Anjan Deka

Prevalence of Resistant Hypertension and Eligibility for Catheter-Based Renal Denervation in Hypertensive Outpatients

BACKGROUND Studies of endovascular renal denervation (RDN) have demonstrated significant blood pressure reduction in eligible patients with resistant hypertension. These trials have used stringent inclusion and exclusion criteria in patient enrollment, potentially selecting for a small subset of patients with resistant hypertension. In this study, we examined the changes in estimated prevalence of resistant hypertension when using increasingly stringent definitions of resistant hypertension in a fixed population and assessed the generalizability of RDN when applying study criteria to a community-based hypertensive population. METHODS A retrospective chart review was done of hypertensive outpatients. Four increasingly stringent interpretations of the American Heart Association definition of resistant hypertension were used to calculate prevalence estimates. Patients eligible for RDN were identified using criteria from SYMPLICITY HTN-3. Demographic and clinical characteristics were compared. RESULTS We identified 1,756 hypertensive outpatients; 55.0% were male, 53.9% were white, and subjects had a mean age of 66.6 ± 12.5 years and a body mass index (BMI) of 30.1 ± 10.7 kg/m(2). Only 14 (0.8%) were eligible for RDN. Among these patients, 10 (71.4%) were female and all were black, with a mean age of 69.9 ± 8.8 and BMI of 35.7 ± 6.6. Congestive heart failure was more common in patients eligible for RDN. CONCLUSIONS Patients eligible for RDN based on published studies represent an exceedingly small proportion of the total hypertensive population. Further studies are necessary to determine if the benefits of RDN can be generalized to a broader range of hypertensive patients than those included in previous trials.

Echocardiographic Assessment of Pulmonary Artery Systolic Pressure and Outcomes in Ambulatory Heart Failure Patients

Background Pulmonary hypertension (PH) in patients with heart failure (HF) is associated with worse outcomes and is rapidly being recognized as a therapeutic target. To facilitate pragmatic research efforts, data regarding the prognostic importance of noninvasively assessed pulmonary artery systolic pressure (PASP) in stable ambulatory patients with HF are needed. Methods and Results We examined the association between echocardiographic PASP and outcomes in 417 outpatients with HF (age, 54±13 years; 60.7% men; 50.4% whites; 24.9% with preserved ejection fraction). Median PASP was 36 mm Hg (interquartile range [IQR]: 29, 46). After a median follow‐up of 2.6 years (IQR: 1.7, 3.9) there were 72 major events (57 deaths; 9 urgent heart transplants; and 6 ventricular assist device implantations) and 431 hospitalizations for HF. In models adjusting for clinical risk factors and therapy, a 10‐mm Hg higher PASP was associated with 37% higher risk (95% CI: 18, 59; P<0.001) for major events, and 11% higher risk (95% CI: 1, 23; P=0.039) for major events or HF hospitalization. The threshold that maximized the likelihood ratio for both endpoints was 48 mm Hg; those with PASP ≥48 mm Hg (N=84; 20.1%) had an adjusted hazard ratio of 3.33 (95% CI: 1.96, 5.65; P<0.001) for major events and 1.47 (95% CI: 1.02, 2.11; P=0.037) for major events or HF hospitalization. Reduced right ventricular systolic function had independent prognostic utility over PASP for adverse outcomes. Right atrial pressure and transtricuspid gradient both contributed to risk. Conclusions Elevated PASP, determined by echocardiography, identifies ambulatory patients with HF at increased risk for adverse events.

