Teresa Pascual

Combined use of high‐sensitivity ST2 and NTproBNP to improve the prediction of death in heart failure

To address the incremental usefulness of biomarkers from different disease pathways for predicting risk of death in heart failure (HF).

Prognostic Implication of Frailty and Depressive Symptoms in an Outpatient Population With Heart Failure

INTRODUCTION AND OBJECTIVES Heart failure patients have high levels of frailty and dependence. Our aim was to determine the impact of frailty and depressive symptoms on the 1-year mortality rate and the rate of hospitalization for heart failure during a follow-up period of 1 year. METHODS All patients underwent geriatric evaluation, and frailty and depressive symptoms were identified. The study included 622 patients (72.5% male; median age, 68 years; 92% in New York Heart Association class II or III; and median ejection fraction, 30%). RESULTS During follow-up, 60 patients (9.5%) died and 101 (16.2%) were hospitalized for heart failure. Overall, 39.9% of patients exhibited frailty, while 25.2% had depressive symptoms. There were significant associations between mortality at 1 year and the presence of frailty (16.9% vs. 4.8%; P< .001) and depressive symptoms (15.3% vs. 7.7%; P=.006). There was also a significant relationship between heart failure hospitalization and the presence of frailty (20.5% vs. 13.3%; P=.01). No relationship was found between heart failure hospitalization and depressive symptoms. Frailty was an independent predictor of mortality but not of hospitalization. CONCLUSIONS Univariate analysis demonstrated significant relationships between frailty and depressive symptoms and mortality at 1 year. In addition, there was a significant relationship between frailty and the need for heart failure hospitalization. However, only frailty showed prognostic value to predict mortality, which was independent of other variables strongly associated to outcome.

Mortalidad y causas de muerte en pacientes con insuficiencia cardiaca: experiencia de una unidad especializada multidisciplinaria

Introduccion y objetivos La mortalidad de la insuficiencia cardiaca es similar o incluso superior a la de muchos canceres. Suele ocurrir por progresion de la enfermedad, aunque la muerte subita se ha descrito como una causa frecuente. El objetivo es evaluar la mortalidad y sus causas en una poblacion ambulatoria de pacientes con insuficiencia cardiaca de etiologia diversa tratados en una unidad especializada multidisciplinaria y analizar los factores asociados con ellas. Metodos Estudio de seguimiento de cohorte (mediana, 36 meses) de 960 pacientes (el 70,9% varones; mediana de edad, 69 anos; mayoritariamente de etiologia isquemica, con fraccion de eyeccion del 31% y en clase funcional fundamentalmente II y III). Resultados Se registraron 351 fallecimientos (36,5%): 230 de causa cardiovascular (65,5%), fundamentalmente por insuficiencia cardiaca (33,2%) y muerte subita (16%), 94 de causa no cardiovascular (26,8%), fundamentalmente neoplasias (10,5%) y procesos septicos (6,8%), y 27 (7,7%) de causa desconocida. Mostraron relacion independiente con la mortalidad: edad, sexo, clase funcional, fraccion de eyeccion, tiempo de evolucion, etiologia isquemica, diabetes mellitus, aclaramiento de creatinina, vasculopatia periferica, fragilidad y ausencia de tratamiento con inhibidores de la enzima de conversion de angiotensina o antagonistas de los receptores de la angiotensina II, bloqueadores beta, estatinas y antiagregantes. El factor principal asociado a muerte cardiovascular fue la etiologia isquemica. No hallamos ningun factor predictor claramente determinante de muerte subita. Conclusiones Aunque la mortalidad de los pacientes atendidos en una unidad especializada de insuficiencia cardiaca no fue baja, una cuarta parte fallecio de causa no cardiovascular. El principal factor asociado a muerte cardiovascular fue la etiologia isquemica. La muerte subita afecto solo al 5,8% de la poblacion.

Depression, antidepressants, and long-term mortality in heart failure

BACKGROUND This study was designed to assess whether depression and the use of antidepressants were related to long-term mortality in heart failure. METHODS Heart failure outpatients (n=1017) from a specialized tertiary unit in Spain were prospectively studied for a median follow-up of 5.4 years (IQR 3.1-8.1). Depressive symptoms were assessed using an abbreviated version of the geriatric depression scale. Survival rates during the study period (August 2001 until December 2010) and hazard ratios (HR) for mortality were adjusted by several demographic and clinical variables. RESULTS Depressive symptoms were detected in 302 patients (29.7%) at baseline and 222 (21.8%) de novo during follow-up; 304 patients (29.9%) received at least one prescription of antidepressants, mainly selective serotonin reuptake inhibitors (92.8%); 441 patients (43.4%) died. In a multivariate Cox proportional hazard model, depression was associated with an increased all-cause (HR, 1.39; 95% CI, 1.15-1.68), but not cardiovascular, mortality risk after adjustment for several demographic and clinical confounders. The use of any antidepressant was not independently associated with mortality (HR, 0.89; 95% CI, 0.71-1.13), but benzodiazepines showed a protective role (HR, 0.70; 95% CI, 0.57-0.87). On the contrary, fluoxetine prescriptions, but not duration of fluoxetine treatment, were associated with increased mortality (HR, 1.66; 95% CI, 1.13-2.44). CONCLUSIONS Depressive symptoms are associated with long-term mortality, but the use of antidepressants and benzodiazepines is safe regarding survival in HF patients, although further research is needed considering individual antidepressants separately.

