Simple clinical criteria to determine the prognosis of heart failure.

OBJECTIVE: To determine whether easily obtained clinical parameters serve as predictors of survival in patients with congestive heart failure. Several scoring systems to predict heart failure survival have been developed; however, many of these deal principally with transplant recipients or do not account for a patient's response to therapy. METHODS: A total of 680 patients with an ejection fraction of less than 40% were included in the analysis. Baseline assessments were performed and treatment regimens were identified; patients were then followed for up to 5 years. Univariate and multivariate Cox regression models were used to determine clinically important predictors of survival. Kaplan-Meier survival functions for patients with and without the prognostic variable were constructed and mortality was calculated at 1 year and 5 years. RESULTS: Ejection fraction improvement at 6 months, diabetes mellitus, age, serum creatinine, and blood urea nitrogen (BUN) were significant predictors for survival in the univariate model. Ejection fraction improvement, age, and BUN were significant predictors in the multivariate model. These findings were used to construct a model for predicting patient mortality. Improved ejection fraction (>15 ejection fraction units) gave a 1-year mortality of 2% and a 5-year mortality of 11%. Mortality rates according to patient age and BUN levels were also calculated. CONCLUSION: Ejection fraction improvement was the most important predictor for survival in patients with systolic dysfunction; monitoring ejection fraction changes through repeat echocardiograms has important prognostic value. In patients without ejection fraction improvement, age and renal function are important survival determinants.

Amiodarone rescue therapy for severe decompensated heart failure initially unsuitable for beta-blockers.

BACKGROUND: Beta-blocker therapy is now standard therapy for patients with stable heart failure; however, fluid-overloaded, New York Heart Association Class IV patients tolerate beta-blockers poorly. Amiodarone, a drug with antiadrenergic effects, has been shown to improve survival for patients with heart rates of 90 beats per minute or greater. METHODS: We reviewed 26 patients with severe decompensated heart failure who were started on oral amiodarone for heart rate control. beta-Blocker titration was attempted when patients became clinically stable. RESULTS: The mean age of the patients was 48.5 +/- 17.5 years, and 73% were male. Fifteen patients were New York Heart Association Class IV, and 11 were Class III. Of these, 23 (88%) were fluid-overloaded, and 11 (42%) were on inotropic agents when amiodarone was started. The mean ejection fraction was 16.1 +/- 6%. The initial dose of amiodarone was 346 +/- 120 mg/day. Twenty (77%) patients were successfully started on beta-blockers. At follow-up prior to beta-blockers, 20 (77%) patients improved by at least one New York Heart Association class. Heart rate decreased from a mean of 98 +/- 15 to 78 +/- 13 beats per minute (P <.0001). Echocardiograms were available in 12 patients, with ejection fractions increasing from 16.1 +/- 8% to 26.8 +/- 13% (P =.004). CONCLUSIONS: Amiodarone may be an effective rescue therapy for patients with decompensated heart failure and serve as a bridge to subsequent beta-blocker therapy.