Renal biomarkers and outcomes in outpatients with heart failure: The Atlanta cardiomyopathy consortium

BACKGROUND/OBJECTIVES Cystatin-C and beta-2-microglobulin may be superior to serum creatinine, blood urea nitrogen (BUN), or estimated glomerular filtration rate (eGFR) in patients hospitalized with heart failure (HF). We compared these renal markers in ambulatory HF patients. METHODS We prospectively evaluated the association of baseline renal markers and eGFR (by 4 different formulas) with (1) the composite of death or HF-related hospitalization and (2) rates of hospitalizations and emergency department (ED) visits in 166 outpatients with HF (57.3±11.6years; 57.2% white, 38.6% black, median left ventricular ejection fraction 27.5% [17.5, 40.0]). RESULTS After a median of 3.9years, 63 (38.0%) patients met the composite endpoint. There were 458 hospitalizations (177 [38.6%] for HF) and 209 ED visits (51 [24.4%] for HF). Cystatin-based eGFR most consistently predicted (1) the composite endpoint (highest-to-lowest tertile adjusted hazard ratio [HR] 4.92 [95% CI 2.07-11.7; P<0.001]); and (2) hospitalization rates, including HF hospitalizations (highest-to-lowest tertile, adjusted relative rate 5.24 [95% CI 1.61-17.01; P=0.006]). Serum creatinine alone was a strong predictor of the composite endpoint (highest-to-lowest tertile, adjusted HR 3.20 [95% CI, 1.51-6.78; P=0.002]). Only the highest tertile of BUN was associated with rates of ED visits. CONCLUSIONS In outpatients with HF, cystatin-based eGFR provides consistent prognostication across outcomes, except ED visits. Serum creatinine is an adequate prognosticator of death or HF hospitalization.

Pulmonary Function Testing and Outcomes in Subjects With Heart Failure Listed for Heart Transplantation

BACKGROUND: Impaired spirometric parameters have been reported in patients with stage C heart failure and portend worse outcomes in these patients. The impact of spirometric parameters on outcomes in patients with stage D heart failure listed for heart transplantation is unknown. METHODS: We collected data on consecutive subjects listed for heart transplantation and examined the association of FEV1, FVC, and FEV1/FVC with (1) death or left ventricular assist device implantation (primary end point) and (2) death, left ventricular assist device implantation, or urgent transplantation (secondary end point). In a secondary analysis, we examined the association of baseline spirometry with post-transplant outcomes. RESULTS: Among 187 subjects (53 ± 10 y old, 17.1% women, 69.5% white subjects, 28.9% black subjects), there were 19 deaths, 28 left ventricular assist device implantations, and 74 urgent transplantations (primary end point of 25.1%, secondary end point of 64.7%) after a median of 5.5 months (interquartile range of 2.3–15.2). For FEV1, the hazard ratios for the primary and secondary end points were 0.93 (95% CI 0.61–1.41, P = .72) and 0.94 (95% CI 0.72–1.21, P = .62) per L, respectively. The hazard ratios of FVC were 0.90 (95% CI 0.65–1.25, P = .52) and 0.92 (95% CI 0.76–1.13, P = .43) per L, respectively. Impairment patterns (obstructive, restrictive, mixed) were not associated with risk for events. There was no interaction of spirometric parameters with smoking or lung disease for outcomes. Baseline spirometry was not associated with perioperative 30-d mortality (1.4%) and 1-y post-transplant survival (97.1%). CONCLUSIONS: In contrast to stage C subjects with heart failure, spirometric parameters were not associated with outcomes in this homogeneous stage D heart failure population.

INCREASED LEVELS OF SOLUBLE FMS-LIKE TYROSINE KINASE 1 (SFLT-1) ARE ASSOCIATED WITH WORSE OUTCOMES IN OUTPATIENTS WITH HEART FAILURE

Results: Over 32±8 months (total: 465 person-years), there were 27 (15.6%) clinical events (22 deaths, 4 transplants, 1 ventricular assist device), 413 all-cause admissions (167 [40.4%] for HF), and 199 ED visits. Baseline sFLT-1, PlGF, and sFLT-1/PlGF were 339±83 pg/ml, 19.2±5.1 pg/ml, and 18.9±7.4, respectively. Compared to the lower sFLT-1 tertile, patients in the upper tertile had (1) increased risk for clinical events (HR 4.5; 95% CI 1.2-17.3; P=0.029) and (2) higher healthcare resource utilization rates (Figure) in models adjusted for age, gender, race, systolic blood pressure, creatinine, NYHA class and EF. PlGF and sFLT-1/PlGF were not predictive of outcomes.