Ahmad Shoaib

Prevalence and Outcomes of Anemia and Hematinic Deficiencies in Patients With Chronic Heart Failure

IMPORTANCE Detailed information on the prevalence, associations, and consequences of anemia and iron deficiency in epidemiologically representative outpatients with chronic heart failure (HF) is lacking. OBJECTIVE To investigate the epidemiology of anemia and iron deficiency in a broad range of patients referred to a cardiology clinic with suspected HF. DESIGN, SETTING, AND PARTICIPANTS We collected clinical data, including hemoglobin, serum iron, transferrin saturation, and serum ferritin concentrations, on consecutive patients referred with suspected HF to a single outpatient clinic serving a local community from January 1, 2001, through December 31, 2010. Follow-up data were censored on December 13, 2011. Patients underwent phenotyping by echocardiography and plasma N-terminal pro-brain natriuretic peptide measurement and were followed for up to 10 years. MAIN OUTCOME MEASURES Prevalences of anemia and iron deficiency and their interrelationship, all-cause mortality, and cardiovascular mortality. RESULTS Of 4456 patients enrolled in the study, the median (interquartile range) age was 73 (65-79) years, 2696 (60.5%) were men, and 1791 (40.2%) had left ventricular systolic dysfunction (LVSD). Of those without LVSD, plasma N-terminal pro-brain natriuretic peptide concentration was greater than 400 pg/mL in 1172 (26.3%), less than 400 pg/mL in 841 (18.9%), and not measured in 652 (14.6%). Overall, 1237 patients (27.8%) had anemia, with a higher prevalence (987 [33.3%]) in patients who met the criteria for HF with or without LVSD. Depending on the definition applied, iron deficiency was present in 270 (43.2%) to 425 (68.0%) of patients with and 260 (14.7%) to 624 (35.3%) of patients without anemia. Lower hemoglobin (hazard ratio 0.92; 95% CI, 0.89-0.95; P < .001) and serum iron (hazard ratio 0.98; 95% CI, 0.97-0.99; P = .007) concentrations were independently associated with higher all-cause and cardiovascular mortality in multivariable analyses. CONCLUSIONS AND RELEVANCE Anemia is common in patients with HF and often associated with iron deficiency. Both anemia and iron deficiency are associated with an increase in all-cause and cardiovascular mortality and might both be therapeutic targets in this population.

Breathlessness at rest is not the dominant presentation of patients admitted with heart failure.

Many assume that most patients hospitalized with heart failure (HF) are short of breath at rest (SOBAR). The National HF Audit for England and Wales suggests that this assumption is false, which has profound implications for management

Measurement of troponin and natriuretic peptides shortly after admission in patients with heart failure-does it add useful prognostic information? An analysis of the Value of Endothelin Receptor Inhibition with Tezosentan in Acute heart failure Studies (VERITAS)

Plasma concentrations of B‐type natriuretic peptide (BNP) and troponin are often measured for diagnostic purposes when patients are admitted with heart failure, but their prognostic value when measured soon after admission is uncertain. We aimed to investigate the added prognostic value of admission measurements of BNP and troponins in patients with acute heart failure.

Hydralazine and nitrates alone or combined for the management of chronic heart failure: A systematic review.

BACKGROUND Hydralazine (H) and nitrates (Ns), when combined, reduced morbidity and mortality in some trials of chronic heart failure (CHF). It is unclear whether either agent used alone provides similar benefits. We aimed to evaluate the effects of H and/or N in patients with CHF. METHODS A systematic review of randomised trials assessing the effects of H and N in CHF. For meta-analysis, only the endpoints of all-cause mortality and cardiovascular mortality were considered. RESULTS In seven trials evaluating H&N in 2626 patients, combination therapy reduced all-cause mortality (OR 0.72; 95% CI 0.55-0.95; p=0.02), and cardiovascular mortality (OR 0.75; 95% CI 0.57-0.99; p=0.04) compared to placebo. However, when compared to angiotensin converting enzyme inhibitors (ACEIs), combination therapy was associated with higher all-cause mortality (OR 1.35; 95% CI 1.03-1.76; p=0.03), and cardiovascular mortality (OR 1.37; 95% CI 1.04-1.81; p=0.03). For N alone, ten trials including 375 patients reported all-cause mortality and showed a trend to harm (13 deaths in those assigned to nitrates and 7 to placebo; OR 2.13; 95% CI 0.88-5.13; p=0.09). For H alone, three trials showed no difference in all-cause mortality compared to placebo (OR 0.96; 95% CI 0.37-2.47; p=0.93), and two trials suggested inferiority to ACEI (OR 2.28; 95% CI 1.03-5.04; p=0.04). CONCLUSIONS Compared to placebo, H&N reduces mortality in patients with CHF. Whether race or background therapy influences benefit is uncertain, but on direct comparison H&N appears inferior to ACEI. There is little evidence to support the use of either drug alone in CHF.

Is the diagnostic coding position of acute heart failure related to mortality? A report from the Euro Heart Failure Survey-1

Most studies on acute heart failure (HF) exploring the relationship between admissions to hospital for HF and subsequent outcomes have focused only on HF coded as the primary diagnosis, but many other patients have admissions complicated by HF requiring attention. Failure to quantify the total hospital burden of HF underestimates its health economic impact, leading to underprovision of resources for its care.

