Predictor Of Acute Heart Failure Research Articles

N-terminal pro-B-type natriuretic peptide and pulmonary echography are predictors of acute heart failure needing early mechanical ventilation in acute coronary syndrome.

The aim of this study was to determine the best clinical predictors of acute heart failure needing mechanical ventilation (MV) in the first 48 h of evolution of patients admitted because of acute coronary syndrome (ACS). We analyzed a cohort of patients admitted for ACS between February 2017 and February 2018. A pulmonary ultrasound was performed on admission and was considered positive (PE+) when there were three or more B-lines in two quadrants or more of each hemithorax. It was compared with N-terminal pro-B-type natriuretic peptide (NT-proBNP), peak troponin T-us value GRACE (Global Registry of Acute Coronary Events), CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology and American Heart Association guidelines - Bleeding Score), CACS (Canada Acute Coronary Syndrome risk score), and HAMIOT (Heart Failure after Acute Myocardial Infarction with Optimal Treatment score) scores, shock index, ejection fraction, chest X-ray, and Killip class at admission as predictors of MV in the first 48 h of admission. A total of 119 patients were included: 54.6% with ST elevation and 45.4% without ST elevation. Twelve patients (10.1%) required MV in the first 48 h of evolution. The sensitivity of PE+ was 100% (73.5-100%), specificity 91.6% (84.6-96.1%), and area under the curve was 0.96 (0.93-0.96). The sensitivity of an NT-proBNP value more than 3647 was 88.9% (51.9-99.7%), specificity 92.1% (84.5-96.8%), and area under the curve was 0.905 (0.793-1). The κ statistic between both predictors was 0.579. All the other scores were significantly worse than PE + . Lung ultrasound and a high NT-proBNP (3647 ng/L in our series) on admission are the best predictors of acute heart failure needing MV in the first 48 h of ACS. The agreement between both tests was only moderate.

246 Sonographic Right Ventricular Dysfunction Predicts Acute Heart Failure Outcomes Independent of Current Emergency Department Risk Measures

Right ventricular dysfunction (RVD) on ultrasound is one of the strongest predictors of acute heart failure (AHF) risk in inpatient and outpatient studies but has not been studied in the ED. We sought to evaluate the performance of RVD-assessment on emergency physician (EP)-performed point of care ultrasound (POCUS) to predict AHF risk when compared to currently utilized measures of AHF risk stratification. Right Ventricular Evaluation in ED AHF (REED-AHF) is an ongoing prospective observational study at two urban-academic hospitals, supported by a grant from the Blue Cross Blue Shield of Michigan Foundation. EP POCUS has been performed in 66 (of planned 123) patients with suspected AHF ≤60 minutes after initiation of IV diuresis, vasodilator, or non-invasive positive pressure ventilation. Ten met exclusion criteria (failure to obtain consent within 24 hours of the POCUS, or ED physician indicated that AHF was not suspected by time of disposition), resulting in a 56-person sample thus far. Patients were followed (phone) at 30 days for the primary composite outcome of AHF-readmission, mortality, new onset dialysis, intubation, acute coronary intervention and/or ICU admission. Using logistic regression, tricuspid annular plane systolic excursion (TAPSE) and free-wall RV strain (fwRVLS) were evaluated in separate models as POCUS markers of RVD for prediction of the primary outcome, adjusted for ED measures of AHF risk specified a priori: troponin, age, estimated glomerular filtration rate, ejection fraction, and chronic obstructive pulmonary disease history. TAPSE and fwRVLS were normally distributed with mean and standard deviation of 20 +/- 6mm and -17 +/- 6 strain units, respectively. Mean age was 62 +/- 13 years, while mean ejection fraction was 31 +/- 13%. The composite outcome occurred in 20 patients (36%). TAPSE was independently associated with the composite outcome (odds ratio [OR]=0.42 per 6 mm increase; 95% confidence interval [CI]:0.20-0.90), while fwRVLS showed a trend towards significance (OR=0.37 per 6 unit improvement; 95% CI: 0.27-1.02). Area under the receiver operating curve (AUROC) for the models of TAPSE and fwRVLS were 0.72 (95% CI:0.58-0.86) and 0.75 (0.61-0.89), respectively. No other risk markers reached statistical significance after adjustment for TAPSE. Further analyses including time to POCUS image acquisition, comparison of TAPSE and fwRVLS cutoffs, and sensitivity analysis for other potential confounders are pending completion of the study enrollment. TAPSE obtained by EPs on POCUS independently predicted 30-day adverse outcomes. Conversely, pending completion of study enrollment, clinical risk-markers currently used for AHF risk-stratification to predict 30-day outcomes were non-significant after adjustment for TAPSE. Further studies are warranted to externally validate our results, and to assess the most effective and feasible clinical implementation of RV POCUS into a broader strategy of AHF risk-stratification by EPs.

