Janet Wynne

Cardiac Troponin and Outcome in Acute Heart Failure

BACKGROUND Cardiac troponin provides diagnostic and prognostic information in acute coronary syndromes, but its role in acute decompensated heart failure is unclear. The purpose of our study was to describe the association between elevated cardiac troponin levels and adverse events in hospitalized patients with acute decompensated heart failure. METHODS We analyzed hospitalizations for acute decompensated heart failure between October 2001 and January 2004 that were recorded in the Acute Decompensated Heart Failure National Registry (ADHERE). Entry criteria included a troponin level that was obtained at the time of hospitalization in patients with a serum creatinine level of less than 2.0 mg per deciliter (177 micromol per liter). A positive troponin test was defined as a cardiac troponin I level of 1.0 microg per liter or higher or a cardiac troponin T level of 0.1 microg per liter or higher. RESULTS Troponin was measured at the time of admission in 84,872 of 105,388 patients (80.5%) who were hospitalized for acute decompensated heart failure. Of these patients, 67,924 had a creatinine level of less than 2.0 mg per deciliter. Cardiac troponin I was measured in 61,379 patients, and cardiac troponin T in 7880 patients (both proteins were measured in 1335 patients). Overall, 4240 patients (6.2%) were positive for troponin. Patients who were positive for troponin had lower systolic blood pressure on admission, a lower ejection fraction, and higher in-hospital mortality (8.0% vs. 2.7%, P<0.001) than those who were negative for troponin. The adjusted odds ratio for death in the group of patients with a positive troponin test was 2.55 (95% confidence interval, 2.24 to 2.89; P<0.001 by the Wald test). CONCLUSIONS In patients with acute decompensated heart failure, a positive cardiac troponin test is associated with higher in-hospital mortality, independently of other predictive variables. (ClinicalTrials.gov number, NCT00366639 [ClinicalTrials.gov].).

Impact of intravenous loop diuretics on outcomes of patients hospitalized with acute decompensated heart failure: insights from the ADHERE registry.

The optimal use of diuretics in decompensated heart failure remains uncertain. We analyzed data from the ADHERE registry to look at the impact of diuretic dosing. 62,866 patients receiving <160 mg and 19,674 patients ≥160 mg of furosemide were analyzed. The patients receiving the lower doses had a lower risk for in-hospital mortality, ICU stay, prolonged hospitalization, or adverse renal effects. These findings suggest that future studies should evaluate strategies for minimizing exposure to high doses of diuretics.

Timing of Immunoreactive B-Type Natriuretic Peptide Levels and Treatment Delay in Acute Decompensated Heart Failure : An ADHERE (Acute Decompensated Heart Failure National Registry) Analysis

OBJECTIVES We undertook this analysis to determine whether there is a relationship between the time to measurement of immunoreactive B-type natriuretic peptide (iBNP) and early intervention for acutely decompensated heart failure (ADHF) and whether these variables are associated with morbidity and mortality in ADHF patients. BACKGROUND Although natriuretic peptides (NPs) can aid emergency department (ED) physicians in the diagnosis of ADHF, the relationship between the time to measurement of NP levels and time to treatment is not clear. In addition, the impact of time to treatment on clinical outcomes has not been demonstrated. METHODS Patients from ADHERE (Acute Decompensated Heart Failure National Registry) who were admitted to the ED and who received intravenous diuretics were included. Recordings of iBNP levels and the timing of intravenous diuretic therapy were documented. Patients were divided by quartiles of time to treatment and iBNP levels, creating 16 categories. RESULTS In 58,465 ADHF episodes from 209 hospitals, patients with the longest average time to iBNP draw also had the longest time to treatment. Mean ED time increased with increased time-to-treatment quartiles. Rales on initial examination were associated with early recognition of HF and earlier institution of therapy. The later the treatment took place, the fewer patients were asymptomatic at the time of hospital discharge. Within the time-to-treatment quartiles, mortality increased with increasing iBNP. Treatment delay was independently, but modestly, associated with increased in-hospital mortality with a risk-adjusted odds ratio 1.021, 95% confidence interval 1.010 to 1.033, and p < 0.0001, per every 4-h delay. CONCLUSIONS In the ED setting, delayed measurement of iBNP levels and delay in treatment for ADHF were strongly associated. These delays were linked with modestly increased in-hospital mortality, independent of other prognostic variables. The adverse impact of delay was most notable in patients with greater iBNP levels (Registry for Acute Decompensated Heart Failure Patients; NCT00366639).

