RESUMEN
BACKGROUND: Anaemia is common among patients with heart failure (HF) and is an important prognostic marker. AIM: We sought to determine the prognostic importance of anaemia in a large multinational pooled dataset of prospectively enrolled HF patients, with the specific aim to determine the prognostic role of anaemia in HF with preserved and reduced ejection fraction (HF-PEF and HF-REF, respectively). DESIGN: Individual person data meta-analysis. METHODS: Patients with haemoglobin (Hb) data from the MAGGIC dataset were used. Anaemia was defined as Hb < 120 g/l in women and <130 g/l in men. HF-PEF was defined as EF ≥ 50%; HF-REF was EF < 50%. Cox proportional hazard modelling, with adjustment for clinically relevant variables, was undertaken to investigate factors associated with 3-year all-cause mortality. RESULTS: Thirteen thousand two hundred and ninety-five patients with HF from 19 studies (9887 with HF-REF and 3408 with HF-PEF). The prevalence of anaemia was similar among those with HF-REF and HF-PEF (42.8 and 41.6% respectively). Compared with patients with normal Hb values, those with anaemia were older, were more likely to have diabetes, ischaemic aetiology, New York Heart Association class IV symptoms, lower estimated glomerular filtration rate and were more likely to be taking diuretic and less likely to be taking a beta-blocker. Patients with anaemia had higher all-cause mortality (adjusted hazard ratio [aHR] 1.38, 95% confidence interval [CI] 1.25-1.51), independent of EF group: aHR 1.67 (1.39-1.99) in HF-PEF and aHR 2.49 (2.13-2.90) in HF-REF. CONCLUSIONS: Anaemia is an adverse prognostic factor in HF irrespective of EF. The prognostic importance of anaemia was greatest in patients with HF-REF.
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Anemia/complicaciones , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/diagnóstico , Volumen Sistólico/fisiología , Anciano , Anemia/mortalidad , Anemia/fisiopatología , Causas de Muerte , Femenino , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Humanos , Masculino , Pronóstico , Modelos de Riesgos Proporcionales , Estudios ProspectivosRESUMEN
BACKGROUND: There is a genetic contribution to the risk of ventricular arrhythmias in survivors of acute coronary syndromes (ACS). We wished to explore the role of 33 candidate single nucleotide polymorphisms (SNPs) in prolonged repolarization and sudden death in patients surviving ACS. METHODS: A total of 2,139 patients (1680 white ethnicity) surviving an admission for ACS were enrolled in the prospective Coronary Disease Cohort Study. Extensive clinical, echocardiographic, and neurohormonal data were collected for 12 months, and clinical events were recorded for a median of 5 years. Each SNP was assessed for association with sudden cardiac death (SCD)/cardiac arrest (CA) and prolonged repolarization at 3 time-points: index admission, 1 month, and 12 months postdischarge. RESULTS: One hundred six SCD/CA events occurred during follow-up (6.3%). Three SNPs from 3 genes (rs17779747 [KCNJ2], rs876188 [C14orf64], rs3864180 [GPC5]) were significantly associated with SCD/CA in multivariable models (after correction for multiple testing); the minor allele of rs17779747 with a decreased risk (hazard ratio [HR] 0.68 per copy of the minor allele, 95% CI 0.50-0.92, P = .012), and rs876188 and rs386418 with an increased risk (HR 1.52 [95% CI 1.10-2.09, P = .011] and HR 1.34 [95% CI 1.04-1.82, P = .023], respectively). At 12 months postdischarge, rs10494366 and rs12143842 (NOS1AP) were significant predictors of prolonged repolarization (HR 1.32 [95% CI 1.04-1.67, P = .022] and HR 1.30 [95% CI 1.01-1.66, P = .038], respectively), but not at earlier time-points. CONCLUSION: Three SNPs were associated with SCD/CA. Repolarization time was associated with variation in the NOS1AP gene. This study demonstrates a possible role for SNPs in risk stratification for arrhythmic events after ACS.
