Jufen Zhang

Red cell distribution width: an inexpensive and powerful prognostic marker in heart failure

Red cell distribution width (RDW) is prognostic in patients with heart failure (HF), but it has not been compared with N‐terminal brain natriuretic peptide (NT‐proBNP). We sought to make this comparison.

Predicting hospitalization due to worsening heart failure using daily weight measurement : analysis of the Trans-European Network-Home-Care Management System (TEN-HMS) study

We sought to test the utility of weight gain algorithms to predict episodes of worsening heart failure (WHF) using home‐telemonitoring data collected as part of the TEN‐HMS study.

IVC Diameter in Patients With Chronic Heart Failure : Relationships and Prognostic Significance

OBJECTIVES The aim of this study was to assess the relation between inferior vena cava (IVC) diameter, clinical variables, and outcome in patients with chronic heart failure (HF). BACKGROUND The IVC distends as right atrial pressure rises. Therefore it might represent an index of HF severity independent of left ventricular ejection fraction (LVEF). The relation between IVC diameter and other clinical variables and its prognostic significance in patients with HF has not been explored. METHODS Outpatients attending a community HF service between 2008 and 2010 were enrolled. Heart failure was defined as the presence of relevant symptoms and signs and objective evidence of cardiac dysfunction: either LVEF <45% or the combination of both left atrial dilation (≥4 cm) and raised amino-terminal pro-brain natriuretic peptide (NT-proBNP) ≥400 pg/ml. Patients were followed for a median of 567 (interquartile range: 413 to 736) days. The primary composite endpoint was cardiovascular death and HF hospitalization. RESULTS Among the 693 patients enrolled, median age was 73 years, 33% were women, and 568 had HF. Patients with HF in the highest tertile of IVC diameter were older; had lower body mass index; were more likely to have atrial fibrillation and to be treated with diuretics; and had larger left atrial volumes, higher pulmonary pressures, and less negative values for global longitudinal strain. The LVEF and systolic blood pressure were similar across tertiles of IVC diameter. The IVC diameter and log [NT-proBNP] were correlated (r = 0.55, p < 0.001). During follow-up, 158 patients reached a primary endpoint. In a multivariable Cox regression model, including NT-proBNP, only increasing IVC diameter, urea, and the trans-tricuspid systolic gradient independently predicted a poor outcome. Neither global longitudinal strain nor LVEF were adverse predictors. CONCLUSIONS In patients with chronic HF with or without a reduced LVEF, increasing IVC diameter identifies patients with an adverse outcome.

Left atrial function measured by cardiac magnetic resonance imaging in patients with heart failure: clinical associations and prognostic value

BACKGROUND Left atrial (LA) volume is an important marker of cardiac dysfunction and cardiovascular outcome in heart failure (HF), but LA function is rarely measured. METHODS Left atrial emptying function (LAEF), its clinical associations and prognostic value was studied in outpatients referred with suspected HF who were in sinus rhythm and had cardiac magnetic resonance imaging (CMRI). Heart failure was defined as relevant symptoms and signs with either a left ventricular ejection fraction (LVEF) <50% or amino-terminal pro-B-type natriuretic peptide (NTproBNP) >400 pg/mL (or >125 pg/mL if taking loop diuretics). RESULTS Of 982 patients, 664 fulfilled the HF criteria and were in sinus rhythm. The median (interquartile range, IQR) LAEF was 42 (31-51)% and 55 (48-61)% in patients with and without HF (P < 0.001). Patients with HF in the lowest quartile of LAEF (23%; IQR: 17-28%) had lower LV and right ventricular (RV) EF, and greater LV and RV mass and higher plasma NTproBNP than those in the highest quartile of LAEF (56%; IQR: 53-61%). Log[LAEF] and log[NTproBNP] were inversely correlated (r = -0.410, P < 0.001). During a median follow-up of 883 (IQR: 469-1626) days, 394 (59%) patients with HF died or were admitted with HF and 101 (15%) developed atrial fibrillation (AF). In a multivariable Cox model, increasing LAEF, but not LVEF, was independently associated with survival (HR for 10% change: 0.81 (95%CI: 0.73-0.90), P = <0.001). Increasing age and decreasing LAEF predicted incident AF. CONCLUSIONS In patients with HF, LAEF predicts adverse outcome independently of other measures of cardiac dysfunction.

