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The prevalence of heart failure (HF) in the population is increasing, concomitant with high incidence of rehospitalizations and mortality. The aim of this study was to characterize a prognostic risk score model for patients with chronic HF. A total of 500 patients followed at the HF clinic were evaluated by clinical, functional, laboratory, imaging, and therapeutic variables that were correlated to mortality during a follow-up period of 25 months. Risk stratification was carried out by applying a risk score model based on multivariate analysis. Predictors correlated with mortality during follow-up were systolic blood pressure <110 mm Hg, male sex, age older than 70 years, 6-minute walk distance <300 m, lack of β-blocker therapy, hyperuricemia (>7.5 mg/dL), hyponatremia, and prolonged QTc interval (>450 ms). Based on these variables, a risk score model (score 0-55) was established and included low risk, score <21 (9% mortality during 2-year follow-up); moderate risk, 21 to 29 (22%); high risk, 30 to 35 (35%), and very high risk: ≥36 points (62% 2-year mortality). The risk model had good discrimination ability (concordance index 0.75), which was better than the performance of the Seattle Heart Failure Model on our cohort (0.69). Simple noninvasive characteristics examined during the initial admission to the HF clinic can serve as prognostic markers for mortality and may help in the process of therapeutic decision-making in patients with HF., (© 2012 Wiley Periodicals, Inc.)

To evaluate, objectively and subjectively, the feasibility of 256-row computed tomography coronary angiography (CTCA) in obese patients. 256-row CTCA was performed in 68 symptomatic patients (age 61 ± 10 years, 37 females), 39 obese (body mass index-BMI > 30 kg/m(2)) and 29 non-obese. Retrospective analysis was performed by two observers who assessed the image quality of each coronary segment using a 4-point subjective scale (1 excellent to 4 non-diagnostic), and another blinded observer measured objective image parameters. BMI in the obese group was 35 ± 5 (32-65) Kg/m(2), and 24 ± 3 (16-29) Kg/m(2) in the non-obese (P = 0.004). Average subjective image quality was similar in obese (1.41 ± 0.40) and non-obese (1.34 ± 0.40) patients, P = 0.17. Proportion of coronary artery segments with non-diagnostic image quality was low in both groups (0.7% in obese and 0.2% in non-obese, P = 0.31). Signal to noise and contrast to noise ratios were not significantly lower in obese than in non-obese patients (9.4 ± 3 vs. 12 ± 2.5, P = 0.16 and 11.1 ± 3.8 vs. 13.7 ± 2.9, P = 0.07 respectively). However, dose length product (1167 ± 567 vs. 827 ± 375 mGy × cm, P = 0.014) and image noise (44 ± 13 vs. 35 ± 5 HU, P < 0.001) were higher in the obese patient group. Image quality was preserved in obese patients undergoing 256-row CTCA at the cost of increased radiation exposure and image noise.

Background: There are conflicting reports regarding the characteristics and mortality rates of heart failure patients with preserved (HFPSF) vs. reduced systolic left ventricular function (SHF)., Methods: We evaluated the clinical profiles, mortality rates and modes of death in 481 consecutive symptomatic heart failure patients. In 317(66%) patients LVEF was <40% (SHF), and in 164(34%) LVEF≥40% (HFPSF)., Results: Compared to the HFPSF group, SHF patients were predominantly younger males with ischemic etiology and less cardiovascular comorbidities such as obesity, hypertension, diabetes mellitus and atrial fibrillation. Over a mean follow-up period of 2 years, 148(31%) patients died. Overall mortality was similar between the two groups: 53(32%) HFPSF patients and 95(30%) SHF patients died (p=0.6), even after adjusting for baseline variables, including age, gender and comorbidities (hazard ratio 1.09; 95% confidence interval 0.74-1.61; p=0.67). In contrast to the similar mortality rates, the modes of death were different. SHF patients had higher death rates due to pump failure compared to the HFPSF group {32/95(34%) vs. 9/53(17%) patients, p=0.03}. A trend towards higher rate of non-cardiac death was observed in HFPSF group {33/53(62%) patients vs. 45/95(47%) patients, respectively, p=0.08}. The prevalence of arrhythmic death was similar in both groups {17/95(18%) vs. 10/53(19%) patients, p=0.9}., Conclusions: Although the characteristics of HFPSF and SHF patients are distinctively different, the mortality rates are similar. The mode of death is different among the two groups of patients, as pump failure death is significantly higher in SHF patients, while non-cardiac mortality is more prevalent in HFPSF patients., (Copyright © 2010 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Aims: The present study was designed to identify and compare predictors of short- and long-term mortality in elderly and young patients hospitalized with acute heart failure (HF)., Methods and Results: The risk of in-hospital, 1- and 4-year mortality was assessed among 2336 acute HF patients in a prospective national survey. Interaction-term analysis was utilized to identify and compare independent risk factors between elderly (>75 years [n = 1182]) and younger (< or =75 years [n = 1154]) study patients. Elderly patients exhibited a 1.8-fold (P = 0.004), 1.4-fold (P < 0.001), and 1.7-fold (P < 0.001) increase in the adjusted risk of in-hospital, 1-year, and 4-year mortality, respectively, as compared with younger patients. Independent risk factors for 4-year mortality among elderly patients included NYHA functional Class III-IV before admission (HR = 1.46, P < 0.001), systolic blood pressure <115 mmHg (HR = 1.45, P = 0.002), renal dysfunction ([eGFR < 60 mL/min/1.73 m(2)] HR = 1.35, P = 0.002), diabetes mellitus (HR = 1.28, P = 0.006), and anaemia (HR = 1.25, P = 0.012). In the young group, but not in the elderly group, left ventricle ejection fraction (LVEF) <50% and hyponatraemia (sodium <136 mmol/L) were significant predictors of 4-year mortality. (LVEF <50%, HR = 1.47 for the young and 1.04 for the elderly, P for interaction = 0.025; hyponatraemia HR = 1.59 for the young and 1.17 for the elderly, P for interaction = 0.035)., Conclusion: Elderly patients exhibit different risk factors for long-term mortality as compared with young patients with acute HF. In contrast to younger patients, mortality risk in the older population is not decreased among those with preserved LVEF.

