Prevalence of conduction abnormalities in a systolic heart failure population by race, ethnicity, and gender.

BACKGROUND: There is paucity of data regarding conduction abnormalities in the Hispanic population with systolic heart failure (HF). We aimed to evaluate the prevalence of electrocardiogram (ECG) abnormalities in a systolic HF population, with attention to the Hispanic population. METHODS: A cross sectional study of 926 patients enrolled in a systolic HF disease management program. ECGS were obtained in patients with an ejection fraction (EF) ≤ 40% by echocardiography at enrollment. Univariate and multivariate analysis adjusted by ethnicities was performed. RESULTS: White patients exhibited higher prevalence of atrial fibrillation (14.7%) than black patients (8.0%, P = 0.01) whereas Hispanics presented higher prevalence of paced rhythm (14.3% in Hispanics vs. 6.5% in whites and 5.2% in blacks, P<0.01 for both comparisons), higher prevalence of left bundle branch block (LBBB, 14.5% in Hispanics vs. 8.8% in whites and 5.8% in blacks, P = 0.002) and increased frequency of abnormal QT intervals (76.7% in Hispanics) than whites (59.6%) and blacks (69%) patients (P< 0.01 for both comparisons). A QRS interval greater than 120 ms was less prevalent among blacks (15.8% vs. 26.0% in whites and 25.3% in Hispanics, P = 0.01 for both comparisons). Univariate and multivariate analysis disclosed no influence of other characteristics (age, sex, coronary artery disease, hypertension, ejection fraction, medications) in the ECG findings. CONCLUSIONS: Hispanics with Systolic HF presented with increased prevalence of paced rhythm, LBBB, and abnormal QT intervals. Attention should be addressed to these ECG variations to recommend additional guidance for therapeutic interventions and provide important prognostic information.

Prevalence of stroke in systolic heart failure.

BACKGROUND: Heart disease is a major independent risk factor for stroke, ranking third after age and hypertension. Heart failure (HF) patient constitutes an important subgroup of patients with stroke, because of their poor outcome and high rates of mortality and stroke recurrence. We examined the prevalence of stroke in patients with heart failure from 3 different geographic regions. METHODS AND RESULTS: We compared the prevalence of self-reported history of stroke in participants with systolic HF from 3 different geographic regions (Houma, LA; Miami, FL; and Tbilisi, Georgia, Eastern Europe). We examined the prevalence of stroke/adjusting for patient demographic and health characteristics. Stroke prevalence was reported by 79 (7.8%) of 1017 participants from Louisiana, 51 (9.2%) of 556 participants from Florida, and 5 (1.3%) of 383 participants from Georgia. After multivariable adjustment, the prevalence of stroke was significantly lower in Georgia compared to Florida and Louisiana sites. Patients on ß-blocker medication were 3.58 times (95% CI 1.96-6.55) more likely to report stroke compared to those without ß-blockers (×2 = 19.5, P ≤ .0001). There were significantly fewer participants on ß-blockers from Georgia (7%) compared to participants from Florida (87%) and Louisiana (94%; (×2 = 24.3, P<.001). CONCLUSIONS: Self-reported stroke prevalence in participants with HF was not consistent among the 3 sites. These differences in prevalence may in part be explained by the lower reported use of ß-blockers in the Georgia site. Longitudinal studies are needed to determine whether ß-blockers increase the risk of stroke in HF population.

Peripheral vascular disease and erectile dysfunction as predictors of mortality in heart failure patients.

