Impact of heart failure drug therapy on rates of gastrointestinal bleeding in LVAD recipients: An INTERMACS analysis

2021 ◽  
pp. 039139882110133
Author(s):  
Douglas L Jennings ◽  
Lauren K Truby ◽  
Audrey J Littlefield ◽  
Alana M Ciolek ◽  
Dylan Marshall ◽  
...  
Keyword(s):  
Heart Failure ◽  
Gastrointestinal Bleeding ◽  
Cox Regression ◽  
Angiotensin Receptor Blockers ◽  
Left Ventricular ◽  
Loop Diuretics ◽  
Mineralocorticoid Receptor Antagonist ◽  
Clinical Variables ◽  
Increased Risk ◽  
Lvad Support

Introduction: Gastrointestinal bleeding (GIB) remains a common and vexing complication of left ventricular assist device (LVAD) support. Recent single-center analyses suggest that ACE inhibitors (ACEi)/angiotensin receptor blockers (ARB) and digoxin may prevent GIB in LVAD patients. Here we evaluate the effect of guideline-directed medical therapies (GDMT) for heart failure (HF) on rates of GIB through analysis of the INTERMACS registry database. Methods: Thirteen thousand seven hundred thirty-two patients who received a continuous-flow LVAD and were on antiplatelet therapy and anticoagulation with warfarin after 3 months of pump support were included in the analysis. GIB events following implant were assessed based on receipt of ACEi/ARB, beta-blockers (BB), mineralocorticoid receptor antagonist (MRA), amiodarone, digoxin, loop diuretics, and phosphiesterase-5 inhibitors (PDE5). Backwards stepwise cox regression was used to control for confounding of each drug class on each other, as well as for clinical variables like age, gender, renal function, HF etiology, and device strategy. Results: After 3 months of pump support medications used in LVAD patients were BB (65.0%), ACEi/ARB (51.7%), Amio (43.7%), MRA (37.9%), and loop diuretics (70.1%). In patients with available data, PDE and digoxin use were 18.2% and 16.9%, respectively. The overall incidence of GIB was 19.5% at 2 years of support. After adjustment for other clinical variables, loop diuretics (HR 1.274, p < 0.001) and PDE5 (HR 1.241, p < 0.001) use were associated with increased risk of GIB, while use of BB (HR 0.871, p = 0.006) was associated with lower risk of GIB. ACEi/ARB (HR 1.002, p = 0.971), Amio (HR 1.083, p = 0.106), AA (HR 0.967, p = 0.522) or digoxin (HR 1.087, p = 0.169) did not affect GIB rates on LVAD support (Figure). Conclusion: Despite recent reports, ACEi/ARB, MRA, Amio, and digoxin use does not appear to be associated with GIB during LVAD support. The heightened risk seen in those on loop diuretics may reflect venous congestion in these patients, while antiplatelet effects of PDE5 could drive the higher risk of GIB.

Myocardial reperfusion reverses the J-curve association of cardiovascular risk and diastolic blood pressure in patients with left ventricular dysfunction and heart failure after myocardial infarction: insights from the EPHESUS trial

2020 ◽  
Vol 41 (17) ◽  
pp. 1673-1683 ◽  
Author(s):  
Michael Böhm ◽  
João Pedro Ferreira ◽  
Felix Mahfoud ◽  
Kevin Duarte ◽  
Bertram Pitt ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Blood Pressure ◽  
Diastolic Blood Pressure ◽  
Cox Regression ◽  
Cardiovascular Death ◽  
Left Ventricular ◽  
Coronary Perfusion ◽  
Increased Risk ◽  
The Impact

