Abstract Background In heart failure (HF), renal dysfunction is associated with an adverse prognosis. Impaired renal perfusion from left ventricular dysfunction is thought to be a principal ...underlying mechanism. Less is known about the influence of venous congestion, including the potential contribution of tricuspid regurgitation (TR). Methods and Results Echocardiograms and a simultaneous (±1 day) blood sample from 196 HF patients were analyzed. Patients with at least moderate TR (n = 78) had larger right-sided cardiac cavities, higher right ventricular systolic pressure, lower estimated glomerular filtration rate (eGFR), higher serum urea nitrogen (SUN), and SUN/creatinine ratio than patients with less than moderate TR (n = 118). In multivariate linear regression analysis, TR severity ( P = .003), older age ( P < .001), and loop diuretic use ( P = .008) were independently associated with lower eGFR, and use of inhibitors of the renin-angiotensin-aldosterone system was associated with higher eGFR ( P = .001). TR severity ( P < .001) and older age ( P < .001) were independently associated with higher SUN. TR severity ( P = .004) and smaller left ventricular end-diastolic diameter ( P = .048) were independent predictors of a higher SUN/creatinine ratio ( P = .004). Conclusions Although a causal relationship cannot be proven, we suggest that significant TR contributes to renal dysfunction in HF patients, probably by elevation of central and renal venous pressure.
Abstract Background Prediction of events in chronic heart failure (CHF) patients is still difficult and available scores are often complex to calculate. Therefore, we developed and validated a ...simple-to-use, multidimensional prognostic index for such patients. Methods A theoretical model was developed based on known prognostic factors of CHF that are easily obtainable: Body mass index (B), Age (A), Resting systolic blood pressure (R), Dyspnea (D), N-termInal pro brain natriuretic peptide (NT-proBNP) (I), Cockroft-Gault equation to estimate glomerular filtration rate (C), resting Heart rate (H), and Exercise performance using the 6-min walk test (E) (the BARDICHE-index). Scores were given for all components and added, the sum ranging from 1 (lowest value) to 25 points (maximal value), with estimated risk being highest in patients with highest scores. Scores were categorized into three groups: a low (≤ 8 points); medium (9–16 points), or high (> 16 points) BARDICHE-score. The model was validated in a data set of 1811 patients from two prospective CHF-cohorts (median follow-up 887 days). The primary outcome was 5-year all-cause survival. Secondary outcomes were 5-year survival without all-cause hospitalization and 5-year survival without CHF-related hospitalization. Results There were significant differences between BARDICHE-risk groups for mortality (hazard ratio = 3.63 per BARDICHE-group, 95%-CI 3.10–4.25), mortality or all-cause hospitalization (HR = 2.00 per BARDICHE-group, 95%-CI 1.83–2.19), and mortality or CHF-related hospitalization (HR = 3.43 per BARDICHE-group, 95%-CI 3.01–3.92; all P < 10–50). Outcome was predicted independently of left ventricular ejection fraction (LVEF) and gender. Conclusions The BARDICHE-index is a simple multidimensional prognostic tool for patients with CHF, independently of LVEF.
Background. Drug trials often exclude subjects with relevant comorbidity or comedication. Nevertheless, after approval, these drugs will be prescribed to a much broader collective. Our goal was to ...quantify the impact of drugs and comorbidity on serum potassium in unselected patients admitted to the hospital. Methods. This was a retrospective pharmacoepidemiologic study in 15 000 consecutive patients admitted to the medical department of the Kantonsspital St. Gallen, a 700-bed tertiary hospital in eastern Switzerland. Patients with ‘haemolytic’ plasma and patients on dialysis or with an estimated glomerular filtration rate (GFR) <10 mL/min/1.73 m2 were excluded. For the remaining 14 146 patients, drug history on admission, age, sex, body weight, physical findings, comorbidity (ICD-10 diagnoses) and laboratory information (potassium and creatinine) were extracted from electronic sources. Results. Estimated GFR was the strongest predictor of serum potassium (P < 0.0001). Angiotensin-converting enzyme inhibitors, cyclosporine, loop diuretics and potassium-sparing diuretics all showed a significant effect modification with decreasing GFR (P < 0.001). Similarly, in patients with liver cirrhosis a significantly stronger effect on potassium was found for angiotensin receptor blockers, betablockers and loop diuretics (P < 0.01). Several significant drug–drug interactions were identified. Diabetes, male sex, older age, lower blood pressure and higher body weight were all independently associated with higher serum potassium levels (P < 0.001). The model explained 14% of the variation of serum potassium. Conclusions. The effects of various drugs on serum potassium are highly influenced by comorbidity and comedication. Although the presented model cannot be used to predict potassium in individual patients, we demonstrate that clinical databases could evolve as a powerful tool for industry-independent analysis of postmarketing drug safety.