59 Is Presentation of Acute Heart Failure Patients Linked to Mortality

Introduction Acute heart failure is an increasingly common cause for hospital admissions. It is largely presumed that these patients have breathlessness at rest, but National Audit data suggest otherwise. In clinical practice, treatment for acutely breathless patients is usually given within minutes of presentation but novel therapies studied in trials are not usually implemented until 6–12 h after initial presentation and treatment. Methods We collected detailed information retrospectively from the case-notes of a representative sample of patients admitted with a primary death/discharge diagnosis of heart failure to determine what proportions of patients were Short Of Breath At Rest (SOBAR) and Comfortable At Rest but Breathless On Slight Exertion (CARBOSE). We measured blood pressure (BP), heart rate and respiratory rate (RR) at initial presentation at 1, 2, 3, 4–6, 6–12 and 12–24 h. Results are described in median and Interquartile (IQR) ranges and the proportion with a systolic BP (SBP) >125 mmHg (RELAX-HF entry criterion). We assessed mortality in different groups at discharge, and 30 days, 90 days and 180 days after presentation. Results Of the 307 patients enrolled, 43% had SOBAR and 57% CARBOSE; 34% were women, the median age was 77 (IQR 71–84) years and median amino-terminal probrain natriuretic peptide (NT-proBNP) was 4082 (IQR: 1895–10,279 ng/L). Compared to patients with CARBOSE, patients with SOBAR were younger (76 vs 78 years), had higher HR (100 vs 85 bpm), SBP (141 vs 122 mmHg) and RR (24 vs 18 rpm) and were more often in atrial fibrillation (54% vs 49%). SBP was >125 mmHg in 73% patients with SOBAR and 46% with CARBOSE. SBP (122–116 mmHg), HR (85–82 bpm), and RR (18–18 rpm) changed little amongst patients with CARBOSE in the first 4–6 h but all declined steeply in patients with SOBAR (141–128 mmHg, 100–90 bpm, and 24–20 rpm, respectively). Overall 47% patients died in CARBOSE and 31% in SOBAR (HR 1.58, p-value = 0.02). After adjusting for age and sex, patients with CARBOSE had significantly higher all-cause mortality than SOBAR (HR = 1.70, p = 0.004). Further adjustment with Systolic Blood pressure, Heart Rate, Respiratory Rate, Creatinine levels and LVSD provided more evidence that CARBOSE was independently predictive of all-cause mortality (HR = 2.26, p = 0.003). Conclusion Most patients admitted with a primary diagnosis of heart failure present with CARBOSE rather than SOBAR. Patients presenting with SOBAR had, as expected, higher BP, heart and respiratory rates. CARBOSE showed little variation in these clinical characteristics in first 24 h but suffered higher mortality during hospital admission and at 30, 90, 180 days of presentation. Despite a higher risk of mortality, due to low BP, relatively fewer numbers of patients were suitable for serelaxin in CARBOSE. Abstract 59 Figure 1

Validation of U.S. mortality prediction models for hospitalized heart failure in the United Kingdom and Japan

Prognostic models for hospitalized heart failure (HHF) were developed predominantly for patients of European origin in the United States of America; it is unclear whether they perform similarly in other health care systems or for different ethnicities. We sought to validate published prediction models for HHF in the United Kingdom (UK) and Japan.

Nitrates for the Management of Acute Heart Failure Syndromes, A Systematic Review

Intravenous nitrates are widely used in the management of acute heart failure syndrome (AHFS) yet with lack of robust evidence to support their use. We therefore sought to analyze all randomized studies that evaluated the effects of nitrates on clinical outcomes in patients with AHFS. In total, 15 relevant trials comparing nitrates and alternative interventions in 1824 patients were identified. All but 3 were conducted before 1998. No trials demonstrated a beneficial effect on mortality, apart from 1 trial reporting a reduction in mortality, which was related to the time of treatment. Retrospective review suggests that there is a lack of data to draw any firm conclusions concerning the use of nitrates in patients with AHFS. More studies are needed to evaluate the safety and efficacy of these agents in the modern era of guideline-directed use of heart failure therapy.

DOES THE SEVERITY OF PERIPHERAL OEDEMA AFFECT THE MORTALITY OF PATIENTS PRESENTING WITH ACUTE HEART FAILURE? A DEEP DIVE INTO THE NATIONAL HEART FAILURE AUDIT

Heart failure (HF) is one of the commonest reasons for hospital admission. Key symptoms of HF are breathlessness (pulmonary oedema) and peripheral oedema. Most studies of ‘acute’ heart failure focus on breathlessness but peripheral oedema might be the more important presentation. We tested the

Nitrates for the Management of Acute Heart Failure Syndromes

Intravenous nitrates are widely used in the management of acute heart failure syndrome (AHFS), yet with lack of robust evidence to support their use. We therefore sought to analyse all randomised studies that evaluated the effects of nitrates on clinical outcomes in patients with AHFS. In total, fifteen relevant trials comparing nitrates and alternative interventions in 1824 patients were identified. All but three were conducted before 1998. No trials demonstrated a beneficial effect on mortality, apart from one trial reporting a reduction in mortality, which was related to the time of treatment. Retrospective review suggests that there is a lack of data to draw any firm conclusions concerning the use of nitrates in patients with AHFS, which is surprising given the widespread use of nitrates. More studies are needed to evaluate the safety and efficacy of these agents in the modern era of guideline-directed use of heart failure therapy.