N.K. Khan

The timing of development and subsequent clinical course of heart failure after a myocardial infarction

AIMS Myocardial infarction (MI) is a common cause of heart failure (HF), which may develop early and persist or resolve, or develop late. The cumulative incidence, persistence, and resolution of HF after MI are poorly described. The aim of this study is to describe the natural history and prognosis of HF after an MI. METHODS AND RESULTS Patients with a death or discharge diagnosis of MI in 1998 were identified from records of hospitals providing services to a local community of 600 000 people. Records were scrutinized to identify the development of HF, defined as signs and symptoms consistent with that diagnosis and treated with loop diuretics. HF was considered to have resolved if diuretics could be stopped without recurrent symptoms. Totally, 896 patients were identified of whom 54% had died by December 2005. During the index admission, 199 (22.2%) patients died, many with HF, and a further 182 (20.3%) patients developed HF that persisted until discharge, of whom 121 died subsequent to discharge. Of 74 patients with transient HF that resolved before discharge, 41 had recurrent HF and 38 died during follow-up. After discharge, 145 (33%) patients developed HF for the first time, of whom 76 died during follow-up. Overall, of 281 deaths occurring after discharge, 235 (83.6%) were amongst inpatients who first developed HF. CONCLUSION The development of HF precedes death in most patients who die in the short- or long-term following an MI. Prevention of HF, predominantly by reducing the extent of myocardial damage and recurrent MI, and subsequent management could have a substantial impact on prognosis.

Epidemiology and management of heart failure and left ventricular systolic dysfunction in the aftermath of a myocardial infarction.

Robust epidemiological data on the incidence of myocardial infarction (MI) are hard to find, but synthesis of data from a number of sources indicates that the average hospital in the UK should admit about two patients with a first MI and one recurrent MI per 1000 population per year. Possibly the most relevant data on the incidence, prevalence, and persistence of post-MI heart failure can be derived from the TRACE study. Most patients will develop heart failure or major left ventricular systolic dysfunction (LVSD) at some time after an MI, most commonly during the index admission. In up to 20% of cases this will be transient, but such patients still have a poor prognosis. There is likely to be around one patient discharged per thousand population per year with heart failure or major LVSD after an acute MI. It is important to organise care structures to ensure that patients with post-MI heart failure and LVSD are identified and managed appropriately.

Predictors of short term mortality in heart failure - insights from the Euro Heart Failure survey.

OBJECTIVE To identify factors associated with short term mortality in hospitalised patients with heart failure. BACKGROUND Hospitalisation is frequent in patients with heart failure and is associated with a high mortality. METHODS The Euro Heart Failure survey collected data from patients with suspected heart failure. We searched this data for predictors of short term mortality. RESULTS Of 10,701 patients, 1404 (13%) died within 12 weeks of admission. On univariate analysis, increasing age, hyponatraemia, renal impairment, hyperkalaemia, anaemia, severe mitral regurgitation, severe LV systolic dysfunction(LVSD), increasing QRS and female sex carried adverse prognosis. ACEI, beta-blockers, nitrates, anti-thrombotic and lipid lowering drugs were associated with a better prognosis. On multivariable analysis the following provided independent prognostic information: increasing age (OR per SD=1.5, 95% CI 1.4-1.6), severe LVSD (1.8, 1.5-2.1), serum creatinine (1.2, 1.2-1.3), sodium (0.9, 0.8-0.9), Hb (0.9, 0.8-0.9) and treatment with ACEI (0.5, 0.5-0.6), beta-blockers (0.7, 0.6-0.8), statins (0.6, 0.5-0.7), calcium channel blockers (0.7, 0.6-0.8), warfarin (0.5, 0.4-0.6), heparin (1.7, 1.4-1.9), anti-platelet drugs (0.6, 0.5-0.6) and need for inotropes (5.5, 4.6-6.6). A simple risk score (range 0-11) identified cohorts with a 12 week mortality ranging from 2% to 44%. CONCLUSIONS Simple and readily available clinical variables and a risk score based on medical history and routine tests that all patients admitted with heart failure have, can identify patients with good, intermediate and high short term mortality.

Prevalence of ECG abnormalities in an international survey of patients with suspected or confirmed heart failure at death or discharge

Most patients suspected of having heart failure (HF) will get a 12‐lead electrocardiogram (ECG) but its utility for excluding HF or assisting in its management has rarely been investigated.

Multi-chamber pacing: a perfect solution for cardiac mechanical dyssynchrony?

See doi:10.1016/S1095-668X(02)00475-Xfor the article to which this editorial refers. When the heart fails, it becomes less efficient, as myocardial energy consumption rises without a corresponding increase in cardiac output. There are many possible reasons for this decline in cardiac efficiency (Fig. 1). Recently, because of the potential value of multi-site pacing, interest has focused on mechanical dyssynchrony, which encompasses a complex array of problems that often coexist in varying degrees along with ‘functional’ mitral regurgitation.1–3 Fig. 1 Some mechanisms of heart failure causation and progression (usually multiple mechanisms operating simultaneously conspire to cause progression of heart failure). It is likely that mechanical dyssynchrony is common, although precisely how common is unclear, and will depend on the definition and the tools used to measure it. The presence and severity of cardiac dyssynchrony can be assessed directly using imaging techniques or indirectly by measuring time-intervals from a standard 12-lead echocardiography (ECG). ECG is the current method of choice owing to its wide availability, high temporal resolution and its ability to assess flow across the valves, although diagnostic criteria for cardiac dyssynchrony are still being refined.4 In the meantime, studies on relatively small numbers of patients have suggested that patients who have a QRS width ≥150ms very often have evidence of major inter- and intra-ventricular dyssynchrony on imaging.5 A high, but as yet uncertain, proportion of patients with QRS 120–150ms will also fulfil current echocardiographic criteria for ventricular dyssynchrony.6,7 Approximately, one in every four patients with heart failure secondary to left ventricular systolic dysfunction (LVSD) will have a QRS width >120ms on their surface ECG.8 The PR interval may be a useful marker for atrio-ventricular dyssynchrony,1 but <5% of patients with heart failure and LVSD will have a PR interval ≥220ms.8–11 Mechanical dyssynchrony and the possibility of …

Relation between severity of left ventricular systolic dysfunction and repolarisation abnormalities on the surface ECG: a report from the Euro heart failure survey

QT prolongation is known to be associated with increased risk of coronary heart disease and cardiovascular death.1,2 A high prevalence of QT prolongation has been reported in heart failure, but whether it is related to the severity of left ventricular systolic dysfunction (LVSD) or poor prognosis remains controversial.3,4 The Euro heart failure survey was conducted to discover whether appropriate tests were being performed according to European Society of Cardiology guidelines in patients hospitalised with or suspected to have heart failure.5 Data from 12 lead ECGs of these patients were used to evaluate whether QT interval is prolonged in LVSD and whether the degree of QT prolongation is related to the severity of LVSD. Data were collected from 11 356 patients with or suspected to have heart failure in 115 hospitals across 24 European countries over six weeks during 2000–2001. For this analysis we considered 5934 patients who had both ECG and an echocardiogram. A single observer, blinded to other data, measured ECG intervals to an accuracy of 0.1 mm (2–4 ms) with digital callipers (ABSolute digimatic, Mitutoyo). QT variables were measured from three non-infarct chest or limb leads and averaged. Co-workers reread and validated 400 ECGs. Bazett’s method of correction for heart rate was used. Local cardiologists reported echocardiograms in the …