Body mass index, body fat, and nutritional status of patients with heart failure: The PLICA study.

BACKGROUND & AIMS: Nutritional assessment may help to explain the incompletely understood obesity paradox in patients with heart failure (HF). Currently, obesity is usually identified by body mass index (BMI). Our objective was to assess the prognostic influence of undernourishment in HF outpatients. METHODS: Two published definitions of undernourishment were used to assess 214 ambulatory HF patients. Definition 1 included albumin, total lymphocyte count, tricipital skinfold (TS), subscapular skinfold, and arm muscle circumference (AMC) measurements (≥2 below normal considered undernourishment). Definition 2 included TS, AMC, and albumin (≥1 below normal considered undernourishment). Patients were also stratified by BMI and body fat percentage and followed for 2 years. All-cause death or HF hospitalization was the primary endpoint. RESULTS: Based on BMI strata, among underweight patients, 60% and 100% were undernourished by Definitions 1 and 2, respectively (31% and 44% among normal-weight, 4% and 11% among overweight, and 0% and 3% among obese patients, respectively, according to the two definitions). The most prevalent undernourishment type was marasmus-like (18% of the total cohort). Undernourishment by both definitions was significantly associated with lower event-free survival. Following multivariable analysis, age, NYHA functional class, NTproBNP, and undernourishment (hazard ratio [HR] 2.25 [1.11-4.56] and 2.24 [1.19-4.21] for Definitions 1 and 2, respectively) remained in the model. In this cohort, BMI and percentage of body fat did not independently predict 2-year event-free survival. CONCLUSIONS: Nutritional status is a key prognostic factor in HF above and beyond BMI and percentage of body fat. Patients in normal BMI range and even in overweight and obese groups showed undernourishment. The high mortality observed in undernourishment, infrequent in high BMI patients, may help to partly explain the obesity paradox. Proper undernourishment assessment should become routine in patients with HF.

Fragility is a key determinant of survival in heart failure patients.

BACKGROUND: Heart failure (HF) is a chronic condition with poor prognosis, and has a high prevalence among older adults. Due to older age, fragility is often present among HF patients. However, even young HF patients show a high degree of fragility. The effect of fragility on long-term prognosis in HF patients, irrespective of age, remains unexplored. The aim of this study was to assess the influence of fragility on long-term prognosis in outpatients with HF. METHODS AND RESULTS: At least one abnormal evaluation among four standardized geriatric scales was used to identify fragility. Predefined criteria for such scales were: Barthel Index, <90; OARS scale, <10 in women and <6 in men; Pfeiffer Test, >3 (± 1, depending on educational grade); and ≥ 1 positive response for depression on the abbreviated Geriatric Depression Scale (GDS). We assessed 1314 consecutive HF outpatients (27.8% women, mean age years 66.7 ± 12.4 years with different etiologies. Fragility was detected in 581 (44.2%) patients. 626 deaths occurred during follow-up; the median follow-up was 3.6 years [P25-P75: 1.8-6.7] for the total cohort, and 4.9 years [P25-P75: 2.5-8.4] for living patients. Fragility and its components were significantly associated with decreased survival by univariate analysis. In a comprehensive multivariable Cox regression analysis, fragility remained independently associated with survival in the entire cohort, and in age and left ventricular ejection fraction subgroups. CONCLUSION: Fragility is a key determinant of survival in ambulatory patients with HF across all age strata.

Soluble ST2 serum concentration and renal function in heart failure.

BACKGROUND: Soluble ST2 (sST2) provides important prognostic information in patients with heart failure (HF). How sST2 serum concentration is related to renal function is uncertain. We evaluated the association between sST2 and renal function and compared its prognostic value in HF patients with renal insufficiency. METHODS AND RESULTS: Patients (n = 879; median age 70.4 years; 71.8% men) were divided into 3 subgroups according to estimated glomerular filtration rate (eGFR): ≥60 mL/min/1.73 m(2) (n = 337); 30-59 mL/min/1.73 m(2) (n = 352); and <30 mL/min/1.73 m(2) (n = 190). sST2 (rho = -0.16; P < .001), N-terminal pro-B-type natriuretic peptide (rho = -0.40; P < .001), and high-sensitivity cardiac troponin T (rho = -0.47; P < .001) inversely correlated with eGFR. All-cause mortality was the primary end point. During a median follow-up of 3.46 years, 312 patients (35%) died, 246 of them from the subgroup of 542 patients with eGFR <60 mL/min/1.73 m(2) (45%). Biomarker combination including sST2 showed best discrimination, calibration, and reclassification metrics in renal insufficiency patients (net reclassification improvement 16.6 [95% confidence interval (CI) 8.1-25; P < .001]; integrated discrimination improvement 4.2 [95% CI 2.2-6.2; P < .001]). Improvement in reclassification was higher in these patients than in the total cohort. CONCLUSIONS: The prognostic value of sST2 was not influenced by renal function. On top of other biomarkers, sST2 improved long-term prediction in patients with renal insufficiency even more than in the total cohort.

Effect of fragility on quality of life in patients with heart failure.