P3535Prognostic value of congestion status by bioelectrical impedance analysis and natriuretic peptide levels in acute heart failure with preserved versus reduced left ventricular ejection fraction

Abstract Background N-terminal pro-brain natriuretic peptide (NT-proBNP) is a well-known predictor of acute heart failure (HF). Congestion volume status estimated by bioelectrical impedance analysis (BIA) is also associated with adverse cardiovascular events in HF patients. However, it is unclear whether these biomarkers reflecting pathophysiological pathways are different between HF with preserved (HFpEF) and reduced ejection fraction (HFrEF). Purpose The aim of this study was to investigate whether the prognostic value of NT-proBNP and extracellular water/free fat mass (ECW%) assessed by BIA is different between HFrEF and HFpEF in acute HF patients. Methods and results One hundred-and-forty-three patients admitted for acute HF between November 2013 and January 2015 were estimated for NT-proBNP levels and ECW% by BIA on admission. A total of 49 HFrEF (LVEF<40%) and 75 HFpEF (LVEF≥50%) patients were included in this study (mean age: 76±14 years, male: 63%). The median of NT-proBNP levels in HFrEF patients was higher than in HFpEF (6022 [IQR: 2531–9163] pg/mL and 3179 [1076–6054] pg/mL, respectively, p=0.012). Conversely, ECW% was similar between HFrEF and HFpEF (29.0 [25.7–33.7] % and 31.7 [27.3–38.8] %, respectively, p=0.088). The primary endpoint was the composite of all-cause mortality and/or hospitalisation due to HF. During a median follow-up of 5.9 months, 16 (35.6%) and 35 (50.7%) patients were observed to have composite events in HFrEF and HFpEF, respectively, (p=0.111). Elevated NT-proBNP levels in HFrEF patients were associated with an increased risk of composite events after adjustment for traditional risk factors (hazard ratio [HR]: 2.39; 95% Confidence interval [CI]; 1.04–5.47; p=0.040), but not in HFpEF (p=0.063). Meanwhile, a high ECW% in HFrEF patients was associated with increasing composite events risk (HR: 3.30; 95% CI; 1.32–8.25; p=0.011), as well as in HFpEF patients (HR: 1.62; 95% CI; 1.03–2.55; p=0.037). Furthermore, the ECW% in addition to NT-proBNP in HFpEF patients resulted in a significant improvement in prediction for composite events (net reclassification improvement 0.67 [95% CI 0.24–1.11]; p=0.002 and integrated discrimination improvement 0.12 [0.004–0.20]; p=0.004). Conclusion Elevated levels of NT-proBNP in acute HF were predictive for mortality and hospitalisation due to HF in HFrEF but may not be for HFpEF patients, and ECW% had a better predictive value than NT-proBNP in HFpEF patients.

P5005Diagnostic and prognostic utilities of insulin-like growth factor-binding protein-7 in patients presenting to the emergency department with dyspnea: results from the ICON-RELOADED study