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Síndrome Coronario Agudo/complicaciones , Arritmias Cardíacas/genética , ADN/genética , Electrocardiografía , Marcadores Genéticos , Predisposición Genética a la Enfermedad , Polimorfismo de Nucleótido Simple , Síndrome Coronario Agudo/genética , Síndrome Coronario Agudo/metabolismo , Anciano , Arritmias Cardíacas/etiología , Arritmias Cardíacas/metabolismo , Femenino , Estudios de Seguimiento , Genotipo , Humanos , Masculino , Estudios Prospectivos , Factores de RiesgoRESUMEN
BACKGROUND: In heart failure (HF), obesity, defined as body mass index (BMI) ≥30 kg m(-2), is paradoxically associated with higher survival rates compared with normal-weight patients (the 'obesity paradox'). We sought to determine if the obesity paradox differed by HF subtype (reduced ejection fraction (HF-REF) versus preserved ejection fraction (HF-PEF)). PATIENTS AND METHODS: A sub-analysis of the MAGGIC meta-analysis of patient-level data from 14 HF studies was performed. Subjects were divided into five BMI groups: <22.5, 22.5-24.9 (referent), 25-29.9, 30-34.9 and ≥35 kg m(-2). Cox proportional hazards models adjusted for age, sex, aetiology (ischaemic or non-ischaemic), hypertension, diabetes and baseline blood pressure, stratified by study, were used to examine the independent association between BMI and 3-year total mortality. Analyses were conducted for the overall group and within HF-REF and HF-PEF groups. RESULTS: BMI data were available for 23 967 subjects (mean age, 66.8 years; 32% women; 46% NYHA Class II; 50% Class III) and 5609 (23%) died by 3 years. Obese patients were younger, more likely to receive cardiovascular (CV) drug treatment, and had higher comorbidity burdens. Compared with BMI levels between 22.5 and 24.9 kg m(-2), the adjusted relative hazards for 3-year mortality in subjects with HF-REF were: hazard ratios (HR)=1.31 (95% confidence interval=1.15-1.50) for BMI <22.5, 0.85 (0.76-0.96) for BMI 25.0-29.9, 0.64 (0.55-0.74) for BMI 30.0-34.9 and 0.95 (0.78-1.15) for BMI ≥35. Corresponding adjusted HRs for those with HF-PEF were: 1.12 (95% confidence interval=0.80-1.57) for BMI <22.5, 0.74 (0.56-0.97) for BMI 25.0-29.9, 0.64 (0.46-0.88) for BMI 30.0-34.9 and 0.71 (0.49-1.05) for BMI ≥35. CONCLUSIONS: In patients with chronic HF, the obesity paradox was present in both those with reduced and preserved ventricular systolic function. Mortality in both HF subtypes was U-shaped, with a nadir at 30.0-34.9 kg m(-2).
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Insuficiencia Cardíaca/mortalidad , Obesidad/mortalidad , Volumen Sistólico , Adulto , Índice de Masa Corporal , Comorbilidad , Femenino , Insuficiencia Cardíaca/fisiopatología , Humanos , Masculino , Obesidad/complicaciones , Pronóstico , Modelos de Riesgos Proporcionales , Factores de Riesgo , Análisis de SupervivenciaRESUMEN
BACKGROUND: There are few current data on the prevalence of hyperuricaemia and gout in New Zealand, particularly among the indigenous Maori population. AIMS: To determine the prevalence of gout and hyperuricaemia in rural and urban Maori and non-Maori community samples and describe the treatment and comorbidities of participants with gout. METHODS: Participants aged 20-64 years were recruited by random selection from the electoral roll. Maori samples were selected from among those identified as being of Maori descent on the roll and who self-identified as being of Maori ethnicity at interview. Personal medical history, blood pressure, anthropometrics, fasting lipids, glucose, HbA1c and urate were recorded. RESULTS: There were 751 participants. Mean serum urate (SU) was 0.30 mmol/L (0.06-0.69 mmol/L). Maori had a significantly higher prevalence of hyperuricaemia (SU > 0.40 mmol/L) compared with non-Maori (17.0% vs 7.5%, P = 0.0003). A total of 57 participants had a history of gout, with a higher prevalence in Maori compared with non-Maori (10.3% vs 2.3%, P < 0.0001). Of the participants, 18/57 (31.6%) with gout were receiving urate-lowering therapy, but in 38.9%, SU was >0.36 mmol/L. Participants with gout were more likely to have metabolic syndrome, diabetes, cardiac disease or hypertension. CONCLUSIONS: Gout and hyperuricaemia were more prevalent in Maori, and participants with gout were more likely to have comorbidities. There was not a higher overall adjusted cardiovascular disease risk in Maori participants with gout. Despite the high prevalence of gout, management remains suboptimal.
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Gota/etnología , Hiperuricemia/etnología , Nativos de Hawái y Otras Islas del Pacífico/etnología , Población Rural , Población Urbana , Adulto , Estudios de Cohortes , Femenino , Gota/diagnóstico , Humanos , Hiperuricemia/diagnóstico , Masculino , Persona de Mediana Edad , Nueva Zelanda/etnología , Adulto JovenRESUMEN
This study examined renin-angiotensin-aldosterone (RAAS) system gene variants for associations with cardiovascular risk factors and outcomes in coronary heart disease. Coronary disease patients (n=1186) were genotyped for 21 single-nucleotide polymorphisms (SNPs) within angiotensinogen (AGT), angiotensin-converting enzyme (ACE), angiotensin-II type-1 receptor (AGTR1) and aldosterone synthase (CYP11B2). Associations with all-cause mortality and cardiovascular readmissions were assessed over a median of 3.0 years. The AGT M235T 'T' allele was associated with a younger age of clinical coronary disease onset (P=0.006), and the AGT rs2478545 minor allele was associated with lower circulating natriuretic peptides (P=0.0001-P=0.001) and E/E(1) (P=0.018). Minor alleles of AGT SNPs rs1926723 and rs11122576 were associated with more frequent history of renal disease (Pîº0.04) and type-2 diabetes (Pîº0.02), higher body mass index (Pîº0.02) and greater mortality (Pîº0.007). AGT rs11568054 minor allele carriers had more frequent history of renal disease (P=0.04) and higher plasma creatinine (P=0.033). AGT rs6687360 minor allele carriers exhibited worse survival (P=0.02). ACE rs4267385 was associated with older clinical coronary disease onset (P=0.008) and hypertension (P=0.013) onset, increased plasma creatinine (P=0.01), yet greater mortality (P=0.044). Less history of hypertension was observed with the AGTR1 rs12685977 minor allele (P=0.039). Genetic variation within the RAAS was associated with cardiovascular risk factors and accordingly poorer survival.