Heart failure (HF) is a chronic disease that frequently causes quality of life (QoL) impairment. We aimed to evaluate whether fragility affects QoL perception in outpatients with HF across age strata. The Minnesota Living with Heart Failure Questionnaire (MLWHFQ) was used to assess QoL, and fragility was defined according to basic standardized geriatric scales. Predefined criteria for such scales were scores of Barthel index <90, Older Americans' Resources and Services scale <10 in women and <6 in men, and Pfeiffer test >3 (±1 depending on educational grade) and ≥1 positive depression response on the abbreviated Geriatric Depression Scale. We evaluated 1,405 consecutive outpatients with HF (27.8% women, median age 69 years [twenty-fifth to seventy-fifth percentiles: 59 to 76 years]). Fragility, defined as at least 1 abnormal evaluation, was detected in 621 patients (44.2%). A positive depression response on the abbreviated Geriatric Depression Scale was the most prevalent (31.2%) component of fragility. We found a strong correlation between MLWHFQ score and the presence of fragility and all fragility components (all p <0.001). These associations prevailed in both younger (<75 years) and older patients (≥75 years; all p values <0.001 except for Pfeiffer test in younger patients [p = 0.007]). In multivariate regression analysis, QoL remained significantly associated with fragility after adjustment for age, gender, etiology of HF, left ventricular ejection fraction, New York Heart Association functional class, co-morbidities, and HF treatment, in both younger and older patients (p <0.001). In conclusion, MLWHFQ, a specific HF QoL questionnaire, is significantly influenced by fragility regardless of age.

Head-to-head comparison of high-sensitivity troponin T and sensitive-contemporary troponin I regarding heart failure risk stratification.

BACKGROUND: High-sensitivity assays for cardiac troponins have recently become available, increasing the value of troponins in heart failure (HF) prognostication. We head-to-head compared the prognostic significance of high-sensitivity cardiac troponin T (hs-cTnT) and sensitive-contemporary cardiac troponin I (sc-cTnI) in an outpatient HF population. METHODS: We studied 876 patients, mainly of ischemic etiology (52.1%). Median left ventricular ejection fraction was 34%. Median follow-up was 3.45 years. Comprehensive statistical measurements of performance (discrimination, calibration, and reclassification) were obtained. RESULTS: hs-cTnT was ubiquitous in the patient cohort; sc-cTnI was detected in 276 patients (31.5%). During follow-up 311 patients died. According to multivariable Cox regression analysis, both hs-cTnT (HR 2.09, 95% CI 1.46-2.99, P<0.001) and sc-cTnI (HR 1.61, 95% CI 1.24-2.08, P<0.001) remained independent predictors of all cause and cardiovascular mortality. Using the best predictive cut-off point for both troponins calibration was better for hs-cTnT, which also reclassified a larger number of patients (NRI 9.0 [2.5;15.5] P = 0.007). The higher sensitivity of hs-cTnT permitted the identification of almost the double of deaths. CONCLUSION: Both hs-cTnT and sc-cTnI predict mortality in a real-life cohort of ambulatory HF patients. However, hs-cTnT showed globally better measures of performance and identified a higher proportion of decedents during follow-up.

Quality of life monitoring in ambulatory heart failure patients: temporal changes and prognostic value.

AIMS: Heart failure (HF) is a chronic condition that typically affects a patient's quality of life (QoL). Little is known about long-term QoL monitoring in HF. This study aimed to evaluate the temporal changes and prognostic value of QoL assessment in a real-life cohort of HF patients. METHODS AND RESULTS: The Minnesota Living with Heart Failure Questionnaire was used to monitor QoL at baseline and at 1, 3, and 5 years for 1151 consecutive patients {71.7% men, median age 69 years [25th-75th percentiles (P(25)-P(75)) 59-76]} in an HF unit. Follow-up for prognosis assessment was extended to 6 years. The number of answered questionnaires was 1151 at baseline, 746 at 1 year, 268 at 3 years, and 240 at 5 years. QoL scores showed a steep decrease (indicating QoL improvement) during the first year [29 (P(25)-P(75) 16-43) at baseline vs. 15 (P(25)-P(75) 8-27) at 1 year, P < 0.001], which was tempered, yet significant up to 5 years [12 (P(25)-P(75) 7-23) at 3 years vs. 10 (P(25)-P(75) 5-21) at 5 years, P = 0.012]. We recorded 457 deaths during follow-up. In a comprehensive multivariable Cox regression analysis, baseline QoL remained a significant prognosticator during follow-up [hazard ratio (HR)(Cox) for death 1.012, 95% confidence interval 1.006-1.018, P < 0.001]. QoL monitoring showed that a score increase ≥10% between consecutive assessments stratified high-risk patients within the next 12 months (P = 0.008). CONCLUSION: Both baseline and follow-up QoL monitoring were useful for patient risk stratification in a real-life HF cohort. Worse QoL may warn of a worse prognosis. Widespread QoL monitoring in routine clinical practice is recommended.

The obesity paradox in heart failure: is etiology a key factor?

