Accumulation of risk markers predicts the incidence of sudden death in patients with chronic heart failure.

BACKGROUND: Sudden death is common in chronic heart failure (CHF). Risk stratification is the first step for primary prevention. AIM: To evaluate the use of risk markers for estimating sudden death risk. METHODS AND RESULTS: We prospectively examined 680 stable patients with CHF. Risk markers were evaluated using the Cox's proportional hazard model in a stepwise manner. Ejection fraction <30%, left ventricular end-diastolic diameter >60 mm, brain natriuretic peptide >200 pg/ml, non-sustained ventricular tachycardia, and diabetes were significantly associated with increased risk of sudden death. When the number of risk markers were included as co-variables, only "number of risk markers >or=3'' entered the model (hazard ratio 8.95, 95% confidence interval 4.57-17.52), while the effects of individual markers did not enter the model. The annual mortality from sudden death was 11% in patients with 3 or more risk markers and 1.4% in patients with 2 or less. CONCLUSIONS: Rather than particular risk markers, the number of accumulated risk markers was a more powerful predictor for sudden death in patients with CHF. The number of risk markers could be useful for risk stratification of sudden death.

Prognostic value of plasma brain natriuretic peptide combined with left ventricular dimensions in predicting sudden death of patients with chronic heart failure.

BACKGROUND: We evaluated a combined assessment of brain natriuretic peptide (BNP) with left ventricular dimensions as a prognostic marker for sudden death in patients with chronic heart failure (CHF). Ventricular dimensions and BNP are separately recognized as prognostic markers for sudden death in patients with CHF. METHODS AND RESULTS: CHF patients at Stage C and B were registered for a prospective study. From the database, we analyzed 417 patients with coronary arterial disease (CAD) or primary/secondary dilated cardiomyopathy (DCM). Main effects of BNP, left ventricular ejection fraction (EF), LV diastolic dimension (LVDD), and interaction of BNP with the EF and LVDD were tested with Cox's proportional hazard model. BNP in sudden death patients was significantly higher than that in event-free patients. Although multivariate analysis revealed that BNP by itself was not an independent risk factor for sudden death after adjustments, it was revealed that BNP entered the model via interaction with EF as a risk factor associating with sudden death. On the other hand, BNP was an independent risk factor associating with heart failure events (death and hospitalization), and BNP did not enter the model via an interaction with EF. CONCLUSION: BNP by itself was an independent risk factor for the heart failure events, but not for sudden death in CHF patients of the present study. However, BNP should be important in predicting sudden death when measured with EF.

Poor prognosis of Japanese patients with chronic heart failure following myocardial infarction--comparison with nonischemic cardiomyopathy.

BACKGROUND: Myocardial infarction (MI) is one of the major etiologies of chronic heart failure (CHF) in Japan. METHODS AND RESULTS: The prognoses of CHF patients after MI (n=283) were investigated by comparing them with those of CHF patients with nonischemic cardiomyopathy (NICM, n=310) from the CHF registry (CHART; n=1,154). The Kaplan-Meier (KM) analyses revealed that the 3-year all-cause mortality was significantly higher in the MI cohort compared with the NICM cohort (29.0% vs 12.4%, p<0.0005). Age/gender/treatment-adjusted KM analysis revealed significant differences only in the cohorts with preserved left ventricular ejection fraction (LVEF), defined as LVEF >45%, or in less symptomatic patients (New York Heart Association I or II). Multivariate Cox regression analysis showed that beta-blocker (BB) was associated with a significant reduction in mortality from cardiac causes, and either angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEI/ARB) was significantly related to the improvement of survival in the MI cohort (adjusted hazard ratio: 0.222 and 0.497, p<0.05), even though these medicines were used significantly less often in the MI cohort. CONCLUSIONS: Underlying MI has a significant impact on the survival of Japanese CHF patients, especially those with preserved LVEF or with fewer symptoms. The appropriate expansion of ACEI/ARB or BB therapy might be necessary to improve their survival.

Analysis of chronic heart failure registry in the Tohoku district: third year follow-up.

BACKGROUND: Because the real prognosis of Japanese patients with chronic heart failure (CHF) is still unknown, the aim of the present study was to clarify the prognosis and predictors for mortality of CHF patients using the Chronic Heart failure Analysis and Registry in Tohoku district (CHART). METHODS AND RESULTS: As of February 2003, 1,154 stable CHF patients with optimum standard therapy have been enrolled in the registry since February 2000 and of these, 175 died of some cause during the follow-up period (mean follow-up period, 1.9+/-0.9 years), giving 1- and 3-year all-cause mortality rates of 7.3% and 20.9%, respectively. Multivariate analysis showed that age at entry, diabetes, ventricular tachycardia, plasma concentration of brain natriuretic peptide (BNP), New York Heart Association (NYHA) functional class and rural residence were significantly associated with all-cause mortality (hazard ratio: 1.028, 1.940, 1.650, 1.001, 1.713, and 2.226). The 1-year all-cause mortality rates of CHF patients with a left ventricular ejection fraction <25%, left ventricular end-diastolic diameter > or =60 mm, BNP > or =500 pg/ml, NYHA > or = III, or with underlying coronary artery disease were 15.0%, 11.4%, 16.8%, 16.3%, and 10.8%, respectively. CONCLUSIONS: The prognosis of Japanese CHF patients with these predictors remains poor. A stratified approach is necessary to improve their survival and quality of life.