Abstract Aims The described association of low diastolic blood pressure (DBP) with increased cardiovascular outcomes could be due to reduced coronary perfusion or is simply due to reverse causation. If DBP is physiologically relevant, coronary reperfusion after myocardial infarction (MI) might influence DBP–risk association. Methods and results The relation of achieved DBP with cardiovascular death or cardiovascular hospitalization, cardiovascular death, and all-cause death was explored in 5929 patients after acute myocardial infarction (AMI) with impaired left ventricular function, signs and symptoms of heart failure, or diabetes in the EPHESUS trial according to their reperfusion status. Cox regression models were used to assess the impact of reperfusion status on the association of DBP and systolic blood pressure (SBP) with outcomes in an adjusted fashion. In patients without reperfusion, lower DBP &lt;70 mmHg was associated with increased risk for all-cause death [adjusted hazard ratios (HRs) 1.80, 95% confidence interval (CI) 1.41–2.30; P &lt; 0.001], cardiovascular death (HR 1.70, 95% CI 1.3–3.22; P &lt; 0.001), cardiovascular death or cardiovascular hospitalization (HR 1.54, 95% CI 1.26–1.87; P &lt; 0.001). In patients with reperfusion, the risk increase at low DBP was not observed. At low SBP, risk increased independently of reperfusion. A sensitivity analysis in the subgroup of patients with optimal SBP of 120–130 mmHg showed again risk reduction of reperfusion at low DBP. Adding the treatment allocation to eplerenone or placebo into the models had no effects on the results. Conclusion Patients after AMIs with a low DBP had an increased risk, which was sensitive to reperfusion therapy. Low blood pressure after MI identifies in patients with particular higher risk. These data support the hypothesis that low DBP in patients with stenotic coronary lesions is associated with risk, potentially involving coronary perfusion pressure and the recommendations provided by guidelines suggesting lower DBP boundaries for these high-risk patients.

scholarly journals 393 Long-term prognostic value of haemodynamic determinants of right ventricular pulsatile afterload in patients with advanced heart failure

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Francesca Rubino ◽  
Roberto Scarsini ◽  
Anna Piccoli ◽  
Livio San Biagio ◽  
Ilaria Tropea ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Right Ventricular ◽  
Primary Endpoint ◽  
Prognostic Value ◽  
Cox Regression ◽  
Left Ventricular ◽  
Advanced Heart Failure ◽  
Strong Impact ◽  
Increased Risk

Abstract Aims Right ventricular (RV) dysfunction demonstrated a strong impact on survival of patients with advanced heart failure with reduced ejection fraction (HFrEF). Increased RV afterload is associated with poor prognosis in patients with HF. To examine the prognostic relevance of RV pulsatile afterload parameters, in particular pulmonary artery compliance (PAC), elastance (PAE), and pulsatile index (PAPi) in a large cohort of patients with advanced HFrEF evaluated for heart transplantation (HT). Methods and results 149 patients with HFrEF enlisted for HT were evaluated with right heart catheterization (RHT) and echocardiography and were followed until death or any censoring events including HT, left ventricular assist device (LVAD), and hospitalization for acute heart failure (HHF). Cox regression and ROC-curve analysis were used to test the prognostic value of RV pulsatile afterload determinants. During a mean observation time of 500 ± 424 days, the primary endpoint occurred in 29 (19.5%) patients. The mean age was 56.6 ± 10.1 years and 85.2% were male. The most frequent etiology of HF was ischaemic cardiomyopathy (52.3%). Mean LV ejection fraction was 25.7 ± 10.2%. Patients who met the primary endpoint were significantly older and with worse haemodynamic profile than event-free survivors. In particular, the primary endpoint occurred in patients with lower PAC (1.8 ± 0.8 vs. 2.7 ± 2.0, P = 0.01), higher mean pulmonary arterial pressure (mPAP) (33.5 ± 11.3 vs. 29.3 ± 11.0, P = 0.05), PVR (3.0 ± 1.6 vs. 2.6 ± 2.0, P = 0.09), and PEA (1.12 ± 0.5 vs. 0.98 ± 0.6, P = 0.04). A significant increased risk of adverse outcome was observed in patients with PAC &lt;1.9 ml/mmHg (HR: 3, 95% CI: 1.3–6, P = 0.007), PEA &gt; 0.9 mmHg/ml (HR: 2.5, 95% CI: 1.1–5.2, P = 0.02) and mPAP ≥25 mmHg (HR: 3.0, 95% CI: 1.0–7.5, P = 0.03). The predictive value of PAC was superior compared with PVR (AUC comparison, P = 0.019) and PAPi (P = 0.03). Conversely, PAC presented similar prognostic accuracy compared with mPAP (P = 0.51) and PEA (P = 0.19). Moreover, PAC demonstrated incremental prognostic value compared with the cardiac index (P = 0.02), whereas mPAP and PAE did not. Conclusions Impaired haemodynamic RV parameters are associated with worse survival in patients with advanced HFrEF. Pulsatile RV afterload indices should be considered in the evaluation of patients enlisted for HT. PAC demonstrated an independent prognostic value in this highly selected cohort of patients awaiting HT.