Abstract Background Increased activity of insulin-like growth factor–binding protein-7 (IGFBP7) is associated with cellular senescence, tissue aging, and obesity. Prior studies in chronic heart failure (HF) have linked IGFBP7 to impaired myocardial relaxation. The role of IGFBP7 measurement in acute HF remains unclear. Purpose To examine whether concentrations of IGFBP7 in patients presenting with dyspnea to the emergency department (ED) will aid in the diagnosis and prognosis of acute HF beyond N-terminal pro- B type natriuretic peptide (NT-proBNP). Methods The ICON-RELOADED (International Collaborative of NT-proBNP- Re-evaluation of Acute Diagnostic Cut-Offs in the Emergency Department) study was a prospective, multicenter clinical trial conducted at 19 sites in North America that enrolled subjects ≥22 years of age presenting to ED with complaints of dyspnea. Subjects were blindly adjudicated for the diagnosis of acute HF. A blood sample was taken at enrollment. Six-month prognosis for death/repeat hospitalization was obtained. IGFBP7 was measured using a pre-clinical research use only assay. Results Among 1449 patients (n=274 with acute HF), those with IGFBP7 concentrations in the highest quartile (>123.7 ng/mL) were older, more likely to be male and to have a history of hypertension and HF (all p<0.001). They also had lower estimated glomerular filtration rate (eGFR) and the lowest left ventricular ejection fraction (41% ± 21%) prior to study enrollment (all p<0.001). Independent predictors of IGFBP7 included age, male sex, history of diabetes, history of HF, and eGFR (all p<0.001). Median concentrations of NT-proBNP (2844 vs. 99 ng/mL) and IGFBP7 (146.1 vs. 86.1 ng/mL) were significantly higher in those with acute HF (both p<0.001); addition of IGFBP7 to NT-proBNP concentrations improved discrimination, increasing the area under the receiver operating curve for diagnosis of acute HF (from 0.91 to 0.94; p<0.001) (Figure 1). Addition of IGFBP7 to a complete model of independent predictors of acute HF (including NT-proBNP) improved model calibration; IGFBP7 also significantly re-classified acute HF diagnosis beyond NT-proBNP alone (net reclassification improvement +0.25; p<0.001). Higher log2-IGFBP7 concentrations predicted death/rehospitalization at 6 months (hazard ratio 1.74 per log2-standard deviation, 95% confidence interval 1.26–2.40, p=0.001). In Kaplan-Meier analyses, supramedian concentrations of IGFBP7 were associated with shorter event-free survival (log-rank p<0.001). ROC curve for diagnosis of acute HF Conclusions Among patients with acute dyspnea, concentrations of IGFBP7 add to NT-proBNP for diagnosis of acute HF and provide added prognostic utility for short-term risk. Acknowledgement/Funding Funding for this study was provided by Roche Diagnostics (Risch-Rotkreuz, Switzerland).

Predictors of acute heart failure in patients during the acute period of Q-wave myocardial infarction

The aim was to identify predictors of acute heart failure (AHF) in patients with acute Q-wave myocardial infarction (MI).Materials and methods. A total of 139 patients in the acute period of Q-wave MI were examined, average age was 66.00 ± 0.97 years (M ± m). Patients were divided into 2 groups depending on AHF presence: without AHF – 46 persons, the mean age was 61.00 ± 1.87 years (M ± m) and with developed AHF – 93 persons (Killip II, n = 51; Killip III, n = 42), the mean age was 69.2 ± 8.3 years (M ± m). The patients underwent general clinical examination, blood glucose level was determined on admission, transthoracic Doppler echocardiography was performed and copeptin and NTproBNP levels were measured.Results. According to univariate logistic regression analysis, hyperglycemia in the acute period of Q-wave MI was associated with a probable increase in the odds ratio of AHF by 1.24 times (95 % CI 1.08–1.44; P = 0.003). According to the results of the ROC-analysis, the critical level of glycemia was >9.3 mmol/l (sensitivity 47.8 %, specificity 78.3 %), the area under the ROC-curve was 0.666 (95 % CI 0.580–0.745; P = 0.0004). With the development of systolic dysfunction in the acute period of MI, the odds ratio of AHF increased by 5.69 times (95 % CI 2.47–13.14; P < 0.0001). An increase in copeptin level of more than 0.53 ng/ml (sensitivity 93.1 %, specificity 28.6 %) and the area under the ROC curve of 0.633 (95 % CI 0.543–0.716; P = 0.0086) were associated with an increase in the odds ratio of AHF by 1.39 times (95 % CI 1.06–1.83; P = 0.02). There was no dependence of AHF on NTproBNP level – OR = 1.001 (95 % CI 0.99–1.01; P = 0.36). According to multivariate logistic regression analysis, independent risk factors for AHF were the hyperglycemia level on admission of more than 9.3 mmol/l OR = 1.19 (95 % CI 1.01–1.39; P = 0.036) and left ventricular (LV) systolic dysfunction – OR = 5.24 (95 % CI 2.03–13.55; P = 0.001).Conclusions. In patients with acute Q-wave MI complicated by AHF, the admission levels of copeptin and glycemia were significantly higher andLV ejection fraction was significantly lower. The dependent risk factors for AHF in patients with acute Q-wave MI were glycemia level of more than 9.3 mmol/l, an increase in copeptin level of more than 0.53 ng/ml, andLV systolic dysfunction. Independent risk factors for AHF in the acute period Q-wave MI were hyperglycemia andLV systolic dysfunction.