Background: Cheyne-Stokes breathing (CSB) has been associated with heart failure (HF) patients for many years; however, its true prevalence and its prognostic implications are still obscure., Hypothesis: The goal of this study was to investigate the prevalence and the possible prognostic implications of nocturnal CSB in advanced heart failure patients., Methods: We performed single night full polysomonography ambulatory sleep studies in 71 HF patients. We analyzed the patients' sleep studies, clinical and laboratory data, and 6 month mortality., Results: A total of 71 chronic systolic HF patients were analyzed, 60 males, 11 females, age 65 +/- 13 years. Mean left ventricular ejection fraction was 27% +/- 11%. Short episodes of CSB (at least 3 min duration) were present in all patients, and mean CSB duration was 1 hour. CSB duration was associated significantly with both high serum levels of N-terminal prohormone brain natriuretic peptide (NT-proBNP) as well as with 6 month mortality. Log CSB time had a significant correlation with log NT-proBNP (r = 0.5, P<.0001). Based on median CSB duration, the Kaplan-Meier survival curve analysis showed significant association with 6 month mortality (P = .03)., Conclusions: CSB prevalence in advanced HF patients is higher than previously reported and is associated with increased serum levels of NT-proBNP and higher 6 month mortality., (Copyright (c) 2010 Wiley Periodicals, Inc.)

Background: Serum natriuretic peptide levels are useful diagnostic and prognostic markers in patients with acute decompensated heart failure, but have been little used to stratify urgency of treatment in the outpatient situation., Objectives: To examine the use of natriuretic peptide to guide priority of patient referral to a heart failure center., Methods: We analyzed data from 70 consecutive patients with chronic heart failure (NYHA class 2-4) referred for first evaluation in a specialized outpatient heart failure center. Serum NT-proBNP was measured at the initial patient visit. We examined correlates and predictive value of mid- and upper tertile NT-proBNP for mortality in comparison with other known prognostic indicators using univariate and multivariate logistic regression analysis., Results: Mortality at 6 months was 26.0% in patients with upper tertile (> 1958 pg/ml) NT-proBNP, 8.7% in the middle tertile group and 0% in the lowest tertile (P=0.017). Patients with upper tertile serum NT-proBNP levels (group 3) had lower left ventricular ejection fraction, were more often in atrial fibrillation (P=0.04) and more often had renal failure (P=0.03). Age-adjusted logistic regression analysis identified upper tertile serum NT-proBNP level as the strongest independent predictor of 6 month mortality with a sixfold risk of early death (adjusted odds ratio 6.08, 95% confidence interval 1.58-47.13, P=0.04). NT-proBNP was a more powerful predictor of prognosis than ejection fraction and other traditional outcome markers., Conclusions: In heart failure patients referred to an outpatient specialized heart failure center, an upper tertile NT-proBNP level identified patients at high risk for mortality. A single high > 550 pg/ml NT-proBNP measurement appears to be useful for selecting patients for care in a heart failure center, and a level > 2000 pg/ml for assigning patients to high priority management.