Abstract 2026: Atrial Fibrillation Predicts Ventricular Arrhythmogenicity In Heart Failure

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Kristina Lemola ◽  
Razi Khan ◽  
Stanley Nattel ◽  
Sakari Lemola ◽  
Peter G Guerra ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Primary Prevention ◽  
Cox Regression ◽  
Left Ventricular ◽  
Hazard Ratio ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Increased Risk ◽  
N 93

Background: Atrial fibrillation (AF) is associated with appropriate ICD discharges in patients with primary prevention indications. We explored potential effect modifiers impacting on ventricular arrhythmogenic risk associated with AF. Methods and Results: A retrospective cohort study was conducted on 215 consecutive patients with ICDs for primary prevention having a left ventricular ejection fraction (LVEF) < <26>35% and followed for 1.3±0.7 years. Mean age was 61.0±0.7 years and 17% were women. Cox regression models were explored in subgroups of patients stratified by demographic parameters, prior medical and surgical history, physical exam features, laboratory findings, and results of diagnostic tests. Appropriate ICD discharges were received by 10% of patients. AF was associated with a 3.5 fold increased risk [95% CI (1,5, 8.1), P=0.005]. Effect modifiers for the relationship between AF and appropriate ICD discharges included QRS duration and QTc. In patients with a QRS>130 msec (N=93), 6 of 33 (18%) patients with AF received appropriate ICD discharges versus 2 of 60 (3%) without AF (P=0.03). In this subgroup, AF was associated with a hazard ratio of 5.1 (P=0.049). Among individuals with a QTc >440 msec (N=93), 6 of 32 (19%) AF patients received appropriate ICD discharges versus 1 of 61 (2%) without AF (P=0.01). AF was associated with a hazard ratio of 10.3 (P=0.031). Five of 28 patients (18%) with both prolonged QRS and QTc duration (N=77) that also having AF received appropriate ICD discharges compared to 0 of 49 of patients without AF (P=0.005). After adjusting for medical therapy, AF independently predicted appropriate ICD discharges in subgroups with and without QRS and QTc increase. Conclusion: AF portends increased risk for ventricular tachyarrhythmias in patients with heart failure, particularly when associated with conduction and/or repolarization abnormalities. This finding may reflect common depolarization and repolarization defects associated with the arrhythmic milieu contributing to AF and ventricular arrhythmias, or adverse consequences of AF on the complex neurohumoral/electrophysiological substrate underlying ventricular arrhythmogenesis in heart failure.

Sex differences in transaortic flow rate and association with all-cause mortality in patients with severe aortic stenosis

2021 ◽  
Author(s):  
Sahrai Saeed ◽  
Anastasia Vamvakidou ◽  
Spyridon Zidros ◽  
George Papasozomenos ◽  
Vegard Lysne ◽  
...  
Keyword(s):  
Sex Differences ◽  
Aortic Stenosis ◽  
Flow Rate ◽  
Cox Regression ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Cox Regression Analysis ◽  
Increased Risk ◽  
All Cause Mortality

