We performed TTE in 1,024 outpatients with stable CAD enrolled in the Heart and Soul study and followed them for 4.4 years. With Cox proportional hazard models, we evaluated the association of 15 TTE measurements with subsequent HF hospital stay. Those measurements that independently predicted HF were combined into an index. Variables were defined as normal or abnormal on the basis of dichotomous cutoffs determined from the American Society of Echocardiography. Abnormal variables in each measurement were assigned points on the basis of strength of association with HF. Of the 15 variables, 5 measurements were independent predictors of HF: left ventricular mass index (LVMI), left atrial volume index (LAVI), mitral regurgitation (MR), left ventricular outflow tract velocity-time integral (VTI(LVOT)), and diastolic dysfunction (DD). In multivariate analysis, each of the 5 measurements independently predicted HF: LVMI >90 g/m(2) (hazard ratio [HR]: 4.1; 95% confidence interval [CI]: 2.3 to 7.2, p < 0.0001); pseudo-normal or restrictive DD (HR: 2.9; 95% CI: 1.8 to 4.5, p < 0.0001); VTI(LVOT) <22 mm (HR: 2.2; 95% CI: 1.4 to 3.5, p = 0.0004); mild, moderate, or severe MR (HR: 1.8; 95% CI: 1.2 to 2.8, p = 0.009); and LAVI >29 ml/m(2) (HR: 1.6; 95% CI: 1.0 to 2.5, p < 0.06). Combining these measurements, the Heart Failure Index ranged from 0 to 8, representing risk as follows: 3 points for LVMI, 2 points for DD, and 1 point for VTI(LVOT), MR, and LAVI. Among participants with 0 to 2 points: 4% had HF hospital stays (reference); 3 to 4 points: 10% (HR: 2.4; 95% CI: 1.3 to 4.4, p = 0.003); 5 to 6 points: 24% (HR: 6.2; 95% CI: 3.6 to 10.6, p < 0.0001); 7 to 8 points: 48% (HR: 13.7; 95% CI: 7.2 to 25.9, p < 0.0001). We identified 5 TTE measurements that independently predict HF in patients with stable CAD and combined them as an index that might be useful for risk stratification and serial observations.

Postinfarct remodeling causes insulin resistance and defects in substrate oxidation

Aims: Post infarction left ventricular remodeling leads to hypertrophy and dilatation. Little is known about substrate metabolism in this setting, although defects in substrate oxidation may cause contractile dysfunction and insulin resistance is an independent predictor of heart failure.

Prognostic Value of Selected Presenting Features of Acute Coronary Syndrome in Predicting In-Hospital Adverse Events: Insight from the Thai Acute Coronary Syndrome Registry

To evaluate the relationship of the presenting features of acute coronary syndrome (ACS) to in-hospital adverse events (total and cardiac deaths, heart failure and serious dysrhythmia) and the effects of coronary intervention. Patients with ACS may present with dyspnea, shock and/or cardiac arrest with or without accompanying chest pain. We evaluated 9,373 patients (age 65+/-12 years and 60% males) enrolled in the Thai ACS Registry. Cardiac dyspnea included shortness of breath on exertion, and/or at rest, orthopnea, or paroxysmal nocturnal dyspnea presumed from cardiac sources. Shock was present if systolic blood pressure was <90 mmHg for >30 min with symptoms of end-organ hypoperfusion. Post cardiac arrest was identified if cardiopulmonary resuscitation was required. We calculated the frequencies of these presenting features and assessed their contribution toward in-hospital adverse events (total and cardiac deaths, heart failure and serious arrhythmias) for the whole ACS and each entity of ACS and the effects of in-hospital interventions, both coronary and medicinal. Cardiac dyspnea, shock and post cardiac arrest were seen in 32.7%, 9.3%, and 4.2% of patients, respectively. In-hospital adverse events occurred more frequently in patients with these presenting features than those without (p<0.05). Cardiac dyspnea and shock were independent predictors of heart failure and death, respectively, while post cardiac arrest independently identified patients at risk of arrhythmia, total and cardiac death, regardless of the subgroup of ACS. Coronary revascularization significantly reduced the risk of total and cardiac death. These 3 presenting features of ACS portend a poor prognosis, regardless of the subgroup of ACS and should be considered as important early indicators for early intervention.

