The association of QRS duration with atrial fibrillation in a heart failure with preserved ejection fraction population: a pilot study.

BACKGROUND: Heart failure is a significant cause of morbidity and mortality, yet patient risk stratification may be difficult. Prevention or treatment of atrial fibrillation (AF) may be an important strategy in these patients that could positively affect their outcome. It has been demonstrated that in patients with systolic dysfunction, prolonged QRS duration (QRSd), an easily measured electrocardiographic parameter, is associated with AF. HYPOTHESIS: Prolonged QRSd is associated with an increase in prevalence of AF in patients with heart failure with preserved ejection fraction(HFPEF). METHODS: Between February 2006 and February 2009, 718 patients were discharged with a diagnosis of HF from the Dartmouth-Hitchcock Medical Center. Of these, 206 had EF ≥50% by echocardiography performed within 72 hours of admission. After exclusions, 82 patients remained, of which 25 had AF and 57 had sinus rhythm. Characteristics of the AF and sinus-rhythm patients were compared in this pilot study. RESULTS: After adjustment for age, prior diagnosis of HF, and left atrial area, there was a nonsignificant trend (odds ratio: 2.2, 95% CI of 0.3-17.2) for a QRSd >120 ms to be associated with AF. CONCLUSIONS: Similar to results in patients with systolic dysfunction, patients with preserved EF may have an association between a prolonged QRSd and AF.

Palliative care consultations for heart failure patients: how many, when, and why?

OBJECTIVE: In preparation for development of a palliative care intervention for patients with heart failure (HF) and their caregivers, we aimed to characterize the HF population receiving palliative care consultations (PCCs). METHODS AND RESULTS: Reviewing charts from January 2006 to April 2011, we analyzed HF patient data including demographic and clinical characteristics, Seattle Heart Failure scores, and PCCs. Using Atlas qualitative software, we conducted a content analysis of PCC notes to characterize palliative care assessment and treatment recommendations. There were 132 HF patients with PCCs, of which 37% were New York Heart Association functional class III and 50% functional class IV. Retrospectively computed Seattle Heart Failure scores predicted 1-year mortality of 29% [interquartile range (IQR) 19-45] and median life expectancy of 2.8 years [IQR 1.6-4.2] years. Of the 132 HF patients, 115 (87%) had died by the time of the audit. In that cohort the actual median time from PCC to death was 21 [IQR 3-125] days. Reasons documented for PCCs included goals of care (80%), decision making (24%), hospice referral/discussion (24%), and symptom management (8%). CONCLUSIONS: Despite recommendations, PCCs are not being initiated until the last month of life. Earlier referral for PCC may allow for integration of a broader array of palliative care services.

The evaluation of creatinine clearance, estimated glomerular filtration rate and serum creatinine in predicting contrast-induced acute kidney injury among patients undergoing percutaneous coronary intervention.

PURPOSE: The purpose of the study was to compare creatinine clearance (CrCl), estimated glomerular filtration rate (eGFR) and serum creatinine (SCr) in predicting contrast-induced acute kidney injury (CI-AKI), dialysis and death following percutaneous coronary intervention (PCI). METHODS AND MATERIALS: Data were prospectively collected on 7759 consecutive patients within the Dartmouth Dynamic Registry undergoing PCI between January 1, 2000, and December 31, 2006. Renal function was measured at baseline and within 48 h after PCI using three methods: CrCl using the Cockcroft-Gault equation, eGFR using the abbreviated Modification of Diet in Renal Disease equation and SCr. We compared CrCl, eGFR and SCr in predicting CI-AKI, post-PCI dialysis-dependent renal failure and in-hospital mortality. Areas under the receiver operating characteristic curve (ROC) were calculated using logistic regression and tested for equality. RESULTS: On univariable analysis, CrCl [ROC: 0.69; 95% confidence interval (CI): 0.67-0.72] predicted CI-AKI better than eGFR (ROC: 0.67; 95% CI: 0.64-0.70) (P=.013) and SCr (ROC: 0.64; 95% CI: 0.61-0.67) (P<.001). Creatinine clearance (ROC: 0.73; 95% CI: 0.69-0.77) and eGFR (ROC: 0.70; 95% CI: 0.65-0.74) outperformed SCr for predicting in-hospital mortality. On multivariable analysis, CrCl (ROC: 0.77; 95% CI: 0.75-0.80), SCr (ROC: 0.78; 95% CI: 0.76-0.80) and eGFR (ROC: 0.77; 95% CI: 0.75-0.80) predicted CI-AKI well. Creatinine clearance (ROC: 0.88; 95% CI: 0.85-0.90) and eGFR (ROC: 0.87; 95% CI: 0.85-0.90) were strong independent predictors of in-hospital mortality. CONCLUSIONS: Creatinine clearance, eGFR and SCr predict CI-AKI equally well. Creatinine clearance and eGFR are strong independent predictors of in-hospital mortality.

Cardiac surgery-associated acute kidney injury: a comparison of two consensus criteria.

BACKGROUND: Cardiac surgery-related acute kidney injury has short- and long-term impact on patients' risk for further morbidity and mortality. Consensus statements have yielded criteria--such as the risk, injury, failure, loss, and end-stage kidney disease (RIFLE) criteria, and the Acute Kidney Injury Network (AKIN) criteria--to define the type and consequence of acute kidney injury. We sought to estimate the ability of both the RIFLE and and AKIN criteria to predict the risk of in-hospital mortality in the setting of cardiac surgery. METHODS: Data were collected on 25,086 patients undergoing cardiac surgery in Northern New England from January 2001 to December 2007, excluding 339 patients on preoperative dialysis. The AKIN and RIFLE criteria were used to classify patients postoperatively, using the last preoperative and the highest postoperative serum creatinine. We compared the diagnostic properties of both criteria, and calculated the areas under the receiver operating characteristic curve. RESULTS: Acute kidney injury occurred in 30% of patients using the AKIN criteria and in 31% of patients using the RIFLE criteria. The areas under the receiver operating characteristic curve for in-hospital mortality estimated by AKIN and RIFLE criteria were 0.79 (95% confidence interval: 0.77 to 0.80) and 0.78 (95% confidence interval: 0.76 to 0.80), respectively (p = 0.369). CONCLUSIONS: The AKIN and RIFLE criteria are accurate early predictors of mortality. The high incidence of cardiac surgery postoperative acute kidney injury should prompt the use of either AKIN or RIFLE criteria to identify patients at risk and to stimulate institutional measures that target acute kidney injury as a quality improvement initiative.