Abstract Background The cardiopulmonary exercise testing (CPET) response in heart failure with preserved left ventricular ejection fraction (HFPEF) is incompletely understood. We aimed to describe ...the CPET response in HFPEF and to assess its invasive hemodynamic determinants. Methods and Results Ten patients with HFPEF and 8 asymptomatic controls underwent resting and exercise right heart catheterization and maximal symptom-limited CPET. The slope of the minute ventilation/carbon dioxide production relationship (VE/VCO2 slope; 34.3 ± 5.4 vs. 28.4 ± 3.4; P = .02) was steeper, peak oxygen consumption (peak VO2 ; 15.1 ± 4.9 vs. 26.6 ± 12.5 mL∗kg-1 ∗min-1 ; P = .02) was lower, and heart rate recovery 1 minute after exercise termination (HRR-1; 10 ± 5 vs. 27 ± 10 beats/min; P < .001) was slower in HFPEF compared to controls. A steeper VE/VCO2 slope ( r = 0.67, P = .002), lower peak VO2 ( r = −0.48, P = .04), and slower HRR-1 ( r = −0.58, P = .02) were significantly related to a higher ratio of the change in pulmonary capillary wedge pressure per change in work rate as a measure of the left ventricular pressure volume relationship. Conclusions In HFPEF patients, fundamental alterations in the CPET profile occur and these may, in part, result from the rapid rise in left ventricular filling pressures which accompanies exercise in these patients.
Display omitted
•Supersonic expansion rotational spectra for 26 different isotopic species.•Waveguide Fourier-transform and broadband mm-wave spectroscopy.•Excited vibrational states and ab initio ...anharmonic force field calculations.•Determination of complete semi-experimental equilibrium geometry.•Electric dipole moment from Stark measurements in supersonic expansion.
The pure rotational spectrum of salicyl aldehyde, C7H6O2, a classic molecule with an OH⋯O intramolecular hydrogen bond, was investigated in detail with several different spectrometers. Supersonic expansion measurements at 8–18GHz were used to determine rotational constants for 26 different isotopologues, either in natural abundance or prepared synthetically, and including single substitution of each of the 15 atoms in the molecule. Further measurements of the room temperature rotational spectrum at 8–230GHz allowed assignment of the five lowest excited vibrational states. Their rotational constants were used to calibrate anharmonic force field calculations, which were then used to determine the semi-experimental equilibrium reSE geometry. This is compared with several other structural determinations and with quantum chemistry calculations. In addition, Stark measurements in supersonic expansion were used to determine the electric dipole moment of salicyl aldehyde.
The relationship between chest radiograph (CXR) findings of pulmonary congestion and invasive hemodynamics and clinical outcomes in patients with cardiac diseases is unclear. We assessed the ...correlation between a CXR-based congestion score (RxCS) and the mean pulmonary artery wedge pressure (mPAWP) and the prognostic impact of RxCS and mPAWP in severe aortic stenosis (AS).
In 471 patients with severe AS undergoing right heart catheterization and upright CXR, the RxCS was calculated (6 items, maximum score: 10 points) independently by 2 radiologists (average value taken) blinded to clinical data. Congestion was defined as an RxCS > 1. Four patterns were defined based on the presence or absence of congestion (C+ or C-) and elevated (> 15 mm Hg) or normal mPAWP (P+ or P-).
The median (interquartile range) RxCS was 1 (0-2). Patients with an RxCS > 1 (n = 207) had a higher mean right atrial pressure, mean pulmonary artery pressure, mPAWP, and pulmonary vascular resistance than patients with an RxCS ≤ 1 (n = 264). However, the correlation between the RxCS and the mPAWP was moderate only (
= 0.45). Patients with a C+/P+ pattern had the worst hemodynamics, whereas C-/P- patients had the most favourable constellation. After a median post-valve replacement follow-up of 1361 days, mortality was higher in patients with RxCs > 1 vs ≤ 1 as well as mPAWP > 15 mm Hg vs ≤15 mm Hg. Mortality was highest in C+/P+ patients and lowest in C-/P- patients, whereas it was intermediate in C-/P+ and C+/P- patients.