Parental history of myocardial infarction and risk of heart failure in male physicians

Although heart failure (HF) remains a major public health issue, limited data are available on the utility of parental information on the risk of HF in offspring. We prospectively examined the association between parental history of myocardial infarction (MI) and incident HF among 20,187 offspring in the Physicians' Health Study I. Parental history and age at MI was assessed by a questionnaire and a Cox regression was used to estimate relative risks of HF. After an average follow-up of 19.6 years, 1036 new HF cases were documented. Overall, while a history of early parental MI (before age 55) was associated with a 32% increased risk of HF in offspring compared with subjects whose parent did not have MI, parental MI at older ages was not associated with HF risk. However, the relation between parental history of MI and HF was stronger and mainly observed for HF with antecedent MI. Compared with subjects without parental history of MI, multivariable adjusted hazard ratios (95% CI) for HF with antecedent MI were 3.44 (2.15-5.51), 2.24 (1.20-4.21), 1.26 (0.63-2.51), and 1.37 (0.92-2.03) for parental MI occurred at the age of < 55, 55-59, 60-64, and 65 + y, respectively. Our data suggest that parental MI at an early age is a strong and independent predictor of HF with antecedent MI among US male physicians. This information, along with existing tools, may help clinicians identify patients at risk of HF with antecedent MI.

New‐Onset Heart Failure After Permanent Right Ventricular Apical Pacing in Patients with Acquired High‐Grade Atrioventricular Block and Normal Left Ventricular Function

Emerging data have suggested that right ventricular (RV) apical pacing results in progressive left ventricular (LV) dysfunction and contributes to the development of heart failure (HF). This study aimed to investigate the prevalence and clinical predictors for the development of new-onset HF after long-term RV apical pacing in patients with acquired atrioventricular (AV) block who require permanent pacing. We studied the clinical outcomes after long-term RV apical pacing for acquired AV block in 304 patients without a prior history of HF. All patients had >90% ventricular pacing as determined by device diagnostic data. After a median follow-up of 7.8 years, 79 patients (26.0%) developed new-onset HF after RV apical pacing. Univariate Cox-regression analysis revealed that older age at the time of pacemaker implantation (P < 0.001), the presence of coronary artery disease (CAD) (P < 0.001) or atrial fibrillation (P = 0.03), VVI pacemaker (P < 0.001), wider paced QRS duration (P < 0.001), and new-onset myocardial infarction (P < 0.001) were predictors for HF. Multivariate analysis revealed that older age at implantation (Hazard ratio [HR] 1.06, 95% confidential interval [CI] 1.04-1.09, P < 0.001), CAD (HR 1.98, 95% CI 1.12-3.50, P < 0.05), and a wider paced QRS duration (HR 1.27 for each 10 ms increment, 95% CI 1.11-1.45, P = 0.001) were independent predictors of HF. Furthermore, cardiovascular mortality was significantly increased in those with HF (36.7% vs. 2.7%, P < 0.001). After a median follow-up of 7.8 years, permanent RV apical pacing was associated with HF in 26% of patients. Elderly age at the time of implant, a wider paced QRS duration and the presence of CAD independently predicted new-onset HF. More importantly, HF after RV apical pacing was associated with a higher cardiovascular mortality.

