Prognosis in patients with heart failure and preserved left ventricular systolic function.

BACKGROUND: It is recognized that heart failure patients with preserved left ventricular systolic function have better prognosis; nevertheless, there are some studies with conflicting results. Also, there is a paucity of data concerning the prognostic factors in this group of patients. OBJECTIVES: To determine possible variables with prognostic relevance in heart failure patients with preserved left ventricular systolic function (ejection fraction > 40%). METHODS: 157 consecutive ambulatory patients with heart failure were assessed; those patients with ejection fraction > 40% were included in the study (n = 46). All patients were evaluated by clinical interview and physical examination, ECG, echocardiogram (M-mode, 2D and pulsed Doppler of mitral flow), biochemical study and determination of type B natriuretic peptide (BNP). The patients were grouped according to the rhythm presented on ECG: Group I--patients with atrial fibrillation; Group II--patients in sinus rhythm Group II was further subdivided in two groups according to the presence or absence of restrictive left ventricular filling pattern. All patients had a clinical follow-up, with recording of events (death or hospitalization from cardiac cause). The mean follow-up time was 682.2 +/- 55 days. RESULTS: The mean age of the patients was 70.4 +/- 1.2 years; 54.3% were women; mean ejection fraction was 49.6 +/- 1%; mean BNP levels were 202.9 +/- 41.3 pg/ml. Mortality was 19.6% and the combined event death or hospitalization from cardiac cause) occurred in 26.1% of the patients. Among the clinical, demographic, biochemical, echocardiographic and neurohumoral parameters, only BNP levels had prognostic significance in the whole population. In Group II patients, BNP levels, heart rate and restrictive left ventricular filling pattern were identified as having prognostic significance. Kaplan-Meyer curve analysis showed that both BNP and restrictive left ventricular filling pattern seemed to be important prognostic markers. CONCLUSIONS: This preliminary study suggests thar neurohumoral activity (determined by plasma BNP levels) and a restrictive ventricular filling pattern may be important factors in prognostic stratification of heart failure patients with preserved left ventricular systolic function.

Echocardiographic patterns and prognosis in heart failure.

BACKGROUND: There are many variables with prognostic value in patients with heart failure (HF). Those related to left ventricular function are among the most important. Recently, the evaluation of the patterns of ventricular filling by pulsed Doppler echocardiography has been studied as a variable with prognostic value. OBJECTIVES: To evaluate the prognostic value of echocardiography variables (diastolic and systolic) in patients with HF. These variables were analysed in respect to hospital admission for cardiovascular reasons or death. MATERIAL AND METHODS: We evaluated 157 consecutive patients with HF and included 110 patients who were in sinus rhythm. The mean age was 68.2 +/- 0.9 years. HF was ischemic in 52.7%. Patients underwent echocardiography examination within the week of reference. The patients were grouped according to left ventricular (LV) systolic dysfunction (LV ejection fraction < 40%). We also classified patients in two groups according to the presence of a restrictive pattern in diastolic transmitral flow profile. Finally, we classified all patients in four groups according to their systolic function and diastolic pattern: Group I--systolic dysfunction and restrictive ventricular filling pattern. Group II--systolic dysfunction without restrictive ventricular filling pattern. Group III--without systolic dysfunction with restrictive ventricular filling pattern. Group IV--without systolic dysfunction without restrictive ventricular filling pattern. The events were death or hospital admission. The mean follow up time was 625 +/- 55 days. We did a statistical analysis and for all tests a p value < 0.05 was considered statistically significant. RESULTS: We found impaired LV systolic function (systolic HF) in 73.6% and restrictive ventricular filling pattern in 45.5%. During the follow-up 41.8% died or were admitted to hospital. Patients with systolic HF had lower admission free survival rate. Patients with restrictive ventricular filling pattern had lower admission free survival rate than those without. Group I had lower admission free survival rate than Group II and Group IV. Group IV had a higher admission free survival than all other Groups. CONCLUSIONS: These results support and expand previous observations that diastolic function variables, such as the pattern of ventricular filling (namely the restrictive) have independent prognostic value in patients with HF.

Determinants of in-hospital mortality in women with acute myocardial infarction who underwent primary coronary angioplasty.

INTRODUCTION: According to recent data, women have a greater risk of dying from an acute coronary event. The determinants of this ominous prognosis are not completely understood. Preliminary analysis of our data suggested that this poorer prognosis is also observed in the subgroup of patients with acute myocardial infarction submitted to direct coronary angioplasty (PTCA). This finding prompted us to investigate gender differences and their determinants in this particular context. OBJECTIVE: To identify risk factors associated with the greater in-hospital mortality of women with acute infarction who underwent PTCA. METHODS: One hundred and forty-five consecutive patients with acute myocardial infarction who underwent direct PTCA in the same hospital were studied retrospectively. Data were collected from the database of the catheterisation laboratory and from clinical files. The following parameters were analysed: in-hospital mortality, age, prevalence of diabetes mellitus, history of coronary heart disease, time elapsed from beginning of symptoms to coronary intervention, peak values of CK and MB-CK, number of coronary arteries with significant disease at angiography, culprit lesion localisation, and prevalence of shock on admission. For statistical analysis, cross-tabulation (Pearson x2) and comparison of means (Student's t test) were employed when appropriate; an error of 5% was admitted for the rejection of the null hypothesis. RESULTS: Women (n = 39) represented 26.9% of sample. In hospital mortality was 28.2% (n = 11) for women and 11.3% (n = 12) for men (p = 0.014). The prevalence of coronary heart disease before the current acute event, the time elapsed from beginning of symptoms to coronary intervention, and maximum values of CK and MB-CK were similar in both genders. Differences between women and men were found as regards the following variables (women vs men): age (61.7 +/- 10 vs 56.1 +/- 12.6 years), prevalence of left main disease (15.3 vs 1.9%) and prevalence of shock (41 vs 17%) and diabetes (38.7 vs 13.6%). Considering women and men who died, only disease severity as evaluated by the number of vessels involved distinguished both genders (p = 0.05). CONCLUSIONS: In our experience, women admitted with acute myocardial infarction and treated by direct PTCA are, on average, older than men and have a greater prevalence of shock at admission, of left main disease and of diabetes, and more severe coronary artery disease. In the present series and as regard in-hospital mortality, disease severity as evaluated by the number of vessels involved is the only variable that discriminates women from men.