INTRODUCTION: Seventy percent to 90% of patients with heart failure (HF) report erectile problems. There are no published data on whether erectile dysfunction (ED) and peripheral vascular disease (PVD) correlate with mortality in HF patients. Also, little is known regarding the impact of HF etiology on mortality in patients with ED. AIMS: Our aim was to investigate the relationship between ED and mortality in HF patients, to evaluate whether the etiology of HF carries a prognostic measure in patients with ED, and to assess the impact of PVD on mortality in optimally treated HF patients with ED. MAIN OUTCOME MEASURES: The measures are: (i) mortality by presence or absence of ED; (ii) mortality by HF etiology and presence or absence of ED; and (iii) PVD and mortality in HF patients on optimal medical therapy with ED. METHODS: This is a single-center, prospective cohort study of 328 male HF patients (ejection fraction < or = 40%) followed while being treated with optimal doses of beta blockers and angiotensin-converting enzyme inhibitors. The Sexual Health Inventory for Men survey was used to assess ED (no ED > or = 22 and ED < or = 21). Ankle brachial index (ABI) was used to assess PVD (normal ABI > or = 0.9 and abnormal ABI < 0.9). RESULTS: Kaplan-Meier curves were constructed to examine the relationship between the presence or absence of ED and PVD, and mortality in a HF population. Although not statistically significant, a trend for increased risk of death was demonstrated in the ischemic cardiomyopathy cohort with ED. CONCLUSIONS: ED, highly prevalent in this cohort, did not identify HF patients on optimal medical therapy at increased risk for mortality. Among the HF patients with ED, HF type was not associated with increased risk for mortality whereas PVD was independently associated with a statistically significant increase in mortality.

Mortality benefit of a comprehensive heart failure disease management program in indigent patients.

BACKGROUND: Heart failure (HF) produces significant morbidity and mortality. Although HF disease management (HFDM) programs have been shown to decrease this morbidity, there is still a paucity of data on their effect on mortality. The objective of this study was to determine whether participation in an HFDM program would reduce mortality in an indigent population from rural Louisiana. METHODS: Proportional hazards modeling was used to determine whether patients participating in the HFDM program had improved survival compared with patients receiving traditional outpatient care at the same institution. Inclusion criteria consisted of an index hospitalization with discharge occurring between July 1, 1997, and May 30, 2002, hospital discharge diagnosis of HF, left ventricular systolic dysfunction documented during hospitalization, and at least 1 subsequent outpatient visit. Data from patients having participated in the HFDM program before their index hospitalization were excluded. RESULTS: Compared with patients who were given traditional care (n = 100), HFDM patients (n = 156) were younger (56.7 vs 60 years, P = .031), more likely to be African American (48.7% vs 33.0%, P = .014), more likely to be uninsured (47.4% vs 27%, P = .001), and more likely to have an ejection fraction of < or = 25% (73.1% vs 36%, P < .001). Overall comorbidity did not differ significantly between the groups. After controlling for differences in demographics, ejection fraction, and comorbidities, participation in the HFDM program was associated with a significant reduction in mortality compared with traditional care (adjusted hazard ratio .33, P < .001). CONCLUSION: In this indigent population, participation in an HFDM program was associated with decreased mortality compared with traditional follow-up care.

Long-term survival in lung transplant recipients after successful preoperative coronary revascularization.

OBJECTIVE: Coronary artery disease is considered a contraindication to lung transplantation. We studied effect of pre-lung transplantation nonobstructive coronary artery disease and revascularized coronary artery disease on long-term lung transplant survival. METHODS: Clinical courses of 172 lung transplant recipients from December 1990 to May 2003 were reviewed. Significant coronary artery disease, defined as left main stenosis of greater than 50% or other epicardial vessel stenosis of greater than 70%, was present in 7 patients; 6 received percutaneous coronary intervention and 1 received coronary artery bypass grafting before transplantation. RESULTS: Groups were similar with regard to sex, race, or length of intensive care days. The group with normal coronary arteries was significantly younger than the groups with coronary artery disease. The revascularized group had a significant increase in dysrhythmias (P < .003) and 1-, 3-, and 5-year survivals of 85%, 85%, and 69%, respectively. Those with insignificant coronary artery disease (14 patients) demonstrated a 1-, 3-, and 5-year survival of 64%, 40%, and 32%, respectively. The normal coronary group (151 patients) had a 1-, 3-, and 5-year survival of 75%, 58%, and 40%, respectively. The revascularized group had a significant survival advantage compared with that of the insignificant coronary artery disease group (P < .04, log-rank test). CONCLUSION: Long-term survival of lung transplant recipients with revascularized coronary arteries is similar to that of subjects with normal coronary arteries, despite an increased incidence of dysrhythmias. Lung transplant recipients with insignificant coronary artery disease had a worse survival than the revascularized group. More studies are needed to ascertain the cause and determine the optimal management for lung transplant recipients with insignificant coronary artery disease.