Smoking accelerates the progression of hypertension-induced myocardial hypertrophy to heart failure in spontaneously hypertensive rats☆

Myocardial hypertrophy often develops in response to hypertension, and it is causal to and an independent predictor of heart failure. Several risk factors modify the progression of hypertrophy, the associated progressive impairment of myocardial function, and eventually the transition to overt congestive heart failure. The aim of the present study was to investigate the effects of smoking on the progression of pressure-dependent myocardial hypertrophy. Spontaneously hypertensive rats (SHR) were used as a model for pressure-dependent hypertrophy. SHR were exposed to mainstream smoke from the Kentucky reference cigarette 2R4F (450 microg total particulate matter/l) or to fresh air (control), 5 days a week, twice for 1 h per day with a 30-minute fresh air exposure break for 30, 60, or 90 days. Endpoints for hypertrophy-associated changes were heart weight to body weight ratio, ventricular expression of hypertrophy-associated genes, ischemic tolerance, and inotropic responsiveness to isoprenaline in post-ischemic hearts. Smoke-exposed SHR showed a significant elevation in heart weight to body weight ratio, increased mRNA expression of atrial natriuretic factor (ANF), transforming growth factor (TGF)-beta(1), ornithine decarboxylase (ODC), and parathyroid hormone-related protein in both ventricles compared to controls. Hearts from smoke-exposed SHR showed a reduced recovery after 30 min global ischemia during the first 5 min of reperfusion and loss of inotropic stimulation after 30 min reperfusion. Smoke cessation was sufficient to reverse most of these alterations. WKY exposed to smoke did not develop similar changes. Our data indicate that several aspects of myocardial hypertrophy are accelerated by smoking.

Right ventricular pacing and the risk of heart failure in implantable cardioverter-defibrillator patients

Right ventricular (RV) pacing in implantable cardioverter-defibrillator (ICD) patients may have detrimental effects on morbidity and mortality, in particular by inducing heart failure (HF). We investigated whether RV pacing increases the risk of HF in an asymptomatic ICD population. We evaluated all patients without symptomatic HF who received an ICD. The primary endpoint was the occurrence of HF, which was defined as new HF, hospitalization for HF, or death due to HF. The secondary endpoint was appropriate shocks. The study population consisted of 456 patients with mean left ventricular ejection fraction (LVEF) 40% +/- 13%. Mean follow-up was 31 +/- 22 months. Because of the bimodal distribution of pacing, patients were divided into two groups: paced <or=50% (median 0%; n = 313) and paced >50% (median 96%; n = 143). HF occurred more often in the paced >50% group (20% versus 9%; P <.001). Multivariate analysis identified RV pacing >50% (adjusted hazard ratio [HR] 1.85; 95% confidence interval [CI] 1.08-3.15; P = .03), baseline LVEF <26% (adjusted HR 3.15; 95% CI 1.77-5.59; P <.001), angina pectoris, history of atrial fibrillation, and baseline diuretic use as independent predictors of HF. RV pacing caused more HF events in patients with LVEF <26% (n = 64; 55% of paced >50% patients versus 20% of paced <or=50% patients; P = .006). RV pacing >50% also independently predicted appropriate shocks (adjusted HR 1.50; 95% CI 1.02-2.20; P = .04). RV pacing was associated with an increased risk of HF in asymptomatic ICD patients, particularly in those with preexistent left ventricular dysfunction.

Device Based Measures of Heart Rate Variability Are Different in Heart Failure Patients with Diabetes Mellitus

Introduction: Diabetes Mellitus (DM) is an independent predictor of heart failure (HF) and an important co-morbidity. Approximately 40% of patients diagnosed with HF have DM (DM-HF). Cardiovascular autonomic neuropathy (CAN) is a common consequence of diabetes disease progression. CAN reduces heart rate variability (HRV), and doubles the relative risk of silent MI and mortality. The dysautonomia associated with HF and CAN is additive and may be reflected in device-based measures HRV. We evaluated patients who received a cardiac resynchronization therapy (CRT) defibrillator to determine if the following device-based measures of HRV differed in DM-HF and non-diabetic HF patients (ND-HF): SDANN and HRV Footprint (a proprietary graphical measure of HRV).