Abstract Aims It is not known whether transaortic flow rate (FR) in aortic stenosis (AS) differs between men and women, and whether the commonly used cut-off of 200 mL/s is prognostic in females. We aimed to explore sex differences in the determinants of FR, and determine the best sex-specific cut-offs for prediction of all-cause mortality. Methods and results Between 2010 and 2017, a total of 1564 symptomatic patients (mean age 76 ± 13 years, 51% men) with severe AS were prospectively included. Mean follow-up was 35 ± 22 months. The prevalence of cardiovascular disease was significantly higher in men than women (63% vs. 42%, P &lt; 0.001). Men had higher left ventricular mass and lower left ventricular ejection fraction compared to women (both P &lt; 0.001). Men were more likely to undergo an aortic valve intervention (AVI) (54% vs. 45%, P = 0.001), while the death rates were similar (42.0% in men and 40.6% in women, P = 0.580). A total of 779 (49.8%) patients underwent an AVI in which 145 (18.6%) died. In a multivariate Cox regression analysis, each 10 mL/s decrease in FR was associated with a 7% increase in hazard ratio (HR) for all-cause mortality (HR 1.07; 95% CI 1.03–1.11, P &lt; 0.001). The best cut-off value of FR for prediction of all-cause mortality was 179 mL/s in women and 209 mL/s in men. Conclusion Transaortic FR was lower in women than men. In the group undergoing AVI, lower FR was associated with increased risk of all-cause mortality, and the optimal cut-off for prediction of all-cause mortality was lower in women than men.

scholarly journals Temporal trends in outcome and patient characteristics in dilated cardiomyopathy, data from the Swedish Heart Failure Registry 2003–2015

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Helen Sjöland ◽  
Jonas Silverdal ◽  
Entela Bollano ◽  
Aldina Pivodic ◽  
Ulf Dahlström ◽  
...  
Keyword(s):  
Heart Failure ◽  
Dilated Cardiomyopathy ◽  
Temporal Trends ◽  
Physical Symptoms ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Continuous Change ◽  
Ventricular Ejection Fraction ◽  
Increased Risk ◽  
Over Time

Abstract Background Temporal trends in clinical composition and outcome in dilated cardiomyopathy (DCM) are largely unknown, despite considerable advances in heart failure management. We set out to study clinical characteristics and prognosis over time in DCM in Sweden during 2003–2015. Methods DCM patients (n = 7873) from the Swedish Heart Failure Registry were divided into three calendar periods of inclusion, 2003–2007 (Period 1, n = 2029), 2008–2011 (Period 2, n = 3363), 2012–2015 (Period 3, n = 2481). The primary outcome was the composite of all-cause death, transplantation and hospitalization during 1 year after inclusion into the registry. Results Over the three calendar periods patients were older (p = 0.022), the proportion of females increased (mean 22.5%, 26.4%, 27.6%, p = 0.0001), left ventricular ejection fraction was higher (p = 0.0014), and symptoms by New York Heart Association less severe (p < 0.0001). Device (implantable cardioverter defibrillator and/or cardiac resynchronization) therapy increased by 30% over time (mean 11.6%, 12.3%, 15.1%, p < 0.0001). The event rates for mortality, and hospitalization were consistently decreasing over calendar periods (p < 0.0001 for all), whereas transplantation rate was stable. More advanced physical symptoms correlated with an increased risk of a composite outcome over time (p = 0.0043). Conclusions From 2003 until 2015, we observed declining mortality and hospitalizations in DCM, paralleled by a continuous change in both demographic profile and therapy in the DCM population in Sweden, towards a less affected phenotype.

Right ventricular rather than left ventricular systolic dysfunction predicts outcome in patients undergoing transcatheter aortic valve implantation: insights from cardiac magnetic resonance imaging

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M Koschutnik ◽  
C Nitsche ◽  
C Dona ◽  
V Dannenberg ◽  
A.A Kammerlander ◽  
...  
Keyword(s):  
Heart Failure ◽  
Cox Regression ◽  
Systolic Dysfunction ◽  
Left Ventricular ◽  
Prognostic Information ◽  
Transcatheter Aortic Valve ◽  
Kaplan Meier ◽  
Lv Volumes ◽  
Valve Implantation ◽  
Rv Function