BACKGROUND: Obesity is paradoxically associated with survival in patients with heart failure (HF). Our objective was to assess whether the relationship between body mass index (BMI) and long-term survival is associated with HF etiology (ischemic vs. non-ischemic) in a cohort of ambulatory HF patients. METHODS: BMI and survival status after a median follow-up of 6.1 years (IQR 2.2-7.8) were available for 504 patients (73% men; median age 68 years [IQR 58-74]). Fifty-nine percent of patients had ischemic etiology. Median left ventricular ejection fraction (LVEF) was 30% (IQR 23-39.7%). Most patients were in NYHA functional class II (51%) or III (42%). Patients were divided into four groups according to BMI: low weight (BMI < 20.5 kg/m(2)), normal weight (BMI 20.5 to < 25.5 kg/m(2)), overweight (BMI 25.5 to < 30 kg/m(2)), and obese (BMI ≥ 30 kg/m(2)). RESULTS: Mortality differed significantly across the BMI strata in non-ischemic patients (log-rank p < 0.0001) but not in ischemic patients. Using normal weight patients as a reference, hazard ratios for low weight, overweight, and obese patients were 2.08 (1.16-3.75, p = 0.014), 0.88 (0.54-1.43, p = 0.60), and 0.49 (0.28-0.86, p = 0.01), respectively, for non-ischemic patients and 1.19 (0.48-2.97, p = 0.71), 0.88 (0.61-1.27, p = 0.48), and 0.96 (0.66-1.41, p = 0.85), respectively, for ischemic patients. After adjusting for age, sex, NYHA functional class, LVEF, co-morbidities, and treatment, BMI remained an independent predictor of survival in non-ischemic patients. CONCLUSION: Over long-term follow-up of ischemic and non-ischemic HF, the obesity paradox was only observed in patients with non-ischemic HF.

Statins in heart failure: the paradox between large randomized clinical trials and real life.

OBJECTIVE: To assess the relationship between statins and prognosis in ischemic and nonischemic patients with heart failure (HF) in a real-life cohort followed up for a long period. PATIENTS AND METHODS: This prospective study included 960 patients with HF with preserved or depressed left ventricular ejection fraction (LVEF), irrespective of HF etiology, who were referred to the HF clinic of a university hospital between August 1, 2001, and December 31, 2008. The patients were followed up for a maximum of 9.1 years (median, 3.7 years), and survival in ischemic and nonischemic patients was determined. RESULTS: Median age was 69 years, and median LVEF was 31%. Of the 960 patients, 532 (55.4%) had ischemic HF etiology, and most received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (846; 88.1%) and ß-blockers (776; 80.8%). Patients with HF of ischemic origin were more often treated with statins (P<.001). During follow-up, 440 patients (45.8%) died. Statin therapy was associated with significantly improved survival (hazard ratio, 0.45 [95% confidence interval, 0.37-0.54]; P<.001). After adjustment for HF prognostic factors (age, sex, cholesterol level, New York Heart Association class, HF etiology, LVEF, body mass index, HF duration, atrial fibrillation, implantable cardioverter-defibrillator therapy, and medicines), statins remained significantly associated with lower mortality risk in both ischemic (P=.007) and nonischemic (P=.002) patients. CONCLUSION: In contrast to results of large randomized trials, statins were independently and significantly associated with lower mortality risk in our real-life HF cohort, including patients with nonischemic HF etiology.

Mortality and cause of death in patients with heart failure: findings at a specialist multidisciplinary heart failure unit.

INTRODUCTION AND OBJECTIVES: Heart failure mortality is similar to or even higher than that due to various cancers. It is usually associated with disease progression, though sudden death has also been reported as a frequent cause of mortality. The objectives of this study were to investigate mortality and its causes in outpatients with heart failure of different etiologies who were treated in a specialist multidisciplinary unit, and to identify associated factors. METHODS: The follow-up cohort study (median duration 36 months) involved 960 patients (70.9% male; median age 69 years; ejection fraction 31%; and the majority had an ischemic etiology and were in functional class II or III). RESULTS: Overall, 351 deaths (36.5%) occurred: 230 due to cardiovascular causes (65.5%), mainly heart failure (33.2%) and sudden death (16%); 94 due to non-cardiovascular causes (26.8%), mainly malignancies (10.5%) and septic processes (6.8%); and 27 (7.7%) due to unknown causes. Mortality was independently associated with age, sex, functional class, ejection fraction, time since symptom onset, ischemic etiology, diabetes, creatinine clearance rate, peripheral vascular disease, fragility, and the absence of treatment with an angiotensin-converting enzyme inhibitor or angiotensin-II receptor blocker, beta-blockers, statins or antiplatelet agents. The principal factor associated with cardiovascular death was an ischemic etiology. No factor studied clearly predicted sudden death. CONCLUSIONS: Even though mortality in patients treated at a specialist heart failure unit was not low, a quarter died from non-cardiovascular causes. The principal factor associated with cardiovascular death was an ischemic etiology. Only 5.8% of the study population experienced sudden death.

Prognostic implication of frailty and depressive symptoms in an outpatient population with heart failure.