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Enfermedad de la Arteria Coronaria/genética , Enfermedad de la Arteria Coronaria/mortalidad , Polimorfismo de Nucleótido Simple , Sistema Renina-Angiotensina/genética , Edad de Inicio , Anciano , Angiotensinógeno/genética , Comorbilidad , Enfermedad de la Arteria Coronaria/etnología , Citocromo P-450 CYP11B2/genética , Femenino , Frecuencia de los Genes , Predisposición Genética a la Enfermedad , Humanos , Hipertensión/genética , Hipertensión/mortalidad , Estimación de Kaplan-Meier , Modelos Lineales , Masculino , Persona de Mediana Edad , Nueva Zelanda/epidemiología , Oportunidad Relativa , Peptidil-Dipeptidasa A/genética , Fenotipo , Pronóstico , Modelos de Riesgos Proporcionales , Receptor de Angiotensina Tipo 1/genética , Medición de Riesgo , Factores de Riesgo , Factores de TiempoRESUMEN
AIM: To determine whether the larger exercise stroke volume in senior endurance-trained athletes results from an attenuation of age-related alterations in left ventricular (LV) early diastolic filling or a more vigorous late filling. METHODS: Body composition (DEXA), VO(2)peak, stroke volume (CO(2) rebreathing) and Doppler measures of early and late mitral inflow and mitral annular velocities were collected at seated upright rest and heart rate-matched exercise (100 and 120 bpm) in trained and untrained younger (18-30 years) men and trained and untrained older (60-80 years) healthy men. RESULTS: Ageing had a greater effect than training status on seated rest mitral inflow and tissue Doppler imaging parameters, as shown by a lower peak early-to-late mitral inflow velocity ratio (E/A ratio) and slower peak early mitral annular velocity (Em) in older compared with younger men. Exercise stroke volume was unaffected by healthy ageing; however, Em, an index of early LV lengthening rate and relaxation, was slower (P < 0.001), while measures of atrial systole were increased (P < 0.001) during exercise in older men. Stroke volume during exercise was larger in the trained men (P < 0.001); however, early and late mitral inflow and tissue velocities were not different between trained and untrained men. CONCLUSION: The larger exercise stroke volume in trained older male athletes does not seem to be related to faster filling or lengthening velocities during early or late filling. Thus, a larger, more compliant left ventricle in combination with an increased blood volume may explain the larger LV filling volumes in trained seniors.
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Envejecimiento/fisiología , Ejercicio Físico/fisiología , Ventrículos Cardíacos , Resistencia Física/fisiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Composición Corporal , Dióxido de Carbono , Ecocardiografía Doppler , Humanos , Masculino , Persona de Mediana Edad , Oxígeno , Volumen Sistólico , Adulto JovenRESUMEN
Left ventricular (LV) hypertrophy, defined as an abnormal increase in LV mass (LVM), is an important prognostic indicator and therapeutic target. LVM is often divided by body surface area to derive indexed mass; however, this does not correctly identify pathological LV hypertrophy in all people, especially when body composition is altered, or in different ethnic groups. We evaluated published ranges of echocardiographic LVM in healthy adult populations from different countries, excluding control groups, and compared them with the American Society of Echocardiography reference ranges. A total of 33 studies met the inclusion criteria. In men and women, there was wide variation in the ranges of LVM with a tendency for the upper limit to increase geographically westward; this variation remained for indexed mass. Several ranges fell outside the upper reference limits: in men, 13 of the mass ranges and 16 of indexed mass; and in women, 8 mass and 16 indexed mass. This review has shown that current guidelines may need revision as some published series suggest that greater LV mass should be considered normal. This may be explained by ethnic differences and supports the need for widely applicable and ethnically diverse reference ranges to be established.