Background: Despite improved management of heart failure patients, their prognosis remains poor., Objectives: To characterize hospitalized HF patients and to identify factors that may affect their short and long-term outcome in a national prospective survey., Methods: We recorded stages B-D according to the American College of Cardiology/American Heart Association definition of HF patients hospitalized in internal medicine and cardiology departments in all 25 public hospitals in Israel., Results: During March-April 2003, 4102 consecutive patients were recorded. Their mean age was 73 +/- 12 years and 57% were males; 75.3% were hypertensive, 50% diabetic and 59% dyslipidemic; 82% had coronary artery disease, 33% atrial fibrillation, 41% renal failure (creatinine > or = 1.5 mg/dl), and 49% anemia (hemoglobin < or = 12 g/dl). Mortality rates were 4.7% in-hospital, 7.6% at 30 days, 18.7% at 6 months and 28.1% at 12 months. Multiple logistic regression analysis revealed that increased 1 year mortality rate was associated with NYHA III-IV (odds ratio 2.07, 95% confidence interval 1.78-2.41), age (for 10 year increment) (OR 1.41, 95% CI 1.31-1.52), renal failure (1.79, 1.53-2.09), anemia (1.50, 1.29-1.75), stroke (1.50, 1.21-1.85), chronic obstructive pulmonary disease (1.25, 1.04-1.50) and atrial fibrillation (1.20, 1.02-1.40)., Conclusions: This nationwide heart failure survey indicates a high risk of long-term mortality and the urgent need to develop more effective management strategies for patients with heart failure discharged from hospitals.

Background: Despite significant advances in the therapy of heart failure, many patients still do not receive optimal treatment., Objectives: To document the standard of care that patients hospitalized with HF in Israel received during a 2 month period., Methods: The Heart Failure Survey in Israel 2003 was a prospective 2 month survey of patients admitted to all 25 public hospitals in Israel with a diagnosis of HF., Results: The mean age of the 4102 patients was 73 years and 43% were female. The use of angiotensin-converting enzyme/angiotensin receptor blockers and beta blockers both declined from NYHA class I to IV (68.8% to 50.6% for ACE-inhibitor/ARB and 64.1% to 52.9% for beta blockers, P < 0.001 for comparisons). The percentage of patients by NYHA class taking an ACE-inhibitor or ARB and a beta blocker at hospital discharge also declined from NYHA class I to IV (47.5% to 28.8%, P < 0.002 for comparisons). The strongest predictor of being discharged with an ACE-inhibitor or ARB was the use of these medications at hospital admission. Negative predictors for their usage were age, creatinine, disease severity class, and functional status., Conclusions: Despite the dissemination of guidelines many patients did not receive optimal care for HF. Reasons for this discrepancy need to be identified and modified.

An anonymous patient perception comprehension and satisfaction questionnaire was sent to 438 patients 1-3 months after they had participated in a clinical cardiovascular trial to examine the level of patient comprehension as perceived by the patient. We compared perceived comprehension in acute (acute myocardial infarction) and chronic (outpatient heart failure) clinical trials. Partially or fully completed questionnaires were received from 220 patients (70 chronic, 150 acute). The findings were similar in the 2 patient groups. Perceived full comprehension (understood most or all) of the trial was reported by 18 (27%) of chronic and 40 (31%) of 129 acute patients, while almost 20% of both groups reported little or no understanding of the trial. The level of comprehension was related to the recollected duration of explanation (p = 0.003 chronic, p < 0.001 acute). Perceived comprehension was not related to the personnel explaining the study (physician or nurse) or to whether the explanation as recollected was oral or written. However, in both acute and chronic patients, the majority (51% chronic; 63% acute) preferentially recalled the oral rather than written explanation of the trial. The very similar findings in the acute and chronic situation suggest that perceived understanding reflects human nature and willingness to be involved in medical issues. Considerable effort should be directed to improve the duration of explanation (particularly oral), if we are to achieve our goal of true informed consent in clinical cardiovascular trials., (Copyright 2003 S. Karger AG, Basel)

Objective: To evaluate the phase plane (PP) ECG as a method for detecting acute coronary occlusion (ACO)., Background: Balloon inflation in a coronary artery during PTCA produces acute myocardial ischemia. The sensitivity of the standard ECG for detecting ACO is approximately 50%, depending on the number of leads recorded., Methods: The standard ECG signals of 18 patients (91 leads), undergoing PTCA were sampled and converted to digital data, prior to, and during acute coronary occlusion. PPs were constructed by projecting the ECG signals and their first derivatives onto a two-dimensional plane. Standard ECG signals and PPs, prior to ACO, were compared to their respective recordings and PPs during ACO., Results: Using the standard ECG analysis, the acute occlusion was detected in 39 of 91 leads (43%), and in 15 of 18 patients (83%), whereas using the PP analysis it was detected in 82 of 91 leads (90%), and in all 18 patients (100%) (P<0.001, for leads). The median number of leads per patient demonstrating standard ECG changes was 2.0, whereas for the PP analysis it was 5.5 (P<0.001). The specificity of the PP method was 83.5%., Conclusions: The sensitivity of the PP method for detecting ACO during PTCA was superior to that of the standard ECG analysis. A smaller lead system is required to detect changes of ACO, during PTCA, when the PP method is used. The PP method is simple, low-priced, and may serve to detect acute myocardial ischemia in a number of clinical settings.