Abstract Background Right ventricular (RV) function is strongly associated with outcome in heart failure. Whether it also adds important prognostic information in patients undergoing transcatheter aortic valve implantation (TAVI) is unknown. Methods We consecutively enrolled patients with severe aortic stenosis (AS) scheduled for TAVI and preprocedural cardiac magnetic resonance (CMR) imaging. Kaplan-Meier estimates and multivariate Cox regression analyses were used to identify factors associated with outcome. A composite of heart failure hospitalization and/or cardiovascular death was selected as primary study endpoint. Results 423 consecutive patients (80.7±7.3 years; 48% female) were prospectively included, 201 (48%) underwent CMR imaging. 55 (27%) patients presented with RV systolic dysfunction (RVSD) defined by RV ejection fraction (RVEF) &lt;45%. RVSD was associated with male sex (69 vs. 40%; p&lt;0.001), New York Heart Association (NYHA) functional status (NYHA ≥ III: 89 vs. 57%; p&lt;0.001), NT-proBNP serum levels (9365 vs. 2715 pg/mL; p&lt;0.001), and history of atrial fibrillation (AF: 51 vs. 30%; p=0.005). On CMR, RVSD was associated with left ventricular (LV) volumes (end-diastolic: 187 vs. 137 mL, end-systolic: 119 vs. 53 mL; p&lt;0.001) and EF (39 vs. 64%; p&lt;0.001). A total of 51 events (37 deaths, 14 hospitalizations for heart failure) occurred during follow-up (9.8±9 months). While LVSD (LVEF &lt;50%) was not significantly associated with outcome (HR 0.83, 95% CI: 0.33 – 2.11; p=0.694), RVSD showed a strong and independent association with event-free survival by multivariate Cox regression analysis (HR 2.47, 95% CI: 1.07–5.73; p=0.035), which was adjusted for all relevant CMR parameters (LV volumes and EF), cardiovascular risk factors (sex, NYHA, AF, diabetes mellitus type II, use of diuretics), and routine biomarkers (NT-proBNP, creatinine). Conclusions RVSD rather than LVSD, as determined on CMR, is an important predictor of outcome in patients undergoing TAVI. RV function might thus add useful prognostic information on top of established risk factors. Figure 1. Kaplan-Meier survival curves Funding Acknowledgement Type of funding source: None

scholarly journals Rationale and design of the PHOspholamban RElated CArdiomyopathy intervention STudy (i-PHORECAST)

2021 ◽  
Author(s):  
W. P. te Rijdt ◽  
E. T. Hoorntje ◽  
R. de Brouwer ◽  
A. Oomen ◽  
A. Amin ◽  
...  
Keyword(s):  
Disease Progression ◽  
Cardiac Fibrosis ◽  
Intervention Study ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Probe Design ◽  
Mineralocorticoid Receptor Antagonist ◽  
Ventricular Ejection Fraction ◽  
Increased Risk ◽  
Overt Disease

Abstract Background The p.Arg14del (c.40_42delAGA) phospholamban (PLN) pathogenic variant is a founder mutation that causes dilated cardiomyopathy (DCM) and arrhythmogenic cardiomyopathy (ACM). Carriers are at increased risk of malignant ventricular arrhythmias and heart failure, which has been ascribed to cardiac fibrosis. Importantly, cardiac fibrosis appears to be an early feature of the disease, occurring in many presymptomatic carriers before the onset of overt disease. As with most monogenic cardiomyopathies, no evidence-based treatment is available for presymptomatic carriers. Aims The PHOspholamban RElated CArdiomyopathy intervention STudy (iPHORECAST) is designed to demonstrate that pre-emptive treatment of presymptomatic PLN p.Arg14del carriers using eplerenone, a mineralocorticoid receptor antagonist with established antifibrotic effects, can reduce disease progression and postpone the onset of overt disease. Methods iPHORECAST has a multicentre, prospective, randomised, open-label, blinded endpoint (PROBE) design. Presymptomatic PLN p.Arg14del carriers are randomised to receive either 50 mg eplerenone once daily or no treatment. The primary endpoint of the study is a multiparametric assessment of disease progression including cardiac magnetic resonance parameters (left and right ventricular volumes, systolic function and fibrosis), electrocardiographic parameters (QRS voltage, ventricular ectopy), signs and/or symptoms related to DCM and ACM, and cardiovascular death. The follow-up duration is set at 3 years. Baseline results A total of 84 presymptomatic PLN p.Arg14del carriers (n = 42 per group) were included. By design, at baseline, all participants were in New York Heart Association (NHYA) class I and had a left ventricular ejection fraction > 45% and < 2500 ventricular premature contractions during 24-hour Holter monitoring. There were no statistically significant differences between the two groups in any of the baseline characteristics. The study is currently well underway, with the last participants expected to finish in 2021. Conclusion iPHORECAST is a multicentre, prospective randomised controlled trial designed to address whether pre-emptive treatment of PLN p.Arg14del carriers with eplerenone can prevent or delay the onset of cardiomyopathy. iPHORECAST has been registered in the clinicaltrials.gov-register (number: NCT01857856).