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Hipertrofia Ventricular Izquierda/epidemiología , Adolescente , Adulto , Anciano , Presión Sanguínea , Superficie Corporal , Comorbilidad , Ecocardiografía , Femenino , Humanos , Hipertrofia Ventricular Izquierda/diagnóstico por imagen , Hipertrofia Ventricular Izquierda/etnología , Masculino , Persona de Mediana Edad , Valores de ReferenciaRESUMEN
BACKGROUND: Standard cardiovascular (CV) risk assessment may underestimate risk in people with type 2 diabetes mellitus (T2DM). Cardiac and vascular imaging to detect subclinical disease may augment risk prediction. This study investigated the association between CV risk, left ventricular hypertrophy (LVH) and carotid intima-media thickness (CIMT) in patients with T2DM free of CV symptoms. METHODS: People with T2DM without known CV disease were recruited from general practice. The 5-year risk of CV events was calculated using an adjusted Framingham equation and the prevalence of LVH and abnormal CIMT across bands of CV risk assessed. In those at intermediate risk, the number needed to scan (NNS) to reclassify one person to high risk was calculated across the group and compared in those above and below 55 years. The association between LV mass and CIMT was also assessed. RESULTS: Mean age 57 years (SD11), 51% female. Median 5-year CV risk 14.3% (interquartile range 10.3, 19.5), 51% had LVH (American Society of Echocardiography criteria) and 31% an abnormal CIMT (age and sex criteria). In the 52% at intermediate risk, 37% had LVH and 36% an abnormal CIMT. The NNS was 1.7 using both imaging techniques, 2.7 using cardiac imaging alone or 2.8 using vascular imaging alone. Almost twice as many people >55 years had an abnormal CIMT than those <55 years. CONCLUSIONS: Cardiac and vascular imaging to detect subclinical disease can be used to augment prediction of CV risk in people with T2DM at intermediate risk. The value of reclassifying risk is as yet unproven and requires outcome data from intervention studies.
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Enfermedades Cardiovasculares/epidemiología , Arterias Carótidas/patología , Diabetes Mellitus Tipo 2/patología , Ventrículos Cardíacos/patología , Factores de Edad , Anciano , Arteriosclerosis/diagnóstico por imagen , Arteriosclerosis/patología , Enfermedades Asintomáticas , Arterias Carótidas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/patología , Diabetes Mellitus Tipo 2/epidemiología , Ecocardiografía , Femenino , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Hipertrofia Ventricular Izquierda/diagnóstico por imagen , Hipertrofia Ventricular Izquierda/patología , Masculino , Persona de Mediana Edad , Nueva Zelanda/epidemiología , Tamaño de los Órganos , Medición de Riesgo , Túnica Íntima/diagnóstico por imagen , Túnica Íntima/ultraestructura , Túnica Media/diagnóstico por imagen , Túnica Media/ultraestructuraRESUMEN
BACKGROUND: The oldest old (85+) are the fastest growing population segment in New Zealand. Cardiovascular disease (CVD) is the main cause of death and is associated with various risk factors including risk of undernutrition. OBJECTIVES: To determine if there is an association between CVD and nutrition risk in advanced age. SETTING: Three North Island locations (rural and urban areas) in New Zealand. PARTICIPANTS: 108 participants aged 85 years (75-79 for Maori). MEASUREMENTS: Comprehensive health assessments were undertaken. Clinically manifest CVD was pre-defined and ascertained from interviews and hospitalisation records. Nutrition risk was assessed using a validated questionnaire-Seniors in the Community: Risk evaluation for eating and nutrition, Version II (SCREEN II). RESULTS: 72 participants (67%) had CVD (49% men); 52% of participants had a SCREEN II score < 50. Those with CVD had lower HDL level [median(IQR)] [1.4(0.7) vs. 1.6(0.6)] (p=0.041), and higher waist circumference [97.5(19.1) vs. 89.3(20.6)] (p=0.043) compared to those without CVD. Those with CVD were at no greater nutrition risk than those without CVD (SCREEN II score: [49(7) vs. 51(10)] (p=0.365). Using logistic regression controlling for confounders, SCREEN II scores trended towards an inverse association with CVD (p=0.10). CONCLUSION: Two thirds of the study participants had CVD and half were at risk of undernutrition. Nutrition risk was mildly associated with CVD. This study provides further evidence that those in advanced age are at risk of undernutrition. Further research is needed to establish how the causes and consequences of CVD are related to nutrition risk.