Open access to an outpatient intravenous diuresis program in a systolic heart failure disease management program.

In order to provide efficient utilization of resources in an outpatient setting for acute exacerbation of heart failure (HF), the authors piloted an open-access outpatient intravenous (IV) diuretic program (IVDP) to evaluate utilization in an HF disease management program (HFDMP), patient characteristics for users of the program, and safety. An outpatient HFDMP at Jackson Memorial Hospital in Miami, Florida, enrolling 577 patients 18 years and older with an ejection fraction ≤40% was implemented. For symptoms or weight gain ≥5 pounds, patients were eligible to use an open-access IVDP during clinic hours. A total of 130 HFDM patients (22.5%) used the IVDP. IVDP users were more likely to be diabetic, with lower body mass indices than non-IVDP users. New York Heart Association class IV patients and previously hospitalized patients were more likely to use the IVDP. There were no documented adverse reactions for patients receiving treatment and no difference in mortality between groups. This open-access outpatient IVDP model for patients with HF was readily utilized by the HFDMP participants and appears safe for use in this population. This unique model may provide alternative access for acute HF treatment. Congest Heart Fail.

Feasibility of a heart failure disease management program in eastern Europe: Tbilisi, Georgia.

BACKGROUND: Little is known about the importation of a heart failure disease management program (HFDMP) into low- and middle-income countries. We examined the feasibility of importing a HFDMP into the country of Georgia, located in the Caucuses. METHODS AND RESULTS: Patients with ejection fraction ≤40% were enrolled into a prospective, observational study consisting of a new HFDMP staffed by local cardiologists. Medications, emergency department use, hospital admissions, and mortality were assessed by interviews with patients or their families. Screening resulted in 400 patients who were followed for 10.2±3.5 months. ß-Blocker prescriptions increased from 7.4-80.7% (P<0.001), angiotensin-converting enzyme inhibitor prescriptions increased from 18.4-92.6% (P<0.001), and mean systolic blood pressure declined from 145 to 114 mm Hg (P<0.001). Patients visiting the emergency department and hospitalizations were lowered by 40.7% and 52.5%, respectively, but were also influenced by the outbreak of war, during which 17.5% (n=70) of patients received follow-up in refugee tents. All-cause mortality extended to 7% of patients, with 12 of 28 deaths caused by war-related events. CONCLUSIONS: Importation of a Western HFDMP was demonstrated to be feasible, with a 5-fold increase in the use of recommended therapies, reduction of blood pressure, decrease of emergency department visits, and hospitalizations for heart failure. These measures could result in substantial cost savings in resource-limited settings, but assessment is complicated in unstable areas. Translating effective interventions to low- and middle-income countries requires sensitivity to regional cultures and flexibility to adapt both clinical goals and strategies to unexpected conditions.

Routine serial echocardiography in systolic heart failure: is it time for the heart failure guidelines to change?

The authors sought to obtain objective evidence for impacting the American College of Cardiology Heart Failure Guidelines for the routine use of serial echocardiography by assessing the reliability of the use of clinician-assessed patient symptoms and New York Heart Association (NYHA) functional classification compared with ejection fraction (EF) measured by echocardiography. A prospective study in 256 patients with systolic heart failure (HF) enrolled into an HF disease management program with EF ≤40% and at least 2 annual echocardiograms were included. Only 86 of 256 (33.5%) patients were correctly classified by NYHA class as showing improvement, no change, or deterioration as compared with echocardiographic assessments. Patients whose NYHA class showed no change between echocardiograms had the lowest survival rate. Quantification in patient's status with NYHA classification is not always a reliable assessment to evaluate prognosis and guide medical therapy for patients with systolic HF.