A validated clinical and biochemical score for the diagnosis of acute heart failure: The ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) Acute Heart Failure Score

No method integrating amino-terminal pro-brain natriuretic peptide (NT-proBNP) testing with clinical assessment for the evaluation of patients with suspected acute heart failure (HF) has been described. Amino-terminal pro-brain natriuretic peptide results and clinical factors from 599 patients with dyspnea were analyzed. The beta coefficients of the 8 independent predictors of HF were used to assign a weighted integeric score for predictor. The sum of these integers provided a diagnostic HF "score" for each patient. Receiver operating characteristic curve analysis determined the optimal cut point for the diagnosis of acute HF. The performance of the score was evaluated in the development cohort and subsequently in a patient population from a separate clinical trial of patients with dyspnea conducted in Christchurch, New Zealand. Eight factors comprised the score: elevated NT-proBNP (4 points), interstitial edema on chest x-ray (2 points), orthopnea (2 points), absence of fever (2 points), loop diuretic use, age > 75 years, rales, and absence of cough (all 1 point). Median scores in patients with acute HF were higher than those without acute HF (9 vs 3 points, P < .001). At a cut point of > or = 6 points, the score had a sensitivity of 96% and a specificity of 84% for the diagnosis of acute HF (P < .001). The score improved diagnostic accuracy over NT-proBNP testing alone and retained discriminative capacity in patients in whom clinical uncertainty was present. Lastly, the accuracy of the score was validated in the external data set of patients with suspected acute HF. We report a simple and accurate scoring system combining NT-proBNP testing and clinical assessment for the diagnosis or exclusion of acute HF in patients with dyspnea.

635 Ischemic mitral regurgitation is an independent predictor of heart failure and death in survivors of myocardial infarction — a prospective study

635 Ischemic mitral regurgitation is an independent predictor of heart failure and death in survivors of myocardial infarction — a prospective study

Incidence, risk factors, and prognosis of inhospital heart failure after percutaneous coronary intervention: Insight from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2)

Prior history of heart failure (HF) has been shown to be a predictor of poor outcomes after percutaneous coronary intervention (PCI). Clinical predictors of the development of inhospital HF and its prognostic significance after PCI have yet to be defined. In this study, we sought to identify the incidence, risk factors, and prognosis of inhospital HF after PCI. Using a contemporary registry of consecutive PCIs, the incidence of HF after PCI was identified. Multivariate logistic regression analysis was used to determine predictors of the development of HF after PCI as well as the impact of HF on inhospital mortality. The incidence of HF after PCI in the overall patient population was 1.4%. Independent predictors of HF were female sex, age > or = 60 years, exceeding a maximum weight- and creatinine-adjusted contrast dose, diabetes, prior HF, prior gastrointestinal bleeding, prior chronic obstructive pulmonary disease, history of atrial fibrillation, American College of Cardiology type B2 or C vessel, emergency PCI, ejection fraction < 50%, myocardial infarction with or without cardiogenic shock, and repeat angiography. After adjustment for comorbidities, the development of HF was independently associated with an increased risk of inhospital death (adjusted OR 2.48, 95% CI 1.77-3.48). The development of HF is a relatively uncommon occurrence after PCI and is associated with a poor prognosis. The identification of risk factors for HF could foster the development of interventions aimed toward its prevention in high-risk patients.

Inflammation, as Measured by the Erythrocyte Sedimentation Rate, Is an Independent Predictor for the Development of Heart Failure

Our objective was to explore inflammation, measured as erythrocyte sedimentation rate (ESR), as a predictor for the development of heart failure (HF). In recent years, evidence of the importance of inflammation in the pathophysiology of HF has emerged, and various inflammatory markers have been found to predict future HF. Erythrocyte sedimentation rate is an inexpensive and easily accessible marker of systemic inflammation, but to this date it is unknown whether ESR predicts subsequent HF. In a community-based prospective study of 2,314 middle-aged men free from HF, myocardial infarction, and valvular disease at baseline, ESR was analyzed in multivariable models together with established risk factors for HF (hypertension, diabetes, electrocardiographic left ventricular hypertrophy, smoking, obesity, and serum cholesterol) and hematocrit. A total of 282 men developed HF during a median follow-up time of 30 years. In Cox proportional hazards analyses, ESR was an independent predictor of HF (hazard ratio 1.46 for highest quartile vs. the lowest, 95% confidence interval 1.04 to 2.06). This observation remained significant when also adjusting for interim myocardial infarction during follow-up. Erythrocyte sedimentation rate was a significant predictor of HF, independent of established risk factors for HF, and interim myocardial infarction after three decades of follow-up in a population-based sample of middle-aged men. Our findings indicate that inflammation occurs early in the process leading to HF and that ESR could be used to evaluate this process.