THE VALUE OF SULPHUR-CONTAINING AMINO-ACIDS IN BLOOD PLASMA AS PROGNOSTIC MARKERS OF COMPLICATED COURSE OF ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION (STEMI) WITHOUT REPERFUSION THERAPY

Relevance. The sulfation of homocysteine is an important element in protecting cells against ischemic-reperfusion injury. In clinical studies the positive effect of N-acetylcysteine ​​on the reduction of necrosis was found in patients with STEMI.&#x0D; Objective of this study was to evaluate the baseline levels of sulphur-containing amino acids in plasma as predictors of early (on the day of admission) systolic dysfunction of left ventricle (SDLV) and acute heart failure (HF) in patients with STEMI without reperfusion therapy (RT).&#x0D; Material and methods. 92 patients with STEMI without RT were examined. The content of free plasma sulphur-containing aminо acids (homocysteine, cysteine ​​and methionine) was investigated on the day of admission by ion-exchanged liquid-column chromatography.&#x0D; Results. The complications of STEMI were associated with increased baseline levels of sulphur-containing aminо acids, especially, cysteine ​​and methionine. Its levels were significantly higher (at 71.7%, р&lt;0.01, and 41.3%, р&lt;0.05, respectively) in patients with early SDLV compared with patients with ejection fraction of left ventricle (LVEF) &gt;40%. The multivariate logistic regression analysis revealed that the baseline level of cysteine in patients with STEMI remained an independent predictor of early (on the day of admission) SDLV (OR=17.4, p&lt;0.001) after adjustment for anamnestic and laboratory factors. The sensitivity and specificity of baseline cysteine ​​level &gt;0.49 mg/dl as a marker of early SDLV were 73.9% and 65.2% respectively (AUC=0.72, p=0.006). The multivariate analysis revealed that the baseline level of methionine was an independent predictor of acute HF on the day of admission after adjustment for laboratory factors (OR=25.9, p&lt;0.001). Also methionine was an independent predictor of persistent / late HF on third day or later in total sampling (OR=25.9, p&lt;0.001) after adjustment for demographic, anamnestic and clinic factors (OR=68.7, p&lt;0.0001), as well as after adjustment for laboratory risk factors (OR=42.5, p&lt;0.0001). The sensitivity and specificity of baseline methionine ​​level &gt;0.31 mg/dl as a marker of persistent / late HF were 87.5% and 63.3% respectively (AUC = 0.77, p &lt;0.0001). Also the baseline level of methionine was an independent predictor of persistent / late HF in patients with EFLV &gt;40% after adjustment for demographic and anamnestic factors (OR=113.3, p &lt;0,0001). The sensitivity and specificity of methionine ​​level &gt;0.41 mg/dl as a marker of persistent / late HF in patients with EFLV &gt;40% were 80.0% and 81.0% respectively (AUC=0.80, р&lt;0.0001).&#x0D; Conclusions. The complicated course of STEMI without RT is associated with increased level of sulphur-containing aminо acids, especially, cysteine ​​and methionine. A higher level of cysteine ​​is associated with early SDLV independently from anamnesis risk factors and creatinine level in plasma. The risk of persistent / late HF (on third day and later) is associated with a higher level of methionine independently from demographic, anamnestic, clinical and laboratory factors risk.

P6418Modified shock index - an independent predictor of acute heart failure and in-hospital mortality in patients with ST-segment elevation myocardial infarction

P6418Modified shock index - an independent predictor of acute heart failure and in-hospital mortality in patients with ST-segment elevation myocardial infarction

Echocardiographic predictor of acute heart failure after spine surgery: a novel tissue Doppler index associated with a potentially fatal complication of the operation

Background contextAcute heart failure (HF) is a potentially fatal complication after spine surgery. PurposeWe sought to identify clinical and echocardiographic predictors of postoperative HF in spine surgery patients. Study designRetrospective observational study. Patient sampleA total of 305 patients (128 men; age, 65±9 years) who underwent spine surgery were consecutively enrolled. A transthoracic echocardiography was performed to all patients before the index operation. Patients with a history of HF or with left ventricular (LV) systolic dysfunction (LV ejection fraction <50%) were excluded. Outcome measuresHeart failure was defined according to the Framingham criteria. The presence of postoperative dyspneic symptom and the sign of bilateral ankle edema were recorded by the physicians. Chest X-ray was mandatory for all patients and interpreted by the two physicians, including at least one radiologist. MethodsClinical, operative, and echocardiographic parameters were compared between patents with and without acute HF during the postoperative period (duration, 11±9 days). This study was supported by Boryung Pharmaceutical Company (Seoul, Republic of Korea; 13,440 USD). ResultsPostoperative HF occurred in 31 patients (10%). Compared with those without postoperative HF, these patients were older (73±7 vs. 64±9 years), had longer anesthesia time (7.4±4.2 vs. 3.6±2.1 hours), and were treated with a greater volume of fluid replacement during the operation (3.8±0.7 vs. 1.3±0.1 L) (p<.05 for all). On echocardiographic evaluation, the ratio of early diastolic mitral inflow velocity to early diastolic mitral annular velocity (E/E′) was higher (11 vs. 8) and left atrial volume index was larger (20±6 vs. 17±6 mL/m2) in patients with HF than in the control group (p<.05 for all), whereas the differences in LV ejection fraction and LV size were not significant. In multivariate analysis, E/E′ (odds ratio, 1.399; 95% confidence interval, 1.169–1.674; p<.0001), age, and quantity of replaced volume during surgery were independent predictors of postoperative HF. ConclusionsAcute HF after spine surgery was rather common even in previously healthy patients. E/E′ reflecting LV filling pressure predicted postoperative HF in patients who underwent spine surgery.

