Incidence, clinical predictors, and prognostic impact of worsening renal function in elderly patients with chronic heart failure on intensive medical therapy.

BACKGROUND: Incidence, predictors, and prognostic impact of worsening renal function (WRF) in elderly patients with chronic heart failure (HF) undergoing intensive contemporary medical therapy are unknown. METHODS AND RESULTS: In 566 patients (age 77 ± 8 years) included in the TIME-CHF, serum creatinine (sCr) was repeatedly measured up to 6 months. Worsening renal function was classified as increase in sCr by 0.2 to 0.3 (WRFI), 0.3 to 0.5 (WRFII), or ≥0.5 mg/dL (WRFIII) within the first 6 months. Outcome events were assessed for 18 months. RESULTS: The incidence of WRF I, II, and III was 12%, 19%, and 22%, respectively. Worsening renal function III was associated with increased mortality (hazard ratio 1.98 [95% CI 1.27-3.07, P = .002] vs no WRF), whereas WRF I/II was not. History of renal failure, spironolactone treatment, higher baseline dose, and higher maximal increase in loop diuretic dose were independently associated with the occurrence of WRF III, whereas angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, and ß-blocker use and allocation to N-terminal pro-B-type natriuretic peptide-guided management were not. Worsening renal function III was an independent predictor of death, death or hospitalization, and death or HF hospitalization also after adjusting for baseline characteristics. CONCLUSIONS: One fifth of elderly patients with chronic HF experienced WRF III on 6-month intensive HF treatment. These patients had higher mortality, whereas patients with smaller sCr rises did not. Occurrence of WRF III was associated with high doses of loop diuretics and spironolactone use but not with other treatments.

Cardiopulmonary exercise testing in mild heart failure: impact of the mode of exercise on established prognostic predictors.

OBJECTIVES: In patients with heart failure (HF), peak oxygen consumption (peak VO(2)), the relationship between minute ventilation and carbon dioxide production (VE/VCO(2) slope) and heart rate recovery (HRR) are established prognostic predictors. However, treadmill exercise has been shown to elicit higher peak VO(2) values than bicycle exercise. We sought to assess whether the VE/VCO(2) slope and HRR in HF also depend on the exercise mode. METHODS: Twenty-one patients with mild HF on chronic beta-blocker therapy underwent treadmill and bicycle cardiopulmonary exercise testing for measurement of peak VO(2) and the VE/VCO(2) slope. In patients with sinus rhythm (n = 16), HRR at 1 (HRR-1) and 2 min (HRR-2) after exercise termination was assessed. RESULTS: Peak VO(2) was higher during treadmill as compared with bicycle testing (21.7 +/- 4.6 vs. 19.6 +/- 3.4 ml/kg/min; p = 0.006). HRR-1 tended to be slower (15 bpm, interquartile range 8-19, vs. 18 bpm, interquartile range 11-22; p = 0.16), and HRR-2 was significantly slower after treadmill exercise (26 bpm, interquartile range 20-39, vs. 31 bpm, interquartile range 22-41; p = 0.04). In contrast, VE/VCO(2) slope values did not differ between the test modes (32.9 +/- 5.5 vs. 32.3 +/- 5.0; p = 0.56). CONCLUSIONS: In contrast to peak VO(2) and HRR, the VE/VCO(2) slope is not affected by the exercise mode in patients with mild HF.

Acute eosinophilic myocarditis with dramatic response to steroid therapy: the central role of echocardiography in diagnosis and follow-up.

Acute eosinophilic myocarditis is a rare cause of acute heart failure. We present the case of a 32-year-old woman who had presumptive eosinophilic myocarditis as part of a generalized hypersensitivity reaction (Drug Rash with Eosinophilia and Systemic Symptoms [DRESS] syndrome) that exhibited a dramatic response to steroid therapy. We highlight the central role of 2-dimensional and tissue-Doppler echocardiography in the diagnosis of myocarditis and the serial evaluation of left ventricular systolic and diastolic function in this setting.