Abstract 3269: Association of Aortic Regurgitation with Cardiovascular Morbidity and Mortality in Hypertensive Patients with Left Ventricle Hypertrophy: The LIFE study

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Zhibin Li ◽  
Kristian Wachtell ◽  
Sverre E. Kjeldsen ◽  
Stevo Julius ◽  
Michael H. Olsen ◽  
...  
Keyword(s):  
Aortic Regurgitation ◽  
Cox Regression ◽  
Left Ventricular ◽  
Morbidity And Mortality ◽  
Hypertensive Patients ◽  
Life Study ◽  
Cardiovascular Morbidity And Mortality ◽  
Increased Risk ◽  
Lv Mass ◽  
Ventricle Hypertrophy

Background : Whether aortic regurgitation (AI) is associated with higher cardiovascular (CV) morbidity and mortality in hypertension with electrocardiographic (ECG) left ventricular hypertrophy (LVH) is unknown. Methods : Hypertensive patients with ECG-LVH were randomized to losartan- or atenolol-based treatment and followed for 4.8 years in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study. In the LIFE echo substudy, echocardiograms were used to detect AI. Baseline clinical, echocardiographic variables and cardiovascular endpoints data were used in current analyses. Results: The presence of AI was detected in 132 participants (68 women; 68.4 ± 7.3 years). AI was associated with older age (p < 0.001) but not gender. After adjustment for age, AI was associated with significantly increased LV mass indexed by body surface area (BSA) and height 2.7 (both p < 0.005), echocardiographic eccentric LVH (p < 0.05) but not concentric left ventricular (LV) geometry (p < 0.05). After adjusting for significant confounders including history of CV disease, Framingham risk score, randomized antihypertensive therapy, LV eccentric geometry, LV mass indexed by BSA and height 2.7 , multivariate Cox regression analyses showed that AI was independently associated with 2.83-fold more CV death (95% confidence interval [CI] 1.12 to 7.13), 2.24-fold more all-cause mortality (95% CI 1.17 to 4.28) (both p < 0.05). Conclusion : In hypertensive patients with ECG-LVH, AI independently identifies patients at increased risk of CV and all-course mortality.

Abstract 14922: Prognostic Value of Baseline BNP and NT-ProBNP and its Interaction With Spironolactone in Patients With Heart Failure and Preserved Ejection Fraction in the TOPCAT Trial

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Inder S Anand ◽  
Scott D Solomon ◽  
Brian Claggett ◽  
Sanjiv J Shah ◽  
Eileen O’Meara ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Primary Outcome ◽  
Cox Regression ◽  
Selection Criterion ◽  
Adverse Outcomes ◽  
Preserved Ejection Fraction ◽  
Patient Selection Criterion ◽  
Increased Risk ◽  
Patients With Heart Failure