Ischemic Mitral Regurgitation and Its Related Risk After Myocardial Infarction

In this issue of Circulation , Bursi et al1 report that ischemic mitral regurgitation is a more common finding after myocardial infarction (MI) than was previously thought and is an independent predictor of heart failure and death among 30-day infarct survivors. Seldom is mitral regurgitation actively investigated, and investigation is often only prompted by clinical examination. The data Bursi et al report support findings from the 1970s, which suggested that clinical examination is not sensitive in the detection and assessment of mitral regurgitation.2 The authors conclude that Doppler echocardiographic assessment of mitral regurgitation should be actively sought and included in post-MI risk stratification. See p 295 Early invasive studies demonstrated an association between mitral regurgitation and increased 1-year mortality. Tcheng et al3 reported a mitral regurgitation prevalence of 17% in 255 patients. One-year mortality rates showed a graded association with the degree of mitral regurgitation: 11%, 22%, and 52% in patients with no regurgitation, angiographic grade 1 to 2 regurgitation, and grade 3 to 4 regurgitation, respectively. When clinical confounders were adjusted for by multivariate analysis, only grade 3 to 4 mitral regurgitation carried a significantly increased 1-year mortality risk. A similarly designed study reported a post-MI mitral regurgitation prevalence of 13% and showed that mitral regurgitation predicted cause-specific cardiovascular mortality.4 The larger SAVE (Survival and Ventricular Enlargement)5 study of 727 patients reported that even mild (grade 1 to 2) ischemic mitral regurgitation was an independent predictor of cause-specific post-MI cardiovascular mortality. Echocardiographic studies of ischemic mitral regurgitation also have confirmed the prognostic significance of even mild mitral regurgitation.6,7 One-year mortality rates of 4.8%, 12.4%, and 24% were observed among 417 patients assessed within 48 hours of MI with absent, mild, and moderate to severe mitral regurgitation, respectively. Multivariate analysis revealed that even mild …

Intra-left ventricular electromechanical asynchrony: A new independent predictor of severe cardiac events in heart failure patients

ObjectivesWe sought to assess the electromechanical parameters, using tissue Doppler echocardiography, as potential independent predictors of heart failure (HF) worsening. BackgroundVentricular conduction disorders worsen the prognosis for HF patients. However, the relationships between the QRS width and morphology, hemodynamic parameters, and presence and magnitude of intra-left ventricular (LV) and inter-ventricular (V) asynchrony have not been well clarified. MethodsA total of 104 patients with an LV ejection fraction (EF) ≤45% and stabilized HF, without myocardial infarction (MI), underwent echocardiography coupled with tissue Doppler imaging and were followed for one year. The protocol analyzed the incidence of worsening HF (hospitalization for cardiac decompensation). Inter-V and regional electromechanical delays for the anterior, septal, inferior, and lateral LV walls were correlated with the QRS morphology and duration. The intra-LV and inter-V asynchrony values of these patients were compared with those of healthy subjects matched by gender and age criteria to determine the respective normal ranges. ResultsThe presence of intra-LV (but not inter-V) asynchrony was identified as an independent predictor of severe cardiac events (hazard ratio 3.39, p < 0.0001), independent of the LVEF and QRS width. Of patients with a QRS width <120 ms (55%; n = 57), 56% presented with major intra-LV asynchrony and 12% with inter-V asynchrony. Intra-LV asynchrony was observed in 84% of left bundle branch block patients, but also in 83% of right bundle branch block patients (p = NS). There was a poor correlation between the QRS width and intra-LV or inter-V asynchrony (r = 0.36, p = NS and r = 0.43, p = 0.05, respectively). ConclusionsIn HF patients without MI, patients with intra-LV asynchrony are those with a significantly higher risk of cardiac events, independent of the QRS width and LVEF. Accordingly, such patients should be more actively identified for early intensive treatment and survey.

