Periaswamy Velavan

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.

Clinical trials update from the American College of Cardiology meeting : CARE-HF and the Remission of Heart Failure, Women's Health Study, TNT, COMPASS-HF, VERITAS, CANPAP, PEECH and PREMIER

This article provides information and a commentary on landmark trials presented at the American College of Cardiology meeting held in March 2005, relevant to the pathophysiology, prevention and treatment of heart failure. All reports should be considered as preliminary data, as analyses may change in the final publication. CARE‐HF showed that Cardiac Re‐synchronisation Therapy, administered in addition to expert pharmacological management, reduced all cause mortality and CV hospitalisation in patients with moderate or severe heart failure and cardiac dyssynchrony. The Womens Health Study showed no benefit of vitamin E supplementation or aspirin in the primary prevention of CV disease. The TNT study showed that reducing LDL cholesterol to levels lower than currently recommended, produced a 22% reduction in the incidence of major cardiovascular events. In COMPASS, an implantable device that continuously monitors intra‐cardiac pressures was shown to be safe and to improve care in patients with chronic heart failure. Tezosentan failed to show benefit in patients with acute heart failure in the VERITAS study. The CANPAP study failed to show a benefit of continuous positive airway pressure on mortality and heart transplantation in heart failure patients with central sleep apnoea. EECP therapy improved exercise capacity but had no effect on peak VO2 in heart failure patients in the PEECH study. In the PREMIER study the matrix metalloproteinase inhibitor PG‐116800 failed to prevent LV remodelling following myocardial infarction.

Clinical trials update from the American Heart Association meeting: Omega-3 fatty acids and arrhythmia risk in patients with an implantable defibrillator, ACTIV in CHF, VALIANT, the Hanover autologous bone marrow transplantation study, SPORTIF V, ORBIT and PAD and DEFINITE

The American Heart Association meeting reported the results of several clinical trials of particular interest to those who care for patients with heart failure. Ω‐3 fatty acids were associated with a trend to increased recurrence of ventricular arrhythmias but not mortality in patients with an implantable debrillator. The ACTIV in CHF study provides more evidence of a therapeutic role for arginine vasopressin antagonists in the treatment of heart failure. The VALIANT study provides further evidence to suggest that a combination of angiotensin receptor antagonist and ACE inhibitor does not reduce mortality but may reduce morbidity in post‐MI patients with heart failure or major LV systolic dysfunction. A study of autologous bone marrow cell transplantation into myocardial scar give gave encouraging results. SPORTIF V showed ximelagation to be as effective as warfarin but with improved safety. ORBIT and PAD showed public access defibrillators saved lives but questioned their cost effectiveness. DEFINITE supported a role for ICDs in patients with non‐ischemic cardiomyopathy, although cost‐effectiveness remains in doubt.

Clinical trials update from the American Heart Association meeting: ACORN‐CSD, primary care trial of chronic disease management, PEACE, CREATE, SHIELD, A‐HeFT, GEMINI, vitamin E meta‐analysis, ESCAPE, CARP, and SCD‐HeFT cost‐effectiveness study

This article provides information and a commentary on landmark trials presented at the American Heart Association meeting held in November 2004, relevant to the pathophysiology, prevention, and treatment of heart failure. An open trial of the ACORN Cardiac Support Device (CSD) showed encouraging preliminary results in patients with severe heart failure. The PEACE (Prevention of Events with Angiotensin‐Converting Enzyme inhibition) study supports data from previous studies showing that ACE inhibitors reduce vascular events in patients at increased risk. The CREATE (clinical trial of metabolic modulation in acute MI treatment evaluation) study of patients with acute myocardial infarction (MI) showed no mortality benefit of a glucose/insulin/potassium regimen, but treatment with reviparin reduced the incidence of death, MI, or stroke. Azimilide was not associated with a significant reduction in shocks, but reduced the shocks or episodes of markedly symptomatic ventricular tachycardia terminated by pacing in the SHIELD (Shock Inhibition Evaluation with Azimilide) study. The addition of isosorbide dinitrate plus hydralazine to standard therapy improved survival in black heart failure patients in the A‐HeFT (African—American Heart Failure Trial) study. In an investigation of hypertensive patients with diabetes, carvedilol had fewer adverse effects on diabetic control than metoprolol. A meta‐analysis of high‐dose vitamin E supplementation suggested an association with increased mortality. The ESCAPE (Evaluation Study of CHF and Pulmonary Artery Catheterisation Effectiveness) study showed no benefit of pulmonary artery catheterisation over clinical management in patients with severe heart failure. Routine prophylactic coronary revascularisation for stable coronary disease prior to major vascular surgery showed no benefit in the CARP (Coronary Artery Revascularization Prophylaxis) study. Analysis of data from SCD‐HeFT supports the cost‐effectiveness of ICDs in heart failure, although overall cost implications may be prohibitive.

Clinical trials update from the European Society of Cardiology Heart Failure meeting and the American College of Cardiology: Darbepoetin alfa study, ECHOS, and ASCOT-BPLA

This article provides information and a commentary on landmark trials presented at the European Society of Cardiology Heart Failure meeting held in June 2005, relevant to the pathophysiology, prevention and treatment of heart failure. All reports should be considered as preliminary data, as analyses may change in the final publication. The erythropoiesis stimulating protein, darbepoetin alfa, increased haemoglobin levels, improved quality of life and showed a trend for improved exercise duration in anaemic patients with symptomatic chronic heart failure. In the ECHOS study, the selective dopamine agonist nolomirole (CHF1035) showed no benefit in heart failure patients. Preliminary results of the ASCOT‐BPLA study, which were reported at the American College of Cardiology meeting in March 2005, showed that in hypertensive patients, treatment with a calcium antagonist plus an ACE inhibitor was more effective at reducing cardiovascular outcomes than atenolol plus a diuretic.

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 …

Fighting against sudden death: A single or multidisciplinary approach

There are many causes of sudden death ranging from accidents and suicide to vascular events and arrhythmias. Most sudden deaths will occur in people who have not been diagnosed with a serious heart condition but at a very low annual rate. Many of these events are probably vascular and might be prevented by reducing the risk of developing coronary disease. Only a minority of sudden deaths occur in people with established cardiac disease, but in patients with major structural heart disease, the annual rate is high. The causes of sudden death are many in this clinical setting also, but dominated by ventricular arrhythmias and vascular events. There is good evidence that conventional treatments for heart failure, including ACE inhibitors, beta-blockers, aldosterone antagonists and cardiac resynchronisation devices reduce the risk of sudden death. Evidence that statins, aspirin or revascularisation are safe or effective in patients with heart failure is currently lacking. Implantable defibrillators confer a small but definite additional survival advantage by treating arrhythmias that have not been prevented.