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Enfermedades Cardiovasculares/complicaciones , HDL-Colesterol/sangre , Evaluación Geriátrica , Desnutrición/complicaciones , Evaluación Nutricional , Circunferencia de la Cintura , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/sangre , Femenino , Humanos , Modelos Logísticos , Masculino , Desnutrición/sangre , Nueva Zelanda , Factores de Riesgo , Encuestas y CuestionariosRESUMEN
BACKGROUND: Heart failure (HF) and atrial fibrillation (AF) are common, associated with significant morbidity and mortality, and frequently coexist. It is uncertain from published data if the presence of AF in patients with HF is associated with an incremental adverse outcome. The aim of this study was to combine the results of all studies investigating prognosis for patients with HF and AF compared with those in sinus rhythm (SR) to asses the mortality risk associated with this arrhythmia. METHODS: Electronic databases were searched (Biological Abstracts, Current Contents, EMBASE, Medline, Medline In-progress, PubMed and Scopus), to 31 December 2006, using the key words congestive heart failure, heart failure, ventricular dysfunction, atrial fibrillation, atrial flutter, sinus rhythm, prognosis, outcome, death and hospitalization. Bibliographies of retrieved publications were hand searched. Studies were eligible if they included a HF population and if outcomes were reported by cardiac rhythm (AF or SR). Studies were reviewed by predetermined protocol (including quality assessment). Data were pooled using a random effects model. RESULTS: Twenty studies were included (from 3380 initially identified) representing 32946 patients (10819 deaths). Nine randomized controlled trials (RCT) were included. The prevalence of AF was 15%, crude mortality rates were 46% (AF) and 33% (SR). The odds ratio for death was 1.33 (95% confidence interval (CI) 1.12-1.59) for AF compared with SR. Eleven observational studies were included. The prevalence of AF was 23%, crude mortality rates were 38% (AF) and 25% (SR). The odds ratio for death was 1.57 (95% CI 1.20-2.05) for AF compared with SR. CONCLUSION: This meta-analysis demonstrates that AF is associated with worse outcomes for patients with HF compared with those with SR. Further research is required to determine whether the adverse outcome associated with AF is related to the arrhythmia itself, or to variables, such as HF severity, patient age and comorbidity.
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Fibrilación Atrial/mortalidad , Insuficiencia Cardíaca/mortalidad , Fibrilación Atrial/complicaciones , Insuficiencia Cardíaca/complicaciones , Humanos , Mortalidad/tendencias , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Factores de RiesgoRESUMEN
AIMS/HYPOTHESIS: Cu(II)-selective chelation with trientine ameliorates cardiovascular and renal disease in a model of diabetes in rats. Here, we tested the hypothesis that Cu(II)-selective chelation might improve left ventricular hypertrophy (LVH) in type 2 diabetic patients. METHODS: We performed a 12 month randomised placebo-controlled study of the effects of treatment with the Cu(II)-selective chelator trientine (triethylenetetramine dihydrochloride, 600 mg given orally twice daily) on LVH in diabetic patients (n = 15/group at baseline) in an outpatient setting wherein participants, caregivers and those assessing outcomes were blinded to group assignment. Using MRI, we measured left ventricular variables at baseline, and at months 6 and 12. The change from baseline in left ventricular mass indexed to body surface area (LVM(bsa)) was the primary endpoint variable. RESULTS: Diabetic patients had LVH with preserved ejection fraction at baseline. Trientine treatment decreased LVM(bsa) by 5.0 +/- 7.2 g/m(2) (mean +/- SD) at month 6 (when 14 trientine-treated and 14 placebo-treated participants were analysed; p = 0.0056 compared with placebo) and by 10.6 +/- 7.6 g/m(2) at month 12 (when nine trientine-treated and 13 placebo-treated participants were analysed; p = 0.0088), whereas LVM(bsa) was unchanged by placebo treatment. In a multiple-regression model that explained ~75% of variation (R (2) = 0.748, p = 0.001), cumulative urinary Cu excretion over 12 months was positively associated with trientine-evoked decreases in LVM(bsa). CONCLUSIONS/INTERPRETATION: Cu(II)-selective chelation merits further exploration as a potential pharmacotherapy for diabetic heart disease. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN 12609000053224 FUNDING: The Endocore Research Trust; Lottery Health New Zealand; the Maurice and Phyllis Paykel Trust; the Foundation of Research, Science and Technology (New Zealand); the Health Research Council of New Zealand; the Ministry of Education (New Zealand) through the Maurice Wilkins Centre for Molecular Biodiscovery; and the Protemix Corporation.
