Right bundle branch block and long-term mortality in patients with acute congestive heart failure.

OBJECTIVES: Risk stratification in acute congestive heart failure (ACHF) is poorly defined. The aim of the present study was to assess the impact of right bundle brunch block (RBBB) on long-term mortality in patients presenting with ACHF. METHODS AND RESULTS: The initial 12-lead electrocardiogram was analysed for RBBB in 192 consecutive patients presenting with ACHF to the emergency department. The primary endpoint was all-cause mortality during 720-day follow-up. This study included an elderly cohort (mean age 74 years) of ACHF patients. RBBB was present in 27 patients (14%). Age, sex, B-type natriuretic peptide levels and initial management were similar in patients with RBBB when compared with patients without RBBB. However, patients with RBBB more often had pulmonary comorbidity. A total of 84 patients died during follow-up. Kaplan-Meier analysis revealed that mortality at 720 days was significantly higher in patients with RBBB when compared with patients without RBBB (63% vs. 39%, P = 0.004). In Cox proportional hazard analysis, RBBB was associated with a two-fold increase in mortality (hazard ratio 2.18, 95% CI 1.26-3.66; P = 0.003). This association persisted after adjustment for age and comorbidity. CONCLUSIONS: RBBB is a powerful predictor of mortality in patients with ACHF. Early identification of this high-risk group may help to offer tailored treatment in order to improve outcome.

The use of B-type natriuretic peptide in the management of patients with diabetes and acute dyspnoea.

AIMS/HYPOTHESIS: The aim of this study was to determine the impact of measurement of B-type natriuretic peptide (BNP) levels on the management of patients with diabetes presenting with acute dyspnoea. METHODS: This study evaluated the subgroup of 103 patients with diabetes included in the B-type Natriuretic Peptide for Acute Shortness of Breath Evaluation (BASEL) study (n=452). Patients were randomly assigned to a diagnostic strategy with (n=47, BNP group) or without (n=56, control group) the use of BNP levels assessed by a rapid bedside assay. Time to discharge and total cost of treatment were recorded as the primary endpoints. RESULTS: Although similar with regard to age and sex, patients with diabetes more often had pre-existing cardiovascular and renal disease and heart failure as the cause of acute dyspnoea compared with patients without diabetes. In addition, medical and economic outcomes were worse in patients with diabetes. The use of BNP levels significantly reduced time to discharge (median 9 days [interquartile range (IQR) 2-16] in the BNP group vs 13 days [IQR 8-22] in the control group; p=0.016). At 30 days, the diabetic patients in the BNP group had spent significantly fewer days in hospital compared with the diabetic patients in the control group (9 days [IQR 2-19] vs 16 days [IQR 8-24], respectively; p=0.008). Total treatment costs at 30 days were US$5,705 (IQR 2,285-9,137) in the BNP group and US$7,420 (IQR 4,194-11,966) in the control group (p=0.036). CONCLUSIONS/INTERPRETATION: The results of this study indicate that measurement of BNP levels improves the management of patients with diabetes presenting with acute dyspnoea.

Coronary artery disease and outcome in acute congestive heart failure.

OBJECTIVES: To quantify the prognostic impact of coronary artery disease (CAD) on patients with acute heart failure (HF). DESIGN: Prospective cohort study of 217 consecutive patients presenting with acute HF to the emergency department. Treatment, hospitalisation, the use of revascularisation procedures, and survival were observed during follow up of up to three years. RESULTS: CAD was present in 153 patients (71%). Patients with and without CAD were similar with respect to age and sex. Although adequate HF treatment was initiated more rapidly among patients with CAD, their initial outcomes including hospitalisation rate, time to discharge, and total treatment cost were significantly worse. Moreover, despite higher use of angiotensin converting enzyme inhibitors and beta blockers during follow up, patients with CAD had a significantly lower survival rate. Cumulative survival at 720 days was 48.7% of patients with CAD as compared with 76.4% of patients without CAD (p = 0.0004). In Cox regression analysis the presence of CAD increased the risk of death by more than 250% (hazard ratio 2.57, 95% confidence interval 1.50 to 4.39, p = 0.001). This strong association persisted after multivariate adjustments. The use of coronary angiography and coronary revascularisation procedures was low, both at initial presentation and during follow up. CONCLUSION: CAD is a strong and independent predictor of mortality among patients with acute HF. Whether, for example, less restrictive use of revascularisation procedures in this elderly HF population can improve the outcome for patients with CAD warrants further study.

The use of B-type natriuretic peptide in the management of elderly patients with acute dyspnoea.

OBJECTIVES: The aim of this study was to define the impact of B-type natriuretic peptide (BNP) levels on the management of elderly patients presenting with acute dyspnoea. DESIGN: We performed a prospective randomized controlled study in 269 elderly patients at least 70 years of age included in the B-type natriuretic peptide for Acute Shortness of breath Evaluation (BASEL) study. Patients were randomly assigned to a diagnostic strategy with (n = 136, BNP group) or without (n = 133, control group) the use of BNP levels provided by a rapid bedside assay. The time to discharge and the total cost of treatment were the primary end-points. RESULTS: Amongst elderly patients, baseline characteristics were well matched between both groups. The use of BNP levels significantly reduced the time to discharge (median 9.0 in the BNP group versus 11.0 days in the control group; P = 0.029). Total treatment cost was $5381 (95% CI, 4482-6280) in the BNP group when compared with $7411 (95% CI, 6180-8642; P = 0.009) in the control group. In addition, a significant reduction in 30-day mortality was observed (9% in the BNP group versus 17% in the control group; P = 0.039). CONCLUSIONS: Used in conjunction with other clinical information, rapid measurement of BNP in the emergency department improved the management of elderly patients presenting with acute dyspnoea and thereby reduced the time to discharge and the total treatment cost. In addition, BNP testing seemed to reduce 30-day mortality.