Background: Plasma natriuretic peptides (NP) are helpful in the diagnosis of heart failure (HF) with preserved ejection fraction (HFpEF) and predict adverse outcomes. Levels of NP beyond a certain cut-off level are often used as inclusion criteria in clinical trials to ensure that the patients have HF, and to select patients at higher risk. Whether treatments have a differential effect on outcomes across the spectrum of NP levels is unclear. In the I-Preserve trial a benefit of irbesartan on all outcomes was only seen in HFpEF patients with low but not high NP levels. We hypothesized that in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial, spironolactone might have a greater benefit in patients with lower NP levels. Methods and Results: BNP (n=468) or NT-proBNP (n=400) levels were available at baseline in 868 patients with HFpEF enrolled in the natriuretic peptide stratum (BNP ≥100 pg/mL or an NT- proBNP ≥360 pg/mL) of the TOPCAT trial. In a multi-variable Cox regression model, that included age, gender, region (Americas vs. Russia/Georgia), atrial fibrillation, diabetes, eGFR, BMI and heart rate, higher BNP or NT-proBNP as a continuous, standardized log-transformed variable or grouped by terciles (see Figure for BNP & NT-proBNP tercile values) was independently associated with an increased risk of the primary endpoint of cardiovascular mortality, aborted cardiac arrest, or hospitalization for heart failure (Figure-1). There was a significant interaction between the effect of spironolactone and baseline BNP or NT-proBNP terciles for the primary outcome (P=0.02, Figure-2), with greater benefit of the drug in the lower compared to higher NP terciles. Conclusions: The benefit of spironolactone in lower risk HFpEF patients may indicate effects of the drug on early, but not late higher-risk stage of the disease. These findings question the strategy of using elevated NP as a patient selection criterion in HFpEF trials.

Abstract 18599: Clinical Assessment of Hemodynamic Profiles Predict Readmission and Mortality in Diastolic Heart Failure Patients

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Mohammed Siddiqui ◽  
Salpy V Pamboukian ◽  
Jose A Tallaj ◽  
Michael Falola ◽  
Sula Mazimba
Keyword(s):  
Heart Failure ◽  
Clinical Assessment ◽  
Diastolic Heart Failure ◽  
Clinical Care ◽  
Systolic Heart Failure ◽  
Health Care Expenditures ◽  
Left Ventricular ◽  
Readmission Rates ◽  
Heart Failure Patients ◽  
Increased Risk

Background: Reducing 30 day readmission rates for patients with heart failure (HF) has been a recent focus of lowering health care expenditures. Hemodynamic profiles (HP) have been associated with clinical outcomes in chronic systolic HF. The relationship of HP to outcomes in acute decompensated diastolic HF (DHF) has not been defined. Methods: This case-control study of 1892 DHF patients discharged alive from an academic hospital between 2002-2012 with left ventricular function greater or equal to 45% were categorized into 4 groups: Profile A, no evidence of congestion and hypoperfusion (dry-warm); Profile B, congestion with adequate perfusion (wet-warm); Profile C, congestion with hypoperfusion (wet-cold); and Profile L, hypoperfusion without congestion (dry-cold). All cause readmissions at 30 days and 1 year and mortality at 30 days and 1 year were examined. Statistical analysis using multivariable Cox Proportional hazard model was performed adjusting for demographic, clinical, care and hospital characteristics. Results: Of the 1892 patients, 1196 (63%) were females; mean age was 68 (±14) years. There were 724(38%), 1000 (53%), 88(5%) and 80 (4%) patients in the hemodynamic profiles A, B, C and L respectively. Profiles B and C were associated with an increased risk for 30-day all-cause HF readmission compared to profiles A and L: Hazard ratio (HR) [1.38 (95% C.I 1.17-1.61)], [1.39 (95% C.I 1.18-1.62)] for B and C profiles respectively. Profiles C and L were associated with increased mortality at 1 year: HR [1.46 (95% CI 1.06-1.89)] and [1.31 (95% CI 1.01-1.64)] for A and L profiles respectively (Table). Conclusions: Clinical assessment of HP can help identify DHF patients at increased risk of readmission and mortality, similar to systolic heart failure patients.

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