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Quelantes/uso terapéutico , Diabetes Mellitus Tipo 2/complicaciones , Angiopatías Diabéticas/tratamiento farmacológico , Hipertrofia Ventricular Izquierda/tratamiento farmacológico , Trientina/uso terapéutico , Adulto , Anciano , Presión Sanguínea/efectos de los fármacos , Superficie Corporal , Creatinina/metabolismo , Angiopatías Diabéticas/fisiopatología , Ecocardiografía , Electrocardiografía , Femenino , Hemoglobina Glucada/metabolismo , Ventrículos Cardíacos/anatomía & histología , Humanos , Hipertrofia Ventricular Izquierda/fisiopatología , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Selección de Paciente , PlacebosRESUMEN
BACKGROUND: The Doppler echocardiographic restrictive mitral filling pattern (RFP) is an important prognostic indicator in patients with heart failure (HF), but the interaction between RFP, left ventricular ejection fraction (LVEF) and filling pattern remains uncertain. AIMS: To determine whether the RFP is predictive of mortality independently of LVEF in patients with HF. METHODS: Online databases were searched to identify studies assessing the relationship between prognosis and LV filling pattern in patients with HF. Individual patient data from 18 studies (3540 patients) were extracted and collated at the MeRGE Coordinating Centre (The University of Auckland). RESULTS: Overall, RFP was associated with higher all-cause mortality than the non-restrictive filling pattern: hazard ratio 2.42 (95% CI 2.06, 2.83). In multivariable analysis the RFP, LVEF, NYHA class and age were independent predictors of mortality. The prevalence of the RFP was inversely related to LVEF but remained a predictor of mortality even in those patients with preserved LVEF. CONCLUSIONS: The restrictive mitral filling pattern is a powerful predictor of mortality, independent of LVEF and age, in patients with HF. Doppler-derived LV filling patterns are an accessible marker from echocardiography that can readily be incorporated in risk stratification of all patients with HF.
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Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Volumen Sistólico/fisiología , Disfunción Ventricular Izquierda/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Restrictive mitral filling pattern (RFP), the most severe form of diastolic dysfunction, is a predictor of outcome after acute myocardial infarction (AMI). Low power has precluded a definite conclusion on the independent importance of RFP, especially when overall systolic function is preserved. We undertook an individual patient meta-analysis to determine whether RFP is predictive of mortality independently of LV ejection fraction (LVEF), end-systolic volume index, and Killip class in patients after AMI. METHODS AND RESULTS: Twelve prospective studies (3396 patients) assessing the relationship between prognosis and Doppler echocardiographic LV filling pattern in patients after AMI were included. Individual patient data from each study were extracted and collated into a single database for analysis. RFP was associated with higher all-cause mortality (hazard ratio, 2.67; 95% CI, 2.23 to 3.20; P<0.001) and remained an independent predictor in multivariate analysis with age, gender, and LVEF. The overall prevalence of RFP was 20% but was highest (36%) in the quartile of patients with lowest LVEF (<39%) and lowest (9%) in patients with the highest LVEF (>53%; P<0.0001). RFP remained significant within each quartile of LVEF, and no interaction was found for RFP and LVEF (P=0.42). RFP also predicted mortality in patients with above- and below-median end-systolic volume index (1575 patients) and in different Killip classes (1746 patients). Importantly, when diabetes, current medication, and prior AMI were included in the model, RFP remained an independent predictor of outcome. CONCLUSIONS: Restrictive filling is an important independent predictor of mortality after AMI regardless of LVEF, end-systolic volume index, and Killip class.
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Infarto del Miocardio/diagnóstico , Disfunción Ventricular Izquierda/mortalidad , Anciano , Ecocardiografía Doppler , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Pronóstico , Factores de Riesgo , Volumen Sistólico , Análisis de SupervivenciaRESUMEN
AIMS: To determine rate and predictors of mortality in patients with Type 2 diabetes living in a population with a large proportion of Maori and Pacific peoples who were admitted to hospital with myocardial infarction (MI) or congestive cardiac failure (CCF). METHODS: The study population included 4193 individuals with Type 2 diabetes who lived in South Auckland and who participated in a primary care audit between 1994 and 1999. We studied a subgroup of 319 patients who subsequently had a hospital admission for MI or CCF between 1999 and 2001. We examined their demographics, drug treatment, vascular risk factors and mortality up to 2003. RESULTS: Following discharge, the prescription of beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, aspirin and statins had all increased significantly. Vascular risk factors including total cholesterol, high-density lipoprotein (HDL) cholesterol, systolic blood pressure and glycated haemoglobin (HbA(1c)) improved significantly. Nevertheless, mortality remained high with individuals admitted because of an MI 7.2-fold more likely to die early and those with a CCF admission 5.9-fold more likely to die early than other individuals with Type 2 diabetes. Maori patients have an 80% excess mortality. CONCLUSIONS: Patients with past admission for MI and/or CCF remain at exceptionally high risk of death for at least 4 years after hospital admission, even with improvements in management of cardiovascular risk factors. Maori individuals are at particular risk.