INTRODUCTION AND OBJECTIVES: Heart failure patients have high levels of frailty and dependence. Our aim was to determine the impact of frailty and depressive symptoms on the 1-year mortality rate and the rate of hospitalization for heart failure during a follow-up period of 1 year. METHODS: All patients underwent geriatric evaluation, and frailty and depressive symptoms were identified. The study included 622 patients (72.5% male; median age, 68 years; 92% in New York Heart Association class II or III; and median ejection fraction, 30%). RESULTS: During follow-up, 60 patients (9.5%) died and 101 (16.2%) were hospitalized for heart failure. Overall, 39.9% of patients exhibited frailty, while 25.2% had depressive symptoms. There were significant associations between mortality at 1 year and the presence of frailty (16.9% vs. 4.8%; P< .001) and depressive symptoms (15.3% vs. 7.7%; P=.006). There was also a significant relationship between heart failure hospitalization and the presence of frailty (20.5% vs. 13.3%; P=.01). No relationship was found between heart failure hospitalization and depressive symptoms. Frailty was an independent predictor of mortality but not of hospitalization. CONCLUSIONS: Univariate analysis demonstrated significant relationships between frailty and depressive symptoms and mortality at 1 year. In addition, there was a significant relationship between frailty and the need for heart failure hospitalization. However, only frailty showed prognostic value to predict mortality, which was independent of other variables strongly associated to outcome.

Estimated creatinine clearance: a determinant prognostic factor in heart failure.

BACKGROUND AND OBJECTIVE: Patients with heart failure and overt kidney failure (KF) have poor prognosis. Even mild degrees of kidney dysfunction might have prognostic value. The aim was to assess whether creatinine clearance values estimated with Cockroft formula correlated with survival at 2 years of follow-up in an outpatient heart failure unit population. PATIENTS AND METHOD: 423 patients (72% men), with a mean (standard deviation) age of 65.5 (11) years, were studied. Etiology of heart failure was mainly ischemic heart disease (59.6%). Mean left ventricle ejection fraction was 32.3% (13.3%). Patients were grouped according to stages of chronic kidney disease: $ 90 ml/min; 89-60 ml/min; 59-30 ml/min; 29-15 ml/min, and < 15 ml/min or on dialysis. KF was defined as creatinine clearance < 60 ml/min. RESULTS: Prevalence of KF was 52%. Mortality at 2 years was 3.2% in patients with creatinine clearance >or= 90 ml/min; 13.7% between 89-60 ml/min; 23.7% between 59-30 ml/min; 51% between 29-15 ml/min and 80% in patients with creatinine clearance < 15 ml/min or on dialysis (p < 0.001). Mortality was 30.4% in patients with KF and 10.3% in those without it (p < 0.001). CONCLUSIONS: Creatinine clearance values estimated by Cockroft formula had a highly predictive prognostic value in patients with heart failure. Even mild degrees of kidney function impairment showed higher mortality than normal kidney function values.

Implicación pronóstica de la fragilidad y los síntomas depresivos en una población ambulatoria con insuficiencia cardiaca / Prognostic Implication of Frailty and Depressive Symptoms in an Outpatient Population With Heart Failure

Introducción y objetivos. Los pacientes con insuficienciacardiaca presentan un elevado grado de fragilidady dependencia. Durante 1 año de seguimiento, examinamosla relación de la fragilidad y los síntomas depresivoscon la mortalidad a 1 año y con la hospitalización por insuficiencia cardiaca.Métodos. Todos los pacientes fueron sometidos a unavaloración geriátrica que permitiría la detección de fragilidad y de síntomas depresivos. Se evaluó a 622 pacientes (el 72,5% varones; mediana de edad, 68 años; el 92% se hallaba en clase II o III de la NYHA; la mediana de fracción de eyección era del 30%).Resultados. Fallecieron durante el seguimiento 60(9,5%) pacientes, y 101 (16,2%) tuvieron que ser hospitalizados por insuficiencia cardiaca. Se detectó fragilidad en el 39,9% de los pacientes y síntomas depresivos en el 25,2%. La fragilidad (el 16,9 frente al 4,8%; p < 0,001) y los síntomas depresivos (el 15,3 frente al 7,7%; p = 0,006) resultaron estar relacionados con la mortalidad a 1 año de forma significativa. También se detectó una relación significativa entre la fragilidad y la hospitalización por insuficiencia cardiaca (el 20,5 frente al 13,3%; p = 0,01).No se observó relación entre síntomas depresivos y hospitalización por insuficiencia cardiaca. La fragilidad resultó tener un valor predictivo independiente de mortalidad pero no de hospitalización.Conclusiones. En el análisis univariable, la fragilidad ylos síntomas depresivos mostraron una relación significativa con la mortalidad a 1 año; además, la fragilidad mostró una relación significativa con la necesidad de hospitalización por insuficiencia cardiaca. Sin embargo, sólo la fragilidad mostró un valor predictivo de mortalidad independiente de otras variables con fuerte influencia en el pronóstico

Introduction and objectives. Heart failure patientshave high levels of frailty and dependence. Our aim wasto determine the impact of frailty and depressivesymptoms on the 1-year mortality rate and the rate ofhospitalization for heart failure during a follow-up period of 1 year.Methods. All patients underwent geriatric evaluation,and frailty and depressive symptoms were identified. Thestudy included 622 patients (72.5% male; median age, 68years; 92% in New York Heart Association class II or III;and median ejection fraction, 30%).Results. During follow-up, 60 patients (9.5%) died and101 (16.2%) were hospitalized for heart failure. Overall,39.9% of patients exhibited frailty, while 25.2% haddepressive symptoms. There were significantassociations between mortality at 1 year and thepresence of frailty (16.9% vs. 4.8%; P<.001) anddepressive symptoms (15.3% vs. 7.7%; P=.006). Therewas also a significant relationship between heart failurehospitalization and the presence of frailty (20.5% vs.13.3%; P=.01). No relationship was found between heartfailure hospitalization and depressive symptoms. Frailtywas an independent predictor of mortality but not ofhospitalization.Conclusions. Univariate analysis demonstrated significant relationships between frailty and depressivesymptoms and mortality at 1 year. In addition, there was a significant relationship between frailty and the need for heart failure hospitalization. However, only frailty showed prognostic value to predict mortality, which wasindependent of other variables strongly associated tooutcome