Usefulness of B-type natriuretic peptide and cardiac troponin levels to predict in-hospital mortality from ADHERE.

B-type natriuretic peptide (BNP) and cardiac troponin (Tn) I or T have been demonstrated to provide prognostic information in patients with acute coronary syndromes. Whether admission BNP and Tn levels provide additive prognostic value in acutely decompensated heart failure (HF) has not been well studied. Hospitalizations for HF from April 2003 to December 2004 entered into ADHERE were analyzed. BNP assessment on admission was performed in 48,629 (63%) of 77,467 hospitalization episodes. Tn assessment was performed in 42,636 (88%) of these episodes. In-hospital mortality was assessed using logistic regression models adjusted for age, gender, blood urea nitrogen, systolic blood pressure, creatinine, sodium, pulse, and dyspnea at rest. Median BNP was 840 pg/ml (interquartile range 430 to 1,730). Tn was increased in 2,370 (5.6%) of 42,636 HF episodes. BNP above the median and increased Tn were associated with significantly increased risk of in-hospital mortality (odds ratios [OR] 2.09 and 2.41 respectively, each p value <0.0001). Mortality was 10.2% in patients with BNP >or=840/Tn increased compared with 2.2% with BNP <840/Tn not increased (OR 5.10, p <0.0001). After covariate adjustment, mortality risk remained significantly increased with BNP >or=840/Tn not increased (adjusted OR 1.56, 95% confidence interval 1.40 to 1.79, p <0.0001), BNP <840/Tn increased (adjusted OR 1.69, 95% confidence interval 1.17 to 2.45, p = 0.006), and BNP >or=840/Tn increased (adjusted OR 3.00, 95% confidence interval 2.47 to 3.66, p <0.0001). Admission BNP and cardiac Tn levels are significant, independent predictors of in-hospital mortality in acutely decompensated HF. Patients with BNP levels >or=840 pg/ml and increased Tn levels are at particularly high risk for mortality. In conclusion, a multimarker strategy for the assessment of patients hospitalized with HF adds incremental prognostic information.

Impact of Early Initiation of Intravenous Therapy for Acute Decompensated Heart Failure on Outcomes in ADHERE

Background: Since most acute decompensated heart failure (ADHF) patients present for hospital care via the emergency department (ED), we sought to determine the impact of early ED initiation of ADHF-specific therapy, as indicated by nesiritide use, on subsequent outcomes. Methods: We queried the Acute Decompensated Heart Failure National Registry (ADHERE®) to identify patients with initial systolic blood pressure >90 mm Hg and negative cardiac biomarkers, hospitalized after presentation to the ED, who received nesiritide but no other intravenous vasoactive drugs. Intensive care unit use and total hospital length of stay were compared based on the hospital unit where nesiritide therapy was initiated after multivariate adjustment for baseline differences in study populations. Results: Nesiritide was started in the ED in 1,613 patients (EDN group) and after admission to an inpatient unit in 2,687 patients (INN group). EDN patients had higher baseline systolic and diastolic blood pressure (both p < 0.001); while INN patients were more likely to be male and have baseline renal dysfunction (both p < 0.001). Nesiritide was initiated a median of 2.8 and 15.5 h after presentation in EDN and INN patients, respectively (p < 0.001). Compared to INN, EDN patients had a shorter adjusted mean total hospital length of stay (5.4 vs. 6.9 days; p < 0.001), were less likely to require transfer to the intensive care unit from another inpatient unit (odds ratio [OR]: 0.301; 95% confidence interval [CI]: 0.206–0.440), and were more likely to be discharged home (OR: 1.154; 95% CI: 1.005–1.325). Conclusions: Initiation of ADHF-specific therapy early, while the patient is in the ED, is associated with improved clinical outcomes.