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Diabetes Mellitus Tipo 2/mortalidad , Angiopatías Diabéticas/mortalidad , Cardiopatías/mortalidad , Nativos de Hawái y Otras Islas del Pacífico/etnología , Anciano , Diabetes Mellitus Tipo 2/etnología , Angiopatías Diabéticas/etnología , Femenino , Cardiopatías/etnología , Humanos , Masculino , Persona de Mediana Edad , Nueva Zelanda/etnologíaRESUMEN
OBJECTIVE: To determine, through a systematic review and meta-analysis, the magnitude of the survival deficit associated with a restrictive filling pattern after acute myocardial infarction (AMI). METHODS: Online databases were searched for prospective echocardiography outcome studies of patients after AMI. All authors were contacted to seek confirmation of their data. Restrictive filling was compared with all non-restrictive filling patterns. Review Manager Version 4.2.7 software was used for analysis. RESULTS: 3855 patients in 16 studies were identified. Follow up varied from two weeks to five years (> 1 year, 10 studies; and > 4 years, four studies). 776 (20%) of patients had a restrictive filling pattern at baseline. 580 patients died (247 in the restrictive group), and the overall odds ratio for death (restrictive filling worse) was 4.10 (95% confidence interval 3.38 to 4.99). CONCLUSIONS: Mortality is about four times higher in patients with a restrictive filling pattern than in those with non-restrictive filling patterns after AMI. Echocardiographic assessment of diastolic filling pattern is an important part of the echocardiographic assessment of patients after myocardial infarction and provides important prognostic information about such patients.
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Infarto del Miocardio/mortalidad , Disfunción Ventricular Izquierda/mortalidad , Diástole , Humanos , Infarto del Miocardio/fisiopatología , Estudios Prospectivos , Medición de Riesgo , Disfunción Ventricular Izquierda/fisiopatologíaRESUMEN
OBJECTIVE: To determine if serum IGF-I concentrations are similar in healthy adult subjects from the Samoan, Maori and European populations in New Zealand. DESIGN: Serum IGF-I concentration was measured in 75 healthy adults, aged 18-50 years, of Samoan (n=23), Maori (n=22) and European (n=30) descent. Body composition was assessed using standard anthropomorphic measures. In addition all subjects had body composition assessed by Dual energy X-ray absorptiometry (DXA). RESULTS: Weight, body mass index (BMI), and fat mass were significantly greater in Maori and Samoan subjects than European subjects (ANOVA p=0.006, p=0.0003, p=0.03, respectively). However, serum IGF-I concentration was similar between the groups (European 186.8 SEM 14.9 microg/l, Maori 204.8 SEM 17.1 microg/l, Samoan 180.0 SEM 17.5 microg/l, p=0.58). IGF-I levels were similar between ethnic groups after adjustment (ANCOVA) for age, sex or BMI (p=0.5) or age, sex and fat mass (p=0.44). In multivariate analysis the only independent predictor of IGF-I was age (p<0.001) and explained 22% of the variance in IGF-I level. CONCLUSIONS: Serum IGF-I concentrations were similar in Maori, Samoan and European population groups in New Zealand, despite significant differences in anthropomorphic variables and body composition.
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Factor I del Crecimiento Similar a la Insulina/análisis , Adulto , Composición Corporal , Índice de Masa Corporal , Humanos , Masculino , Persona de Mediana Edad , Nueva Zelanda , Población Blanca/etnologíaRESUMEN
BACKGROUND: Multidisciplinary heart failure programs including patient education and self-management strategies such as daily recording of body weight and use of a patient diary decrease hospital readmissions and improve quality of life. However, the degree of uptake of individual components of these programs and their contribution to patient benefit are uncertain. METHODS: Patients with heart failure admitted to Auckland Hospital were randomised into the management or usual care groups of the Auckland heart failure management study (AHFMS). Patients in the management group were given a heart failure diary for the recording of daily weights, attended a heart failure clinic and were encouraged to attend three education sessions. Patients in the usual care group received routine clinical care, mainly from general practitioners. Patients were followed to 12 months. This study investigated the uptake of self-management by assessing diary use and self-weighing behaviour in the group receiving the heart failure intervention, and compared the level of knowledge of heart failure self-management of the management group to the control group after 12 months. RESULTS: Of the 197 patients in the AHFMS, 100 patients were included in the management group and received a diary and education about heart failure self-management including monitoring weight daily. Of these patients, 76 patients used the diary. These patients were on more medication; were more likely to attend the education sessions, heart failure clinic, and primary care, and had a lower mortality rate over the course of the study. Variables independently associated with use of the diary included less severe symptoms (OR 15, 95% confidence intervals 1.7, 144), frequent attendance at the heart failure clinic (OR 15, 95% CI 3, 78) and attendance at an education session (OR 8, 95% CI 1.5, 42). Of the 76 patients who used the diary, 51 weighed themselves regularly. More of these patients owned scales at home; they were also more likely to attend the education sessions, and experienced fewer hospital admissions than those patients who did not weigh themselves regularly. Variables independently associated with regular self-weighing included the presence of scales at home (OR 6.3, 95% CI 1.7, 14.1), left ventricular ejection fraction >30% (OR 4.3, 95% CI 1.1, 17.5), and attendance at the education session(s) (OR 6.3, 95% CI 1.7, 14.1). Patients in the management group exhibited higher levels of knowledge at 12 months of follow-up and were more likely to monitor their condition using daily weighing, compared to the control group. CONCLUSIONS: At 12 months of follow-up, implementation of self-management strategies including daily weight monitoring and level of education on self-management was significantly higher in the management group than the control group. For the patients in the management group, not using the diary or inability to perform daily weighing were associated with less frequent attendance at the heart failure clinic and education sessions and poorer health outcomes. In this study, attendance at the education sessions was associated with the adoption of self-management, underlining the importance of education in multidisciplinary heart failure programmes. Self-weighing could be increased by provision of scales to all patients. The subset of patients who did not adopt self-management strategies in this study were at high risk of death or readmission.