Estimated creatinine clearance: a determinant prognostic factor in heart failure

FUNDAMENTO Y OBJETIVO: Los pacientes con insuficiencia cardíaca e insuficiencia renal (IR) establecidatienen peor pronóstico. Incluso grados leves de disfunción renal pueden tener significadopronóstico. El objetivo del estudio ha sido evaluar si los valores de aclaramiento de creatinina estimados mediante la fórmula de Cockroft se relacionan con la supervivencia a los 2 años de seguimiento en pacientes ambulatorios de una unidad de insuficiencia cardíaca.PACIENTES Y MÉTODO: Se estudió a 423 pacientes (un 72% varones) con una edad media (desviación estándar) de 65,5 (11) años. La etiología de la insuficiencia cardíaca fue principalmente la cardiopatía isquémica (59,6%). La fracción de eyección media del ventrículo izquierdo era del 32,3% (13,3%). Se dividió a los pacientes de acuerdo con los estadios de IR crónica ( 90; 89-60; 59-30; 29-15, y < 15 ml/min o en diálisis). Se consideró que había IR establecida cuando el aclaramiento de creatinina era inferior a 60 ml/min.RESULTADOS: La prevalencia de IR fue del 52%. La mortalidad a los 2 años fue del 3,2% en el grupo con aclaramiento de creatinina 90 ml/min; del 13,7% en el de 89-60 ml/min; del 23,7% en el de 59-30 ml/min; del 51% en el de 29-15 ml/min, y del 80% en pacientes conaclaramiento de creatinina < 15 ml/min o en diálisis (p < 0,001). La mortalidad fue del 30,4% en pacientes con IR y del 10,3% en aquellos sin la enfermedad (p < 0,001).CONCLUSIONES: Los valores de aclaramiento de creatinina estimados por la fórmula de Cockroft mostraron un alto valor pronóstico predictivo en pacientes con insuficiencia cardíaca. Incluso los pacientes con un grado leve de disfunción renal presentaron una mortalidad más elevada que aquellos con valores normales de función renaln

BACKGROUND AND OBJECTIVE: Patients with heart failure and overt kidney failure (KF) have poorprognosis. Even mild degrees of kidney dysfunction might have prognostic value. The aim was to assess whether creatinine clearance values estimated with Cockroft formula correlated with survival at 2 years of follow-up in an outpatient heart failure unit population.PATIENTS AND METHOD: 423 patients (72% men), with a mean (standard deviation) age of 65.5 (11) years, were studied. Etiology of heart failure was mainly ischemic heart disease (59.6%). Mean left ventricle ejection fraction was 32.3% (13.3%). Patients were grouped according to stages of chronic kidney disease: 90 ml/min; 89-60 ml/min; 59-30 ml/min; 29-15 ml/min,and < 15 ml/min or on dialysis. KF was defined as creatinine clearance < 60 ml/min.RESULTS: Prevalence of KF was 52%. Mortality at 2 years was 3.2% in patients with creatinineclearance 90 ml/min; 13.7% between 89-60 ml/min; 23.7% between 59-30 ml/min; 51% between 29-15 ml/min and 80% in patients with creatinine clearance < 15 ml/min or on dialysis (p < 0.001). Mortality was 30.4% in patients with KF and 10.3% in those without it (p <0.001).CONCLUSIONS: Creatinine clearance values estimated by Cockroft formula had a highly predictiveprognostic value in patients with heart failure. Even mild degrees of kidney function impairmentshowed higher mortality than normal kidney function values

[Prognostic significance of creatinine clearance rate in patients with heart failure and normal serum creatinine]. / Significado pronóstico del aclaramiento de creatinina en pacientes con insuficiencia cardiaca y creatinina sérica normal.

Kidney failure is an important prognostic factor in patients with heart failure. Renal function is usually evaluated by measuring the serum creatinine level. However, a normal creatinine level can mask established kidney failure. We investigated the prognostic significance of the estimated creatinine clearance rate (Cockcroft formula) in 235 patients with heart failure and a normal serum creatinine level. The two-year mortality rate was significantly higher in patients who had established kidney disease (i.e., a creatinine clearance rate <60 mL/min) than in those who did not (35.1% vs. 10.1%, P<.001). Even when only patients without established kidney failure were analyzed, the creatinine clearance rate had prognostic significance (rate > or = 90 mL/min, mortality 3.2%; rate 89-60 mL/min, mortality 13.9%; P=.02). On Cox regression analysis, which included age, sex, heart failure etiology, left ventricular ejection fraction, diabetes and hypertension, the creatinine clearance rate remained an independent predictor of mortality.