Illicit Stimulant Use in a United States Heart Failure Population Presenting to the Emergency Department (from the Acute Decompensated Heart Failure National Registry Emergency Module)

Illicit stimulant drug use may have a profound clinical impact in acute decompensated heart failure (ADHF). The chronic use of cocaine and methamphetamine may lead to overt cardiomyopathy and ADHF. The Acute Decompensated Heart Failure National Registry Emergency Module (ADHERE-EM) collected data on patients presenting to emergency departments with ADHF at 83 geographically dispersed hospitals in the United States. This registry was queried to determine the rate of self-reported illicit drug use in emergency department patients presenting with ADHF and compare these patients with those without illicit drug use. The registry enrolled 11,258 patients with ADHF with drug use data from January 2004 to March 2006. Of these patients, 594 (5.3%) self-reported current or past stimulant drug use. Compared with nonusers, these patients were more likely to be younger (median age 49.7 vs 76.1 years), to be African American (odds ratio 11.9, 95% confidence interval 9.8 to 14.4), and to have left ventricular ejection fractions <40% (odds ratio 3.4, 95% confidence interval 2.8 to 4.2). Admitted users had no difference in mortality (adjusted odds ratio 0.83, 95% confidence interval 0.25 to 2.72) compared with nonusers. In conclusion, data from ADHERE-EM suggest that a clinically important percentage of patients with ADHF report the use of illicit stimulant drugs. Although these patients are younger with a greater degree of LV dysfunction, they did not have greater risk-adjusted mortality.

Characteristics and Outcomes in African American Patients With Decompensated Heart Failure

BACKGROUND Outcomes in patients with chronic heart failure vary by race. Racial differences in the characteristics and outcomes of patients with acute decompensated heart failure (ADHF) have not been well characterized. Therefore, we assessed race-related differences in presentation, treatment, in-patient experiences, and short-term mortality due to ADHF before and after accounting for known covariates. METHODS The Acute Decompensated Heart Failure National Registry database was analyzed to evaluate demographic and mortality differences in African American and white patients with ADHF entered into the database from its initiation in September 2001 to December 31, 2004. Stratified analyses by cause, age, left ventricular function, and history of heart failure subgroups were also conducted. RESULTS A total of 105,872 episodes of ADHF occurred in white patients and 29,862 occurred in African American patients. African American patients with ADHF were younger than white patients (mean [SD] age, 63.5 [15.4] vs 72.5 [12.5] years) and had lower mean left ventricular ejection fractions. The prevalence of hypertension, diabetes mellitus, and obesity was higher in African American patients. African American race was associated with lower in-hospital mortality after adjustment for known predictors (2.1% vs 4.5%; adjusted odds ratio [OR], 0.79; 95% confidence interval [CI], 0.72-0.87; P < .001). This association persisted for all age cohorts, was independent of the use of intravenous vasoactive drugs, and was especially present in African American patients in the nonischemic subgroup (adjusted OR, 0.74; 95% CI, 0.57-0.96) but not the ischemic subgroup (adjusted OR, 0.91; 95% CI, 0.76-1.09). CONCLUSION In ADHF, African American race is associated with lower in-hospital mortality compared with white race, despite certain indicators of increased disease severity.

Risk stratification in women enrolled in the Acute Decompensated Heart Failure National Registry Emergency Module (ADHERE-EM)

OBJECTIVES It has been reported that the mortality risk for heart failure differs between men and women. It has been postulated that this is due to differences in comorbid features. Variation in risk profiles by gender may limit the performance of stratification algorithms available for heart failure in women. This analysis examined the ability of a published risk stratification model to predict outcomes in women. METHODS The Acute Decompensated Heart Failure National Registry Emergency Module (ADHERE-EM) database was used. Characteristics, treatments, and outcomes for men and women were compared. The ADHERE registry classification and regression tree (CART) analysis was used for the risk stratification evaluation. RESULTS Of 10,984 ADHERE-EM patients, 5,736 (52.2%) were women. In-hospital mortality was similar between men and women (p = 0.727). Significant differences (p < 0.0002) were noted by gender in all three variables in the CART model (blood urea nitrogen [BUN] > or = 43 mg/dL, systolic blood pressure < 115 mm Hg, and serum creatinine > or = 2.75 mg/dL). However, the CART model effectively stratified both genders into distinct risk groups with no significant difference in mortality by gender within stratified groups. CONCLUSIONS The ADHERE Registry CART tool is effective at predicting risk in ED patients, regardless of gender.