Prognostic implications of restrictive left ventricular filling in reperfused anterior acute myocardial infarction

OBJECTIVESWe sought to assess the relative prognostic role of a restrictive left ventricular (LV) filling pattern after a first anterior acute myocardial infarction (AMI) in patients treated with primary percutaneous transluminal coronary angioplasty (PTCA).BACKGROUNDIn thrombolized patients, a short Doppler-derived mitral deceleration time (DT) of early filling is a powerful independent predictor of heart failure and death. However, it is still unknown whether the outcome of patients with AMI with a short DT may be improved by a more aggressive treatment.METHODSIn 104 patients, two-dimensional and Doppler echocardiograms were obtained three days after the index AMI. Coronary angiography was performed in all patients one and six months after PTCA. The patients were classified into two groups according to the DT duration: group 1 (n = 34) with DT ≤130 ms and group 2 (n = 70) with DT >130 ms. All patients were followed-up for a mean (±SD) period of 32 ± 10 months.RESULTSDuring the follow-up period, 14 patients (13%) were admitted to the hospital for congestive heart failure, and 9 patients (9%) died. All cardiac deaths (n = 7) occurred in group 1. The survival rate at mean follow-up was 79% in group 1 and 97.2% in group 2 (p = 0.003). Multivariate Cox analysis showed that only age and restrictive filling were independent predictors of event-free survival. Furthermore, when survival with no cardiovascular events was analyzed, a short DT still emerged as the most powerful independent predictor.CONCLUSIONSPatients with a restrictive LV filling pattern early after anterior AMI have a poor clinical outcome, even if treated with primary PTCA.

Risk factors for heart failure in the elderly: a prospective community-based study

PURPOSE: The risk factors for the development of heart failure are not clearly defined, particularly for older adults. We undertook the current investigation to examine the associations of traditional cardiovascular risk factors, comorbidity, and psychosocial factors with the risk of heart failure during 10 years of follow-up in a community-based elderly population. SUBJECTS AND METHODS: We evaluated 1,749 subjects, 65 years of age or older, free of heart failure, myocardial infarction, and angina at baseline, who were participating in the New Haven, Connecticut cohort of the Established Population for Epidemiologic Studies of the Elderly program. Cox proportional hazards regression models were used to determine risk ratios (RR) and 95% confidence intervals (CI). RESULTS: During 13,811 person-years of follow-up, 173 subjects developed incident heart failure, as confirmed by chart review. Five factors were independent predictors of heart failure: male sex (RR = 1.7; CI, 1.3 to 2.4), older age (RR = 1.9; CI, 1.3 to 2.7 for age 75 to 84 years, RR = 3.0; CI, 1.7 to 5.5 for age 85 years and older, compared with ≤74 years), diabetes (RR = 2.9; CI, 2.0 to 4.3), pulse pressure ≥70 mm Hg (RR = 2.3; CI, 1.3 to 4.3, compared with <50 mm Hg), and body mass index ≥28 kg/m 2 (RR = 1.6; CI, 1.0 to 2.4, compared with <24 kg/m 2). Myocardial infarction occurred during follow-up in 8% of the cohort and was also an important predictor of heart failure (RR = 21; CI, 15 to 31). CONCLUSIONS: Age and traditional cardiovascular risk factors are associated with the development of heart failure in the elderly. Preventive strategies should focus on the management of diabetes, blood pressure, and weight, in addition to the prevention and management of myocardial infarction.