Mortality and Cause of Death in Patients With Heart Failure: Findings at a Specialist Multidisciplinary Heart Failure Unit

INTRODUCTION AND OBJECTIVES Heart failure mortality is similar to or even higher than that due to various cancers. It is usually associated with disease progression, though sudden death has also been reported as a frequent cause of mortality. The objectives of this study were to investigate mortality and its causes in outpatients with heart failure of different etiologies who were treated in a specialist multidisciplinary unit, and to identify associated factors. METHODS The follow-up cohort study (median duration 36 months) involved 960 patients (70.9% male; median age 69 years; ejection fraction 31%; and the majority had an ischemic etiology and were in functional class II or III). RESULTS Overall, 351 deaths (36.5%) occurred: 230 due to cardiovascular causes (65.5%), mainly heart failure (33.2%) and sudden death (16%); 94 due to non-cardiovascular causes (26.8%), mainly malignancies (10.5%) and septic processes (6.8%); and 27 (7.7%) due to unknown causes. Mortality was independently associated with age, sex, functional class, ejection fraction, time since symptom onset, ischemic etiology, diabetes, creatinine clearance rate, peripheral vascular disease, fragility, and the absence of treatment with an angiotensin-converting enzyme inhibitor or angiotensin-II receptor blocker, beta-blockers, statins or antiplatelet agents. The principal factor associated with cardiovascular death was an ischemic etiology. No factor studied clearly predicted sudden death. CONCLUSIONS Even though mortality in patients treated at a specialist heart failure unit was not low, a quarter died from non-cardiovascular causes. The principal factor associated with cardiovascular death was an ischemic etiology. Only 5.8% of the study population experienced sudden death.

Valoración clínica, ecocardiográfica y pronóstica de la fibrilación auricular en pacientes con insuficiencia cardíaca

Fundamento y objetivo: Valorar la prevalencia de fibrilacion auricular (FA) en pacientes con insuficiencia cardiaca de una unidad multidisciplinaria, analizar los factores asociados y evaluar su significacion pronostica. Pacientes y metodo: Se incluyo a 389 pacientes, 64 con FA en la primera visita. La media (desviacion estandar) de la edad fue 65,38 (10,77) anos; el 72,5% eran varones. La etiologia era isquemica en el 59,9%. La fraccion de eyeccion (FE) media era de 32,25% (13%). A los 2 anos conociamos la situacion vital de 377 (97%) pacientes (314 en ritmo sinusal [RS] y 63 en FA). Resultados: La prevalencia de FA era del 15,8% y se asociaba con mayor edad, sexo femenino, etiologias hipertensiva y valvular, mayor duracion de los sintomas, mejor FE, mayor diametro de la auricula izquierda, mayor grado de insuficiencia mitral y peor calidad de vida, pero no con la clase funcional de la New York Heart Association (NYHA). La mortalidad a los 2 anos (16,7%) era significativamente mayor en los pacientes con FA (el 33,3 frente al 18,4%; odds ratio = 2,20; intervalo de confianza del 95%, 1,21-4), aunque al ajustar por otras variables relevantes como la edad, el sexo, la clase funcional, la FE y la etiologia, la FA no se mantuvo como factor pronostico independiente. Las diferencias mas importantes de mortalidad ocurrian en la insuficiencia cardiaca de causa isquemica y por miocardiopatia dilatada. Conclusiones: La FA tuvo relacion, fundamentalmente, con la edad, la etiologia valvular e hipertensiva y un mayor diametro de la auricula izquierda. La mortalidad a los 2 anos era significativamente mayor en los pacientes con FA, aunque otros parametros como la edad y la clase funcional de la NYHA tenian mayor significacion pronostica.

Cardiac Rehabilitation and Outcome in Stable Outpatients With Recent Myocardial Infarction

OBJECTIVE To compare the mortality rate and the rate of subsequent ischemic events (myocardial infarction [MI], ischemic stroke, or limb amputation) in patients with recent MI according to the use of cardiac rehabilitation or no rehabilitation. DESIGN Longitudinal observational study. SETTING Ongoing registry of outpatients. PARTICIPANTS Patients (N=1043) with recent acute MI were recruited; of these, 521 (50%) participated in cardiac rehabilitation. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Subsequent ischemic events and mortality rates were registered. RESULTS Over a mean follow-up of 18 months, 50 patients (4.8%) died and 49 (4.7%) developed 52 subsequent ischemic events (MI: n=43, ischemic stroke: n=6, limb amputation: n=3). Both the mortality rate (.16 vs 5.57 deaths per 100 patient-years; rate ratio=.03; 95% confidence interval [CI], 0.0-0.1]) and the rate of subsequent ischemic events (1.65 vs 4.54 events per 100 patient-years; rate ratio=0.4; 95% CI, 0.2-0.7) were significantly lower in cardiac rehabilitation participants than in nonparticipants. Multivariate analysis confirmed that patients in cardiac rehabilitation had a significantly lower risk of death (hazard ratio=.08; 95% CI, .01-.63; P=.016) and a nonsignificant lower risk of subsequent ischemic events (hazard ratio=.65; 95% CI, .30-1.42). CONCLUSIONS The use of cardiac rehabilitation in patients with recent MI was independently associated with a significant decrease in the mortality rate and a nonsignificant decrease in the rate of subsequent ischemic events.