Successful management of a case of electrical storm due to invasive endocarditis.

We present a 44-year-old man with invasive aortic and tricuspid valve endocarditis complicated by electrical storm, which was immediately diagnosed and successfully treated due to the patient's telemetry electrocardiogram (ECG). This case highlights a rare but potentially fatal complication in patients with invasive endocarditis and the need for very careful clinical evaluation and monitoring of these patients.

Relevance of short-term variation of B-type natriuretic peptide in patients with clinically stable heart failure.

BACKGROUND: In patients with clinically stable chronic heart failure, circulating B-type natriuretic peptide (BNP) levels may exhibit considerable variation over a period of a few days. The aim of this study was to evaluate the clinical impact of this phenomenon. METHODS: In 23 patients with clinically stable mild-to-moderate systolic heart failure [median (interquartile range) 72 (64-77) years, left ventricular ejection fraction 30 (27-40)%] and a history of previous hospitalization for heart failure, BNP was measured at two time points [T1 and T2, interval 5 (3-7) days] for calculation of the absolute change in BNP concentrations between T1 and T2 (DeltaBNP; irrespective of whether there was a decrease or increase). Follow-up for rehospitalization was 436 (407-458) days. RESULTS: In the group overall, DeltaBNP was 26 (9-116) pg/ml [19 (10-28)% of the value at T1]. During follow-up, 8/23 (35%) patients were rehospitalized. BNP concentrations at T1 [340 (187-533) vs. 210 (108-606) pg/ml; P = 0.33] and T2 [328 (125-491) vs. 259 (89-536) pg/ml; P = 0.51] were similar in patients who were rehospitalized and those who were not; however, DeltaBNP was higher in patients requiring rehospitalization [98 (36-186) vs. 19 (6-93) pg/ml; P = 0.04]. Patients with DeltaBNP <26 pg/ml had a longer rehospitalization-free survival than those with DeltaBNP > or = 26 pg/ml (log rank P = 0.02). Sensitivity and specificity of DeltaBNP > or = 26 pg/ml for the prediction of rehospitalization were 88% and 67% respectively. CONCLUSIONS: In this small study among patients with clinically stable heart failure, higher DeltaBNP over a period of a few days was associated with a higher likelihood of rehospitalization during follow-up.

B-type natriuretic peptide kinetics and cardiopulmonary exercise testing in heart failure.

BACKGROUND: In patients with chronic heart failure (CHF), B-type natriuretic peptide (BNP) is related to peak oxygen consumption (peak VO2) and the relationship between minute ventilation and carbon dioxide production (VE/VCO2 slope). However, the exercise response depends on the mode of exercise. This study sought to compare peak treadmill and bicycle exercise responses with respect to their relationship with BNP and to assess whether BNP measured at rest or during exercise could identify patients with greater functional impairment and ventilatory inefficiency. METHODS: Twenty-three patients with mild-to-moderate stable systolic CHF (age 72+/-8 years, left ventricular ejection fraction 32+/-7%) underwent treadmill and bicycle cardiopulmonary exercise testing within 5 (interquartile range 3-7) days. BNP was measured at rest and at peak exercise. RESULTS: BNP at rest was an independent multivariate predictor of both peak VO2 and the VE/VCO2 slope for both exercise modes. However, the proportion of variance explained univariately and multivariately was < or = 0.55, indicating that BNP did not strongly explain the variation of peak VO2 and the VE/VCO2 slope. The exercise-induced rise in circulating BNP did not differ between the test modes [treadmill: 50 (24-89) pg/ml vs. bicycle: 46 (15-100) pg/ml; p=0.73]. BNP levels at peak exercise were strongly related to resting values, but did not provide additional information on peak VO2 or the VE/VCO2 slope. CONCLUSIONS: In typical CHF patients, BNP measured at rest or at peak exercise does not strongly predict peak VO2 or the VE/VCO2 slope regardless of the exercise mode, and is therefore not a sufficiently accurate surrogate for cardiopulmonary exercise testing.