Low serum sodium as a poor prognostic indicator for mortality in congestive heart failure patients.

BACKGROUND: The incidence of congestive heart failure (CHF) has not significantly declined over the past 50 years, and overall survival rates are low at 5 years following diagnosis. Numerous studies have shown low serum sodium to be a poor prognostic indicator of all cause mortality in CHF patients. HYPOTHESIS: The goal of this hypothesis was to validate if hyponatremia is an important predictor of mortality in an outpatient population of CHF patients on maximal combined angiotensin-converting enzyme inhibitor (ACEI) and ß-blocker therapy. METHODS: A total of 364 (13% with hyponatremia) patients with CHF (ejection fraction [EF] ≤ 40%) were enrolled in a heart failure disease management program. The mean New York Heart Association (NYHA) class was II.XII. The average baseline serum sodium was 138.2 mEq/L. RESULTS: We evaluated the relationship between hyponatremia (<135 mEq/L) and all-cause mortality at 40 months. During follow-up, 8 patients in the hyponatremia group compared to 31 in the normonatremic group died. Results of Kaplan-Meier analyses indicated there were no significant differences in mortality between the hyponatremia and normonatremic groups (log-rank test = 0.39). Results for Cox proportional hazards models indicated low sodium was not a significant predictor of mortality (unadjusted odds ratio [OR]: 1.41, 95% confidence interval [CI]: 0.65, 3.07; adjusted OR: 1.60, 95% CI: 0.57, 4.53). CONCLUSIONS: The relationship between hyponatremia and all-cause mortality did not reach significance. Hyponatremia did not significantly predict mortality in a CHF population on maximal medical therapy. Copyright © 2010 Wiley Periodicals, Inc.

Utility of the 6-minute walk test following lung transplantation.

BACKGROUND: The 6-minute walk test (6-MWT) has replaced standard cardiopulmonary exercises for the evaluation of lung disease. However, data on the utility and characteristics of the 6-MWT following lung transplant are lacking. This study aimed to determine if 6-MWT distance has a normal distribution at 6 months post-transplant and if lower 6-MWT distance was predictive of all-cause mortality. METHODS: We performed a retrospective chart review of 6-MWT data on all patients who were lung transplant recipients at Ochsner Medical Center between 2000 and 2005. Forty-nine lung transplant recipients completed a 6-MWT at 6 months following transplant. Of these 49 patients, 34 had completed both the 6-month and 12-month 6-MWT, and data from these were used to evaluate change in distance walked over time. RESULTS: The mean age was 46 ± 16 years, 57% were female, and 69% received a bilateral lung transplant. Normal distribution by Kolmogorov-Smirnov was demonstrated for 6-MWT distance at 6 months (P  =  0.873). Mean distance walked improved from 348 ± 15 m to 478 ±14 m at 12 months (P  =  0.0001). The 6-MWT distance at 6 months was not a predictor of survival (OR  =  1.002). CONCLUSIONS: Distance for the 6-MWT followed a normal distribution following lung transplant, and distances walked continued to improve for a year following transplant. Although 6-MWT distances are not a predictor of survival, other components of the test may strengthen the predictive value for morbidity and mortality post-transplant.

Epidemiology and survival of the five stages of chronic kidney disease in a systolic heart failure population.

