Is the diagnostic coding position of acute heart failure related to mortality? A report from the Euro Heart Failure Survey-1.

AIMS: Most studies on acute heart failure (HF) exploring the relationship between admissions to hospital for HF and subsequent outcomes have focused only on HF coded as the primary diagnosis, but many other patients have admissions complicated by HF requiring attention. Failure to quantify the total hospital burden of HF underestimates its health economic impact, leading to underprovision of resources for its care. METHODS AND RESULTS: The First Euro Heart Failure Survey (EHFS-1) screened consecutive deaths and discharges, regardless of cause, from medical wards in 115 hospitals from 24 European countries during 2000-2001, to identify patients with known or suspected HF. Information on presenting symptoms and signs were gathered. Of 10 701 patients enrolled, HF was reported as the primary reason for admission in 4234 (40%), a secondary reason for admission if it complicated or prolonged stay in 1772 (17%), and in 4695 (43%) patients it was uncertain whether HF was actively contributing to the admission. Mortality on the index admission was 301 (7%), 290 (16%), and 189 (4%), respectively, with hazard ratios of 1.73 (P < 0.001) and 3.26 (P < 0.001) compared with the 'uncertain' group. In the 12 weeks following discharge, 287 (7%) patients with a primary, 117 (8%) with a secondary, and 238 (5%) with an incidental or uncertain diagnosis of HF died. CONCLUSION: Patients admitted to hospital with HF as a secondary rather than a primary diagnosis have a high mortality. More attention should be focused on patients with a secondary diagnosis of HF in terms of both care and research.

Renal dysfunction in acute and chronic heart failure: prevalence, incidence and prognosis.

Most patients with heart failure have mild or moderate renal dysfunction. This reflects the combined impact of chronic renal parenchymal disease, renal artery disease, renal congestion and hypoperfusion, neuroendocrine and cytokine activation and the effects of treatments for heart failure. Remarkably, with good treatment, the average annual rate of decline in renal function is similar in patients with chronic heart failure and healthy people of a similar age. Urea appears to be a stronger marker of an adverse prognosis than creatinine-based measures of renal function. Recent evidence suggests that minor, transient increases in creatinine in the setting of acute heart failure are not prognostically important but persistent deterioration does indicate a higher mortality. The poor prognosis of patients with worsening renal function ensures that few require renal dialysis but this may change as methods to prevent sudden death improve and new ways are found to control fluid congestion. Reversing renal dysfunction and stopping its progression remain important targets for treatment of heart failure.

Does the physical examination still have a role in patients with suspected heart failure?

AIMS: The prognostic value of signs of congestion in patients suspected of having chronic heart failure (CHF) is unknown. Our objectives were to define their prevalence and specificity in diagnosing CHF and to determine their prognostic value in patients in a community heart failure clinic. METHODS AND RESULTS: Analysis of referrals to a community clinic for patients with CHF symptoms. Systolic CHF (S-HF) was defined as left ventricular ejection fraction (LVEF) ≤45%, heart failure with normal ejection fraction (HeFNEF) as LVEF > 45%, and amino-terminal pro-brain natriuretic peptide >50 pmol L(-1); other subjects were defined as not having CHF. Signs of congestion were as follows: no signs; right heart congestion (RHC: oedema, jugular venous distension); left heart congestion (LHC: lung crackles); or both (R + LHC). Of 1881 patients referred, 707 did not have CHF, 853 had S-HF, and 321 had HeFNEF. The median inter-quartile range (IQR) age was 72 years (64-78), 40% were women, and LVEF was 47% (35-59). Overall, 417 patients had RHC of whom 49% had S-HF and 21% HeFNEF. Eighty-five patients had LHC of whom 43% had S-HF and 20% had HeFNEF. One hundred and seventy-two patients had R + LHC of whom 71% had S-HF and 16% had HeFNEF. During a median (IQR) follow-up of 64(44-76) months, 40% of the entire patient cohort died. The combination of R + LHC signs was an independent marker of an adverse prognosis (χ(2)-log-rank test = 186.1, P< 0.0001). CONCLUSION: Clinical signs of congestion are independent predictors of prognosis in ambulatory patients with suspected CHF.

The national heart failure audit for England and Wales 2008-2009.