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Insuficiencia Cardíaca/terapia , Evaluación de Programas y Proyectos de Salud , Autocuidado , Adulto , Anciano , Anciano de 80 o más Años , Peso Corporal/fisiología , Femenino , Estudios de Seguimiento , Conocimientos, Actitudes y Práctica en Salud , Insuficiencia Cardíaca/etiología , Insuficiencia Cardíaca/mortalidad , Humanos , Masculino , Registros Médicos , Persona de Mediana Edad , Monitoreo Ambulatorio , Isquemia Miocárdica/complicaciones , Isquemia Miocárdica/mortalidad , Isquemia Miocárdica/terapia , Nueva Zelanda , Cooperación del Paciente , Educación del Paciente como Asunto , Participación del Paciente , Readmisión del Paciente , Valor Predictivo de las Pruebas , Atención Primaria de Salud , Calidad de Vida , Volumen Sistólico/fisiología , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
INTRODUCTION: Heart failure (HF) is characterised by frequent hospital admissions and prolonged length of hospital stay. Admissions for HF have increased over the last decade while length of stay has decreased; the reasons for this change in length of stay are uncertain. This study investigates the effect of patient-related variables, in-hospital progress and complications on length of stay. METHODS: Patients admitted to Auckland Hospital general medical service and randomised into the Auckland Heart Failure Management Programme were included in this study. RESULTS: One hundred and ninety-seven patients were included in this study. Mean age 73 years, mean left ventricular ejection fraction 32%; 52% had one or more previous HF admissions and 75% were New York Heart Association class IV at admission. Median length of hospital stay was 6 days (IQR 4, 9) which is comparable to the national average from New Zealand admission databases. Longer than average length of stay, defined as >6 days, was associated with the presence of peripheral congestion, duration of treatment with intravenous diuretic, the development of renal impairment, other acute medical problems at admission, iatrogenic complications during hospital stay, and social problems requiring intervention. Factors independently associated with length of stay in the top quartile (>10 days) on logistic regression included the presence of oedema at admission (OR 10.5), change in weight during stay (OR 1.3), duration of treatment with iv diuretic (OR 7.5), the development of renal impairment (OR 9.8), concurrent respiratory problems requiring specific treatment (OR 3.8), and social problems requiring intervention (OR 6.8). CONCLUSIONS: Peripheral congestion, concomitant acute medical problems requiring specific treatment, the development of renal impairment and the presence of social problems were related to a longer than average length of hospital stay. Multivariate models only partly explained variance in hospital stay, suggesting the importance of pre-admission and post-discharge factors, including the healthcare environment, the availability of primary and secondary care resources, and the threshold for hospital admission.
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Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/terapia , Tiempo de Internación , Readmisión del Paciente , Anciano , Anciano de 80 o más Años , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Biomarcadores/sangre , Presión Sanguínea/fisiología , Estudios de Cohortes , Comorbilidad , Creatinina/sangre , Diuréticos/uso terapéutico , Ecocardiografía , Femenino , Furosemida/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Frecuencia Cardíaca/fisiología , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Nueva Zelanda/epidemiología , Valor Predictivo de las Pruebas , Estudios Prospectivos , Factores de Riesgo , Volumen Sistólico/fisiología , Función Ventricular Izquierda/fisiologíaRESUMEN
AIMS: To determine the effect of an integrated heart failure management programme, involving patient and family, primary and secondary care, on quality of life and death or hospital readmissions in patients with chronic heart failure. METHODS AND RESULTS: This trial was a cluster randomized, controlled trial of integrated primary/secondary care compared with usual care for patients with heart failure. The intervention involved clinical review at a hospital-based heart failure clinic early after discharge, individual and group education sessions, a personal diary to record medication and body weight, information booklets and regular clinical follow-up alternating between the general practitioner and heart failure clinic. Follow-up was for 12 months. One hundred and ninety-seven patients admitted to Auckland Hospital with an episode of heart failure were enrolled in the study. There was no significant difference between the intervention and control groups for the combined end-point of death or hospital readmission. The physical dimension of quality of life showed a greater improvement in the intervention group from baseline to 12 months compared with the control group (-11.1 vs -5.8 respectively, 2 P=0.015). The main effect of the intervention was attributable to the prevention of multiple admissions (56 intervention group vs 95 control group, 2 P=0.015) and associated reduction in bed days. CONCLUSIONS: This integrated management programme for patients with chronic heart failure improved quality of life and reduced total hospital admissions and total bed days.