Significado pronóstico del aclaramiento de creatinina en pacientes con insuficiencia cardiaca y creatinina sérica normal / Prognostic significance of creatinine clearance rate in patients with heart failure and normal serum creatinine

La insuficiencia renal es un importante factor pronóstico en pacientes con insuficiencia cardiaca. Para valorar la función renal se suelen utilizar las cifras de creatinina sérica. Sin embargo, cifras normales pueden ocultar una insuficiencia renal establecida. Hemos evaluado el significado pronóstico del aclaramiento de creatinina estimado (Cockcroft) en 235 pacientes con insuficiencia cardiaca y cifras de creatinina normales. Los pacientes con insuficiencia renal establecida (aclaramiento < 60 ml/min) tuvieron una mortalidad a 2 años muy superior a la de aquellos sin ella (el 35,1 y el 10,1%; p < 0,001). Incluso al analizar exclusivamente a los pacientes sin insuficiencia renal establecida, el aclaramiento de creatinina demostró tener significación pronóstica (≥ 90 ml/min, mortalidad del 3,2%; 89-60 ml/min, mortalidad del 13,9%; p = 0,02). En el análisis de regresión de Cox en el que se incluyeron además edad, sexo, etiología de la insuficiencia cardiaca, clase funcional, fracción de eyección de ventrículo izquierdo, diabetes e hipertensión, el aclaramiento de creatinina permaneció como predictor independiente de mortalidad (AU)

Kidney failure is an important prognostic factor in patients with heart failure. Renal function is usually evaluated by measuring the serum creatinine level. However, a normal creatinine level can mask established kidney failure. We investigated the prognostic significance of the estimated creatinine clearance rate (Cockcroft formula) in 235 patients with heart failure and a normal serum creatinine level. The two-year mortality rate was significantly higher in patients who had established kidney disease (i.e., a creatinine clearance rate <60 mL/min) than in those who did not (35.1% vs. 10.1%, P<.001). Even when only patients without established kidney failure were analyzed, the creatinine clearance rate had prognostic significance (rate ≥ 90 mL/min, mortality 3.2%; rate 89­60 mL/min, mortality 13.9%; P=.02). On Cox regression analysis, which included age, sex, heart failure etiology, left ventricular ejection fraction, diabetes and hypertension, the creatinine clearance rate remained an independent predictor of mortality (AU)

[Clinical, echocardiographic and prognostic evaluation of atrial fibrillation in patients with heart failure]. / Valoración clínica, ecocardiográfica y pronóstica de la fibrilación auricular en pacientes con insuficiencia cardíaca.

BACKGROUND AND OBJECTIVE: We aimed to assess the prevalence of atrial fibrillation (AF) in a general heart failure (HF) population admitted to a HF unit, analyze the parameters associated with AF, and evaluate its prognostic significance. PATIENTS AND METHOD: 389 patients, 64 with AF at the first visit. Mean (SD) age was 65.38 (10.77) years and 72.5% were men. The main etiology was ischemic heart disease (59.9%). Mean ejection fraction (EF) was 32.25% (13%). Vital status at 2 years was available in 377 patients (97%), 314 in sinus rhythm (SR) and 63 in AF. RESULTS: The prevalence of AF was 15.8%. AF was associated with: older age, female gender, valvular and hypertensive etiology, longer time since the onset of HF symptoms, higher EF, higher left atrium diameter, degree of mitral regurgitation, and lower quality of life, but not with the NYHA functional class. The 2-years mortality (16.7%) was significantly higher in patients with AF (33.3% vs 18.4%; OR = 2.20; 95% confidence interval, 1.21-4). However, when adjusted for other relevant variables such as age, NYHA functional class, ejection fraction, sex and etiology, AF did not remain as an independent prognostic factor. The strongest mortality differences between patients with AF and those with SR where observed in ischemic heart disease and dilated cardiomyopathy. CONCLUSIONS: AF was associated mainly with age, valvular and hypertensive etiology, higher left atrium diameter and lower end-systolic left ventricular diameter. Two years mortality was significantly higher in patients with AF, although other parameters such as age and NYHA functional class had a higher prognostic value.

Valoración clínica, ecocardiográfica y pronóstica de la fibrilación auricular en pacientes con insuficiencia cardíaca / Clinical, echocardiographic and prognostic evaluation of atrial fibrillation in patients with heart failure