Characteristics and 1-year prognosis of medically treated patients with chronic heart failure in Japan.

The study was designed to characterize patients with chronic heart failure (CHF) in Japan in terms of the etiologies and prognosis. CHF was defined by ejection fraction (EF >or=50%), left ventricular diastolic dimension (LVDD >or=55 mm) or a past history of congestive heart failure. Among the 721 recruited patients, the most frequent etiology for CHF was dilated cardiomyopathy (DCM) in patients aged less than 59 years, and valvular heart disease (VHD) in those aged 70 years or more. The 1-year crude mortality was 8% overall and 12% in patients with myocardial infarction (MI). Sudden death accounted for 40% of the total deaths among all patients, and 60% in patients with MI. Multivariate logistic regression analysis showed that brain natriuretic peptide (BNP) was a consistent prognostic marker in CHF patients with a variety of etiologies. Total death and hospitalization because of heart failure were significantly less frequent in patients with BNP less than 100 pg/ml. In conclusion, the etiologies of Japanese CHF appear to be more diverse than those of other Western countries, but BNP is an excellent prognostic marker despite the etiological diversity. Sudden, unexpected death in CHF patients is also a serious problem in Japan. A nation-wide epidemiologic study should be done to characterize Japanese CHF.

Comparison of the efficacy of reperfusion therapies for early mortality from acute myocardial infarction in Japan: registry of Miyagi Study Group for AMI (MsAMI).

The current reperfusion strategy in Japan for acute myocardial infarction (AMI) is that the majority of early arrival patients are treated with primary percutaneous coronary intervention (PCI). However, the efficacy of primary PCI, intravenous thrombolysis (IV-T), intracoronary thrombolysis (IC-T) and rescue PCI has not been compared in the clinical situation. In the present study, 3,258 cases of AMI in 1992-2000 from the data base of the Miyagi Study Group for AMI were analyzed. These patients were hospitalized within 6 h of the onset of symptoms. IV-T and IC-T were initially performed in 120 and 441 patients, respectively, and 41 and 199 rescue PCI procedures, respectively, were needed. Primary PCI was performed in 1,822 cases, and no reperfusion therapy was done in 875 patients. The crude 30-day in-hospital mortality was 12.7% for IV-T, 3.7% for IC-T, 4.8% for primary PCI, 7.9% for rescue PCI, and 14.1% in patients who did not undergo reperfusion therapy. The covariate-adjusted odds ratio (95% confidence interval) was 0.38 (0.28-0.52) for primary PCI, 0.30 (0.15-0.60) for IC-T, 1.04 (0.51-2.10) for IV-T and 0.77 (0.46-1.30) for rescue PCI. The present data verify that primary PCI is superior to other reperfusion strategies in the real clinical situation and justifies the current unique strategy of reperfusion therapy for AMI used in Japan.

Evaluation of heart-rate turbulence as a new prognostic marker in patients with chronic heart failure.

The significance of heart-rate turbulence (HRT) in patients with chronic heart failure (CHF) was evaluated to examine whether it is sensitive to the risk of ventricular tachycardia (VT). HRT is reported to predict the prognosis after myocardial infarction (MI), but its prognostic value in patients with CHF remains unknown. HRT was measured in 50 CHF patients (left ventricular ejection fraction <50% and/or left ventricular end-diastolic diameter >55 mm, 34 cardiomyopathy, 16 post-MI) and 21 patients without obvious heart diseases (control). HRT slope and HRT onset were measured by the original definitions using digitized Holter ECG recordings. Cardiac pump function was assessed by echocardiography. The value of the HRT slope was significantly lower in CHF than in control (3.7 +/- 1.7 vs 16.4 +/- 5.3, mean +/- SD, p < 0.01). The value of the HRT onset in patients with CHF was significantly higher than that in control patients (-1.1 +/- 1.9 vs -3.6 +/- 1.7, mean +/- SD, p < 0.05). The HRT slope and onset in CHF patients with VT were nearly identical to those without VT. The HRT slope appears to be a powerful prognostic marker that shows significant differences between CHF subgroups when divided by clinical events; that is, CHF death and CHF hospitalization. However, it has limited value for predicting fatal ventricular arrhythmias.