In AS patients, RxCS and mPAWP have a significant but moderate correlation. Both RxCS and mPAWP provide prognostic information.
Abstract Background Pulmonary hypertension due to left heart disease is very common. Our aim was to investigate the relationship of the severity of left ventricular diastolic dysfunction with ...precapillary and postcapillary pulmonary hypertension (PH) in an elderly heart failure (HF) population. Methods and Results A post hoc analysis of the Trial of Intensified Medical Therapy in Elderly Patients With Congestive Heart Failure data was done. Baseline transthoracic echocardiography was used to categorize diastolic function, estimate pulmonary artery pressure and pulmonary capillary wedge pressure, and calculate the transpulmonary pressure gradient (TPG). Among 392 HF patients, PH was present in 31% of patients with grade 1, in 37% of patients with grade 2, and in 65% of patients with grade 3 diastolic dysfunction; 54% of all HF patients with PH had a TPG >12 mm Hg, suggesting not only a postcapillary but also an additional precapillary component of PH. Survival was not related to the severity of diastolic dysfunction, but was worse in patients with PH (hazard ratio 1.63, 95% confidence interval 1.07–2.51; P = .024). Conclusions Our data indicate that HF patients with even mild diastolic dysfunction often have PH. Echocardiographic assessment suggest that the presence of PH might not simply be due to increased PCWP, but in part due to a precapillary component.
Abstract Background The accuracy of Doppler echocardiography to estimate key hemodynamic parameters in subjects with normal left ventricular ejection fraction (LVEF) has not been fully investigated. ...Methods and Results Thirty-six subjects with LVEF >50% (median age 62 years), with a broad clinical profile, underwent Doppler echocardiography immediately followed by right heart catheterization. Correlation coefficients between invasive and noninvasive right atrial pressure (RAP), systolic (sPAP) and mean (mPAP) pulmonary artery pressure, cardiac output (CO), and pulmonary vascular resistance (PVR) were 0.39, 0.70, 0.72, 0.57, and 0.60 ( P < .001 for all). There was no significant correlation between invasive and noninvasive (based on the peak early transmitral to peak early septal mitral annular velocity ratio) pulmonary capillary wedge pressure (PCWP; r = 0.23; P = .18). Bland-Altman plots revealed variable bias but with consistently large limits of agreement for all noninvasive parameters, particularly PCWP. Areas under the receiver operating characteristic curve for noninvasive sPAP, CO, PVR, and PCWP to predict an invasively assessed mPAP ≥25 mm Hg, cardiac index <2.5 L min−1 m−2 , PVR >3 Wood units, and PCWP ≤15 mm Hg, respectively, were 0.92, 0.83, 0.70, and 0.58. Conclusions Single Doppler echocardiography parameters are not accurate enough to reliably estimate key hemodynamic parameters, particularly PCWP, in subjects with normal LVEF.
Abstract Background There is little information regarding the prognostic role of resting heart rate (HR) in older compared with younger patients with chronic heart failure (HF). Methods and Results ...In patients enrolled in the Trial of Intensified Medical Therapy in Elderly Patients With Congestive Heart Failure (TIME-CHF) with sinus rhythm, effects of baseline HR (≥70 vs <70 beats/min bpm) on 18-month outcomes were compared between older (≥75 years; n = 186) and younger (<75 years; n = 141) patients. Older patients with lower (61 ± 6 bpm) and higher (83 ± 9 bpm) HR had similar left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) functional class, N-terminal pro–B-type natriuretic peptide (NT-proBNP), and survival and HF hospitalization–free survival. In contrast, younger patients with higher HR (81 ± 7 bpm) had higher NT-proBNP and NYHA functional class, lower LVEF, and a higher risk of death (hazard ratio 4.01 95% confidence interval (CI) 1.17 −13.69; P = .02) and death or HF hospitalization (hazard ratio 2.35 95% CI 1.01–5.50; P = .04) than those with lower HR (62 ± 5 bpm), with the association between higher HR and survival remaining significant after adjustment for NYHA functional class, LVEF, and NT-proBNP. Conclusions In contrast to HF patients aged <75 years, we found no association between HR and worse outcomes in HF patients aged ≥75 years.
PDF