Differential clinical characteristics and outcome predictors of acute heart failure in elderly patients

ObjectiveWe determined the clinical-epidemiological characteristics and prognostic factors of early mortality and re-consultation in an elderly population attending the hospital emergency department (HED) for acute heart failure (AHF). Patients and methodsA prospective, observational, non interventional study including all the patients with AHF attended in the Spanish's HED. Two groups were defined: elderly (≥80years) and controls (<80years). Variables: demographic characteristics, comorbidity, degree of cardiac involvement, previous treatment, symptoms and signs of the AHF episode, precipitating factors, treatment in the HED and outcome. Outcome variables: mortality and re-consultation within 30days. ResultsOf the 942 patients included, 455 of whom were elderly (48.3%). In this elderly population female sex, auricular fibrillation and a history of ictus and a poor functional status predominated. The type of ventricular dysfunction was unknown in 70%. No main differences in the presentation of AHF were found between the two groups. Mortality and re-consultation to the HED within 30days were similar in both groups. While several factors were identified to be related to mortality or re-consultation in control group, in the elderly group it was more difficult to identify patients who will die or re-consult to the HED within the following 30days. Only respiratory insufficiency on arrival to the HED was found to predict a greater probability of death (OR 3.55; CI95% 1.39–9.11). ConclusionsAHF in elderly patients presents some differential characteristics and, most importantly, it is more difficult to identify which of these patients will die or re-consult in the short-term.

Prognostic Implications of Serial Assessments of Pulmonary Hypertension in Severe Chronic Heart Failure

It is unknown whether time-related changes of pulmonary hypertension (PH) have prognostic relevance in severe chronic heart failure (CHF). All CHF patients referred for follow-up from 1996 through 2003 were screened for this study. Eligibility depended on availability of a concomitant clinical, laboratory, electrocardiographic (ECG), echocardiographic and right-heart catheterization (RHC) assessment at index evaluation, as well as absence of pre-capillary PH. One hundred ninety-six patients (age 54 +/- 9 years; 27% women, 73% men; 50% in New York Heart Association [NYHA] Class III or IV) were included. PH at index evaluation was an independent predictor of acute heart failure or cardiovascular death (AHF/CD), with adjusted risk ratio (RR) = 2.30, 95% confidence interval (CI) 1.42 to 3.73 and p < 0.001. A pre-study (> or =6 months) RHC was available for 174 of the 196 patients. Worsening of mean pulmonary artery pressure (mPAP) of > or =30% (a pre-specified cut-off corresponding to the 75th percentile of DeltamPAP%) provided prognostic information independent of all index-evaluation parameters (adjusted RR = 2.60, 95% CI 1.45 to 4.67, p = 0.001), and from time-related changes in the other hemodynamic parameters (p < or = 0.033). PH retains independent prognostic significance even after adjusting for a large set of clinical/laboratory/instrumental parameters. Furthermore, serial measurements of mPAP seem to provide additional prognostic information as compared with a single assessment. These findings indicate that serial evaluations of PAP may help identify a sub-set of high-risk CHF patients deserving a particularly close follow-up to facilitate timely indications for non-pharmacologic strategies, including (when appropriate) heart transplantation.

59 Admission hyperglycemia is an independent predictor of acute heart failure and short-term mortality in patients after acute myocardial infarction in the contemporary primary angioplasty era

59 Admission hyperglycemia is an independent predictor of acute heart failure and short-term mortality in patients after acute myocardial infarction in the contemporary primary angioplasty era

QT dispersion as a predictor of acute heart failure after high-dose cyclophosphamide

No useful predictor of risk of acute heart failure in peripheral-blood stem-cell transplantation (PBSCT) regimens, Including high-dose cyclophosphamide, has previously been available. Corrected QT dispersion can predict acute heart failure after high-dose cyclophosphamide chemotherapy used in PBSCT.