Fundamento y objetivo: Valorar la prevalencia de fibrilación auricular (FA) en pacientes con insuficiencia cardíaca de una unidad multidisciplinaria, analizar los factores asociados y evaluar su significación pronóstica. Pacientes y método: Se incluyó a 389 pacientes, 64 con FA en la primera visita. La media (desviación estándar) de la edad fue 65,38 (10,77) años; el 72,5% eran varones. La etiología era isquémica en el 59,9%. La fracción de eyección (FE) media era de 32,25% (13%). A los 2 años conocíamos la situación vital de 377 (97%) pacientes (314 en ritmo sinusal [RS] y 63 en FA). Resultados: La prevalencia de FA era del 15,8% y se asociaba con mayor edad, sexo femenino, etiologías hipertensiva y valvular, mayor duración de los síntomas, mejor FE, mayor diámetro de la aurícula izquierda, mayor grado de insuficiencia mitral y peor calidad de vida, pero no con la clase funcional de la New York Heart Association (NYHA). La mortalidad a los 2 años (16,7%) era significativamente mayor en los pacientes con FA (el 33,3 frente al 18,4%; odds ratio = 2,20; intervalo de confianza del 95%, 1,21-4), aunque al ajustar por otras variables relevantes como la edad, el sexo, la clase funcional, la FE y la etiología, la FA no se mantuvo como factor pronóstico independiente. Las diferencias más importantes de mortalidad ocurrían en la insuficiencia cardíaca de causa isquémica y por miocardiopatía dilatada. Conclusiones: La FA tuvo relación, fundamentalmente, con la edad, la etiología valvular e hipertensiva y un mayor diámetro de la aurícula izquierda. La mortalidad a los 2 años era significativamente mayor en los pacientes con FA, aunque otros parámetros como la edad y la clase funcional de la NYHA tenían mayor significación pronóstica

Background and objective: We aimed to assess the prevalence of atrial fibrillation (AF) in a general heart failure (HF) population admitted to a HF unit, analyze the parameters associated with AF, and evaluate its prognostic significance. Patients and method: 389 patients, 64 with AF at the first visit. Mean (SD) age was 65.38 (10.77) years and 72.5% were men. The main etiology was ischemic heart disease (59.9%). Mean ejection fraction (EF) was 32.25% (13%). Vital status at 2 years was available in 377 patients (97%), 314 in sinus rhythm (SR) and 63 in AF. Results: The prevalence of AF was 15.8%. AF was associated with: older age, female gender, valvular and hypertensive etiology, longer time since the onset of HF symptoms, higher EF, higher left atrium diameter, degree of mitral regurgitation, and lower quality of life, but not with the NYHA functional class. The 2-years mortality (16.7%) was significantly higher in patients with AF (33.3% vs 18.4%; OR = 2.20; 95% confidence interval, 1.21-4). However, when adjusted for other relevant variables such as age, NYHA functional class, ejection fraction, sex and etiology, AF did not remain as an independent prognostic factor. The strongest mortality differences between patients with AF and those with SR where observed in ischemic heart disease and dilated cardiomyopathy. Conclusions: AF was associated mainly with age, valvular and hypertensive etiology, higher left atrium diameter and lower end-systolic left ventricular diameter. Two years mortality was significantly higher in patients with AF, although other parameters such as age and NYHA functional class had a higher prognostic value

Does heart failure therapy differ according to patient sex?

OBJECTIVES: To assess differences in clinical characteristics, treatment and outcome between men and women with heart failure (HF) treated at a multidisciplinary HF unit. All patients had their first unit visit between August 2001 and April 2004. PATIENTS: We studied 350 patients, 256 men, with a mean age of 65 +/- 10.6 years. In order to assess the pharmacological intervention more homogeneously, the analysis was made at one year of follow-up. RESULTS: Women were significantly older than men (69 +/- 8.8 years vs. 63.6 +/- 10.9 years, p < 0.001). Significant differences were found in the HF etiology and in co-morbidities. A higher proportion of men were treated with ACEI (83% vs. 68%, p < 0.001) while more women received ARB (18% vs. 8%, p = 0.006), resulting in a similar percentage of patients receiving either of these two drugs (men 91% vs. women 87%). No significant differences were observed in the percentage of patients receiving beta-blockers, loop diuretics, spironolactone, anticoagulants, amiodarone, nitrates or statins. More women received digoxin (39% vs. 22%, p = 0.001) and more men aspirin (41% vs. 31%, p = 0.004). Carvedilol doses were higher in men (29.4 +/- 18.6 vs. 23.8 +/- 16.4, p = 0.03), ACEI doses were similar between sexes, and furosemide doses were higher in women (66 mg +/- 26.2 vs. 56 mg +/- 26.2, p < 0.05). Mortality at 1 year after treatment analysis was similar between sexes (10.4% men vs. 10.5% women). CONCLUSIONS: Despite significant differences in age, etiology and co-morbidities, differences in treatment between men and women treated at a multidisciplinary HF unit were small. Mortality at 1 year after treatment analysis was similar for both sexes.

Tratamiento de la insuficiencia cardíaca en pacientes mayores de 75 años. Estudio comparativo con los pacientes más jóvenes / Treatment of heart failure in patients aged 75 years or older: comparison with younger patients