Is Heart Rate Important for Patients With Heart Failure in Atrial Fibrillation

OBJECTIVES This study sought to investigate the relationship between resting ventricular rate and mortality in patients with chronic heart failure (CHF) and reduced left ventricular ejection fraction (LVEF) who were in sinus rhythm (SR) or atrial fibrillation (AF). BACKGROUND Slower heart rates are associated with better survival in patients with CHF in SR, but it is not clear whether this is true for those in AF. METHODS We assessed 2,039 outpatients with CHF and LVEF ≤50% undergoing baseline assessment, of whom 24% (n = 488) were in AF; and 841 outpatients reassessed after attempted treatment optimization at 1 year, of whom 22% (n = 184) were in AF. Cox proportional hazards models were used to assess the relationships between heart rate and survival in patients with CHF and AF or sinus rhythm. We analyzed heart rate and rhythm data recorded at the baseline review and after 1-year follow-up. Proportional hazards assumptions were checked by Schoenfeld and Martingale residuals. RESULTS The median survival for those in AF was 6.1 years (interquartile range [IQR]: 5.3 to 6.9 years) and 7.3 years (IQR: 6.5 to 8.1 years) for those in SR. In univariable analysis, patients with AF had a worse survival (hazard ratio [HR]: 1.26, 95% confidence interval [CI]: 1.08 to 1.47; p = 0.003) but after covariate adjustment, survival rates were similar. After adjusting Cox regression models, there was no association between heart rate (per 10 beats/min increments) and survival in patients with AF before (HR: 0.94, 95% CI: 0.88 to 1.00, p = 0.07) or after (HR: 1.00, 95% CI: 0.99 to 1.00, p = 0.84) therapy optimization. For patients in SR, higher heart rates were associated with worse survival, both before (HR: 1.10, 95% CI: 1.05 to 1.15, p <0.0001) and after (HR: 1.13, 95% CI: 1.03 to 1.24, p = 0.008) therapy optimization. CONCLUSIONS In patients with CHF and a reduced LVEF, slower resting ventricular rate is associated with better survival for patients in SR but not for those with AF.

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.

Does the physical examination still have a role in patients with suspected heart failure

The prognostic value of signs of congestion in patients suspected of having chronic heart failure (CHF) is unknown. Our objectives were to define their prevalence and specificity in diagnosing CHF and to determine their prognostic value in patients in a community heart failure clinic.

Identifying patients at risk of death or hospitalisation due to worsening heart failure using decision tree analysis: Evidence from the Trans-European Network-Home-Care Management System (TEN-HMS) Study

OBJECTIVES To stratify patients recently discharged from hospital with heart failure (HF) according to their risk of death and/or hospitalisation for worsening HF (WHF), to enable timely and appropriate monitoring and intervention. METHODS Data from the TEN-HMS study were used in this analysis. Chi-square automatic interaction detector (CHAID) decision trees were constructed using a 10-fold cross-validation to predict events at 1-year and compared with logistic regression (LR) models using ROC curve analysis. RESULTS 284 patients were used for training and 160 patients available at 4-month for validation. Amino-terminal pro-brain natriuretic peptide (NT-proBNP) was the strongest predictor of mortality identifying groups with high (>13,492 pg/ml), medium (3127-13,492 pg/ml) and low (≤ 3127 pg/ml) risk, followed by MI, systolic blood pressure, age, heart rhythm, study randomisation group and serum sodium. NT-proBNP was also the strongest predictor for death or hospitalization for WHF identifying groups with high (>13,492 pg/ml), medium (584-13,492 pg/ml), and low (≤ 584 pg/ml), followed by MI, creatinine, heart rhythm, potassium and urea. CHAID trees tended to perform better than LR-models (prediction of the composite outcome: ROC area with 95% CI, 0.797 (0.745-0.849) for CHAID and 0.738 (0.680-0.796) for LR-model; p=0.041; prediction of mortality: 0.892 (0.853-0.931) for CHAID and 0.858 (0.813-0.904) for LR; p=0.15). CONCLUSIONS Decision trees are an alternative classification method used to differentiate risk in patients with HF. The resultant models are concise, free of subjective variables and understood easily by clinicians. Further exploration of their potential and validation in other data-sets is justified.

Prognostic value of simple frailty and malnutrition screening tools in patients with acute heart failure due to left ventricular systolic dysfunction

BackgroundFrailty and malnutrition are common in patients with heart failure (HF), and are associated with adverse outcomes. We studied the prognostic value of three malnutrition and three frailty indices in patients admitted acutely to hospital with HF.Methods265 consecutive patients [62% males, median age 80 (interquartile range (IQR): 72–86) years, median NTproBNP 3633 (IQR: 2025–6407) ng/l] admitted with HF between 2013 and 2014 were enrolled. Patients were screened for frailty using the Derby frailty index (DFI), acute frailty network (AFN) frailty criteria, and clinical frailty scale (CFS) and for malnutrition using the geriatric nutritional risk index (GNRI), controlling nutritional status (CONUT) score and prognostic nutritional index (PNI).ResultsAccording to the CFS (> 4), DFI, and AFN, 53, 50, and 53% were frail, respectively. According to the GNRI (≤ 98), CONUT score (> 4), and PNI (≤ 38), 46, 46, and 42% patients were malnourished, respectively. During a median follow-up of 598 days (IQR 319–807 days), 113 patients died. One year mortality was 1% for those who were neither frail nor malnourished; 15% for those who were either malnourished or frail; and 65% for those who were both malnourished and frail. Amongst the malnutrition scores, PNI, and amongst the frailty scores, CFS increased model performance most compared with base model. A final model, including CFS and PNI, increased c-statistic for mortality prediction from 0.68 to 0.84.ConclusionWorsening frailty and malnutrition indices are strongly related to worse outcome in patients hospitalised with HF.

What proportion of patients with chronic heart failure are eligible for sacubitril–valsartan?

The PARADIGM‐HF trial showed that sacubitril–valsartan, an ARB–neprilysin inhibitor, is more effective than enalapril for some patients with heart failure (HF). It is uncertain what proportion of patients with HF would be eligible for sacubitril–valsartan in clinical practice.