OBJECTIVES: To obtain national data on the clinical characteristics, investigation, management and outcome of patients hospitalised with a diagnosis of heart failure. METHOD: A survey was carried out of the first 10 patients hospitalised with a primary diagnosis of heart failure each month in 86 hospitals providing services for acute medical admissions in England and Wales from April 2008 until March 2009. The main outcome measures were rates of investigations, treatments and specialist management, length of hospital stay and mortality. RESULTS: The 86 hospitals enrolled 6170 patients with a median age of 78 years (IQR 70-85 years), including 2639 (43%) women. At admission, only 30% of patients were breathless at rest, while 43% had peripheral oedema. Echocardiograms were recorded in 75% of patients and left ventricular ejection fraction (LVEF) was ≤40% in 78%. Natriuretic peptides were rarely measured. Allowing for missing data, >90% of patients were treated with loop diuretics at discharge, 80% with ACE inhibitors or angiotensin receptor blockers, 50% with ß-blockers and 30% with aldosterone antagonists. Patients with an LVEF <40% were more likely to receive these agents. Median hospital stay was 9 days (IQR 5-17) and in-patient mortality was 12%. Patients admitted to general medicine rather than cardiology wards were more likely to die (HR=2.5, 95% CI 2.0 to 3.3, p<0.001) even after adjusting for differences (HR=1.9, 95% CI 1.5 to 2.5, p<0.001). Projected 1-year mortality below and above age 75 years was 26% and 56%, with higher rates if managed on general medicine rather than cardiology wards (HR=1.4, 95% CI 1.2 to 1.6, p<0.001). CONCLUSION: The prognosis of patients hospitalised with heart failure remains poor and investigation and treatment suboptimal. Specialist services are associated with higher rates of investigation and treatment and improved outcome.

Clinical trials update from the European Society of Cardiology Meeting 2009: AAA, RELY, PROTECT, ACTIVE-I, European CRT survey, German pre-SCD II registry, and MADIT-CRT.

This article provides information and a commentary on trials relevant to the pathophysiology, prevention, and treatment of heart failure presented at the annual meeting of the European Society of Cardiology held in Barcelona in 2009. The AAA study does not support the routine use of aspirin for the prevention of vascular events in patients with asymptomatic atherosclerosis. RELY suggests that dabigatran may be more effective than warfarin for the prevention of stroke in patients with atrial fibrillation. Rolofylline was not superior to placebo in improving outcomes in patients with acute heart failure enrolled in the PROTECT study, but dyspnoea was improved. Data from ACTIVE-I suggest that irbesartan does not provide additional therapeutic benefit in patients with atrial fibrillation who are well controlled on current therapy. The European cardiac resynchronization therapy (CRT) survey provides interesting epidemiological data on current CRT device usage. The German pre-SCD II registry identified a low prevalence of patients with a reduced ejection fraction following myocardial infarction. Implantation of CRT-D rather than an implantable cardioverter defibrillator in patients with mild heart failure and QRS >/=130 ms reduced the risk of hospitalization for heart failure in MADIT-CRT; mortality was similarly low with each device.

Clinical trials update from the American College of Cardiology 2008: CARISMA, TRENDS, meta-analysis of Cox-2 studies, HAT, ON-TARGET, HYVET, ACCOMPLISH, MOMENTUM, PROTECT, HORIZON-HF and REVERSE.

This article provides information and a commentary on trials relevant to the pathophysiology, prevention and treatment of heart failure, presented at the American College of Cardiology. Unpublished reports should be considered as preliminary data, as analyses may change in the final publication. CARISMA investigated the use of implantable loop recorders for detecting life-threatening arrhythmias in patients with LVSD after MI and found that brady- and ventricular tachy-arrhythmias predicted an adverse prognosis. The TRENDS study showed that the burden of atrial fibrillation detected by pacemakers or defibrillators predicted the risk of embolic events but not with sufficient precision to justify changes in anti-thrombotic management. A meta-analysis of six trials reported an increased cardiovascular risk associated with celecoxib, particularly for heart failure, which was related to dose and baseline cardiovascular risk. The HAT study failed to show a benefit of providing post-MI patients with a home defibrillator. MOMENTUM, a study of a device designed to augment aortic blood flow, was stopped early due to increased bleeding risk. Results from PROTECT support the use of rolofylline 30 mg/day in acute heart failure, a definitive study is now underway. Istaroxime, an agent that appears to have both inotropic and lusitropic effects, improved haemodynamics when added to standard therapy in patients stabilised after admission with heart failure in HORIZON-HF. The REVERSE study suggested that CRT improves ventricular function and reduces morbidity even in patients with few or no symptoms of heart failure and may delay or prevent worsening heart failure.