AIMS: The epidemiology of the five stages of chronic kidney disease (CKD) in systolic heart failure (HF) patients has predominantly been described in hospitalized White patients, with little known about the prevalence in outpatient Blacks and Hispanics. The purpose of this study was to compare the prevalence of the five stages of CKD by race, ethnicity (Whites, Blacks, and Hispanics), and gender in an outpatient systolic HF population and also to evaluate the impact of CKD on mortality. METHODS AND RESULTS: We conducted a prospective study of 1301 patients recruited from two hospital facilities in Louisiana and Florida, USA. All patients were enrolled in a systolic HF disease management programme (HFDMP), which enrolled patients with an ejection fraction of < or =40% by echocardiography. The estimated glomerular filtration rate was calculated using the abbreviated Modification of Diet in Renal Disease Study equation. Patients were classified into five stages of CKD according to the National Kidney Foundation classification system. A total of 338 patients (26%) were found to have CKD. Patients with CKD were older, more likely to be Hispanics, to have less education, New York Heart Association class III, elevated systolic blood pressure, and diabetes. There was no statistical difference in prevalence by gender. Survival was reduced in patients with CKD. CONCLUSION: The prevalence of CKD in an outpatient systolic HFDMP is high, with over one in four patients affected. CKD patients had significantly lower survival rates compared with patients without CKD.

Prevalence of electrocardiographic abnormalities in a systolic heart failure disease management population by race, ethnicity, and sex.

The prevalence of electrocardiographic (ECG) abnormalities in systolic heart failure patients have predominantly been described in white patients, with relatively little known about their prevalence in black and Hispanic populations. The purpose of this study is to compare the prevalence of ECG abnormalities by race, ethnicity, and sex. The authors conducted an observational prospective study that included 926 patients from 2 hospital facilities. A systolic heart failure disease management program implemented in both sites enrolled patients with an ejection fraction < or =40% by echocardiography. Black patients had less evidence of myocardial infarction than whites and Hispanics. Black patients had more evidence of left ventricular hypertrophy than Hispanics and whites. Hispanics evidenced more ischemic changes than blacks and whites. Among black patients, left ventricular hypertrophy was more prevalent in women. ECG abnormalities vary across race, ethnicity, and sex. These variations may have implications for further diagnostic testing and potential treatment regimens.

The impact of a standardized disease management program on race/ethnicity and gender disparities in care and mortality.

BACKGROUND: Data on racial and gender differences in mortality in patients followed in a standardized heart failure disease management program (HFDMP) are scarce. METHODS: Survival was calculated by race/ethnicity and gender for 837 patients enrolled in a HFDMP. (The patients studied were indigent African American and White outpatients [39% African American, 36% female] enrolled into at Leonard J. Chabert Medical Center in Houma, Louisiana.) The hazard ratio associated with demographic and clinical characteristic individually and as a whole, was estimated for the four groups. RESULTS: White males had the highest mortality (African American female: HR=0.64, African American male: HR=0.65, White female: HR=0.67, p<.05). Age (HR=1.04, p<.001), ejection fraction (HR=0.97, p<.001), New York Heart Association (NYHA) (HR=1.57, p<.001), systolic blood pressure (HR=0.99, p<.05), hematocrit (HR=0.96, p<.01), diabetes (HR=0.98, p<.05), and body mass index (HR=0.98, p<.05) were significant predictors of mortality in the univariate model. Age (HR=1.04, p<.001), NYHA (HR=1.40, p<.001), diabetes (HR=2.52, p<.001), and White female (HR=.44, p<.01) were significant predictors of mortality in the multivariate model. CONCLUSION: With the exception of White females, who demonstrated lower mortality, amongst African American males and females and White males who participated in a HFDMP no difference in survival was observed.

Treatment of hypertension for patients with diastolic dysfunction.

Diastolic dysfunction is a poorly understood pathophysiological entity; its importance is magnified by the increasing prevalence of diastolic heart failure. Forty-six million people in the US are experiencing heart failure and 550000 new cases are diagnosed annually. A large percentage of these patients with heart failure have a normal or nearly normal left-ventricular ejection fraction. Isolated diastolic dysfunction may be associated with an increased mortality. One of the major causes of diastolic dysfunction is hypertension. Advances in diagnosis and treatment strategies may improve the clinical outcome for patients with diastolic dysfunction.