Objetivos: analizar las diferencias clínicas, terapéuticas y evolutivas entre los pacientes mayores y menores de 75 años diagnosticados de insuficiencia cardíaca (IC). Pacientes y métodos: pacientes atendidos en una unidad multidisciplinaria de IC (UMIC) de los que se disponía datos diagnósticos y terapéuticos y de mortalidad de un año de seguimiento. Para analizar las diferencias existentes entre los 2 grupos de edad, se utiliza la prueba de la χ2, t de Student o Kruskal-Wallis, según el tipo de variables y el ajuste a la normalidad (intervalo de confianza del 95%). Resultados: se estudió a 323 pacientes, con una media ± desviación estándar de edad de 64,9 ± 10,5 años (35-85). El 73% en el momento de la primera visita eran varones; 57 eran ≥ 75 años. No hay diferencias etiológicas de la IC entre ambos grupos. En el de más edad había más mujeres (el 42,1 frente al 23,8%; p = 0,003) y eran más prevalentes la patología respiratoria (el 29,8 frente al 18,4%; p = 0,05) y la anemia (el 42,1 frente al 24,8%; p = 0,008). Más pacientes < 75 años fueron tratados con inhibidores de la enzima de conversión de la angiotensina (IECA) o con antagonistas de los receptores de la angiotensina II (el 91,7 frente al 77,2%; p = 0,001), bloqueadores beta (el 81,6 frente al 49,3%; p 0,001) y estatinas (el 62,8 frente al 43,1%; p = 0,004). Más pacientes ≥ 75 años fueron tratados con hidralazina + nitratos (el 19,2 frente al 6,8%; p = 0,003) y amiodarona (el 36,8 frente al 16,9%; p = 0,001). Las dosis de carvedilol eran más bajas en los más ancianos: 14,6 ± 10,6 mg frente a 29,4 ± 18,4 mg, p < 0,001. Las dosis de IECA eran similares en los 2 grupos de edad y las dosis de furosemida eran mayores en los ≥ 75 años: 67,0 ± 2,5 mg frente a 56,2 ± 27,3 mg, p = 0,008. La mortalidad un año después del análisis del tratamiento era significativamente mayor en los pacientes ≥ 75 años (el 22 frente al 8%). Conclusiones: las diferencias de tratamiento entre los pacientes ancianos y los más jóvenes con IC atendidos en una UMIC son evidentes en esta muestra, sobre todo en el empleo de bloqueadores beta. La mortalidad, como era predecible, fue significativamente más elevada en los pacientes de 75 años o mayores

Objectives: to analyze the differences in clinical features, therapy and outcome in elderly patients and those aged less than 75 years with a diagnosis of heart failure. Patients and methods: patients managed in a multidisciplinary heart failure unit in whom data on diagnosis, treatment and mortality were available at 1 year of follow-up were included. To analyze differences between the two age groups, a χ2 test and Student's t-test or the Kruskal-Wallis test were used, according to the type of variables and normality of the distribution (95% confidence interval). Results: there were 323 patients, with a mean age of 64.9 years, SD 10.5 (range: 35-85); 73% were men. Fifty-seven patients were aged ≥ 75 years. There were no differences between the two groups in the etiology of heart failure. Women were more frequent in the group aged 75 years or older (42.1% versus 23.8%, p = 0.003) and respiratory disease (29.8% versus 18.4%, p = 0.05) and anemia (42.1% versus 24.8%, p = 0.008) were more common. The group aged < 75 years was more frequently treated with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor antagonists (91.7% versus 77.2%, p = 0.001), beta-blockers (81.6% versus 49.3%, p < 0.001) and statins (62.8% versus 43.1%, p = 0.004). A greater number of patients aged ≥ 75 were treated with hydralazine + nitrates (19.2% versus 6.8%, p = 0.003) and amiodarone (36.8% versus 16.9%, p = 0.001). Carvedilol doses were lower in the elderly group: 14.6 mg (SD 10.6) versus 29.4 mg (SD 18.4), p < 0.001. Doses of ACE inhibitors were similar in the two groups and furosemide doses were higher in patients aged ≥ 75 years: 67.0 mg (SD 2.5) versus 56.2 mg (SD 27.3), p = 0.008. Mortality 1 year after analysis of treatment was significantly higher in patients aged ≥ 75 years (22% versus 8%). Conclusions: differences in treatment between elderly patients and those aged < 75 years with heart failure were evident in this sample, especially in the use of beta blockers. Predictably, mortality was significantly higher in patients aged ≥ 75 years

[Use of betablockers in elderly patients with congestive heart failure]. / Uso de bloqueadores beta en pacientes ancianos con insuficiencia cardíaca.

BACKGROUND AND OBJECTIVE: Few studies of betablockers (BB) have been performed specifically in older patients with congestive heart failure (CHF). We evaluated the characteristics of elderly patients with CHF treated with BB. Moreover, we assessed whether BB are associated with a better outcome in them. PATIENTS AND METHOD: We evaluated clinical and functional characteristics of patients aged > or = 75 years with CHF treated with or without BB, with special interest being paid in the mortality. RESULTS: 47 out of 107 patients were treated with BB. Only in 3 it was necessary to withdraw BB. Patients treated with no BB were older, with a higher New York Heart Association (NYHA) class, more prevalent chronic obstructive pulmonary disease (COPD) and in poorer functional situation. In patients treated with BB, ischemic heart disease was more prevalent. Reasons for "no treatment with BB" were severe aortic stenosis (n = 2), severe mitral regurgitation (n = 9), asthma-COPD (n = 28), arterial disease (n = 16) and fragility (n = 9). 25% of the patients on BB reached the target dose. One-year mortality (5.7% vs 27.6%) and 2-year mortality (20.68% vs 60%) were both significantly lower (p = 0.01 and p = 0.002, respectively) in patients on BB. CONCLUSIONS: 44% of our elderly patients with CHF received BB with good tolerance. Patients treated with BB were younger, with more ischemic heart disease, better NYHA class, less functional deterioration and without COPD. One-year and two-year mortality in patients who can receive BB were lower.