Clinical profile and in-hospital outcomes in patients admitted for heart failure with preserved or reduced ejection fraction. EPI-CARDIO prospective registry Tajer, C; Mariani, J; de Abreu, M; Charask, A; Gonzalez, M; Gagliardi, J; Doval, H. GEDIC-GESICA, Argentina
BACKGROUND Heart failure is a growing cause of hospitalizations around the world, and it has been shown that a relevant proportion is not related to left ventricular systolic disfunction. Evolution and treatment strategies of HF without LVSD is heterogeneous. We have no extensive data about this particular presentation of acute heart failure in Latin-America.
Objectives: To assess clinical profile and inhospital evolution in patients admitted for heart failure (HF) with preserved or reduced ejection fraction in a wide network (37 CCU). To evaluate strategies of treatment applied.
Electronic discharge record form (Epicrisis) Included as discharge report of the clinical record form of each institution.
Network operation Coordinating center Processing Scientific Committee Send Individual and global reports EPICARDIO Centers DATA BASE Backup Attending Physician Clinical record Patient
Distribution of EPI-CARDIO 37 (42) Centers in Argentina Oct 2006 - Dec 2009 38.680 hospitalizations Monthly > 1.000
Causes of admission to CCU oct-06 /may-08 Other 21% Angina 15% Non C Diag 4% PM. ICD 4% Syncope 3% CVSurg 6% Arrhythmias 14% Heart Failure 7% M. Infarction 9% NC CH.Pain 6% Hem Lab Proc. 11% n: 19190
Heart failure with or without LVSD Heart Failure: 1263p 1160p with complete data (HF form) LVSD non LVSD Definitions Group A: depressed LVEF: 788 (67.9%) LVEF 40% Moderate or severe depression of LVEF (angiography qualitative estimation) Group B: preserved LVEF: 372 p (32.1%) n:; 372; 32% n:; 788; 68% n: 1160p
Heart failure with or without LVSD N:19190 Heart Failure: 1160p with complete data (HF form) N: 38680 Update 2009 2349p with complete data (HF form) LVSD non LVSD LVSD non LVSD n:; 372; 32% n:; 979; 42% n:; 1370; 58% n:; 788; 68% n: 1160p n: 2349p
Triggers of HF 100% + Infection 75% + + Arrhythmia Progression Salt excess 50% + Discontinuation of treatment Medication change 25% Others Without data 0% DHF SHF p < 0.001
Clinical presentation 100% p < 0.01 Shock HT acute pulmonary edema Progression HF Others % 0% Shock 0.8 4.2 HT acute pulmonary edema DHF SHF 23.9 11.8 Progression HF 66.4 77.7 Others 3 3.3
Heart failure: congestion and/or hypoperfusion DHF SHF 100% 75% 50% 25% LV + RV PC + LCO Low Cardiac output RV failure Pulmonary congestion Without data % % 14.8 19.8 12.6 22.5 6.5 17.6 11.8 5.8 53.8 32.9 0.5 1.4 0% DHF SHF p < 0.001
Clinical characteristics and history Reduced ejection fraction n: 788p Preserved ejection fraction n: 372p p value Age 69.6 ± 14 72.6 ± 13 0.01 Systolic BP 129 ± 31 143 ± 34 0.01 % % Female 37.2 47.3 0.01 Hypertension 64.2 73.7 0.01 Atrial fibrillation 27.4 34.9 0.01 Previous MI 23.6 12,9 0.01 Previous CABG 10.7 6.5 0.02 Chronic HF 50.3 41.9 0.01
Inhospital treatment Reduced LVEF n: 788p % Preserved LVEF n: 372p % p value Diuretics infusion 25 25 NS Ultrafiltration 1.3 2.2 NS Swan Ganz Catheter 5.6 1.3 0.001 Non invasive ventilation 2.5 4.8 0.05 Mechanical ventilation 7.9 5.6 NS Inotropics 27.2 12.4 0.001 Inhospital Stay 3.5(1.5-6.5) 3.5 (1.5-7.5) NS
HF treatment at discharge Reduced LVEF n: 788p % Preserved LVEF n: 372p % p value Calcium Blockers 6.6 21 0.01 Spironolactone 36.2 24.5 0.01 ACE inhibitors 56.7 54 NS ACE inh or ARB 64.3 62.1 NS Digoxin 16.4 14.5 NS Beta Blockers 52.5 54.3 NS Fursemide 61.7 62.9 NS
Antithrombotic and digoxin treatment at discharge Interaction with Atrial Fibrillation Reduced LVEF Preserved LVEF p value n: 788p % n: 372p % Aspirin 57.3 51 0.05 Clopidogrel 8.4 9.9 NS Oral Anticoagulation 19.8 21.5 NS Atrial Fibrillation Oral Anticoagulation 47.2 46.4 NS Digoxin 34.3 34.6 NS Sinus Rhythm 0.01 0.01 0.01 0.01 Oral Anticoagulation 9.4 8.3 Digoxin 9.6 3.7 0.01
Inhospital mortality 8 7 6 0.01 6.6 5.5 % 5 4 3 3.0 DHF SHF Global 2 1 0 Unadjusted Adjusted DHF/SHF OR 0.4 (0.2-0.78)
1160p /19190p Inhospital mortality Update 2349p /38680p % 8 7 6 5 4 3 2 1 0 *** 6.6 3.0 Unadjusted 5.5 DHF SHF Global % 8 7 6 5 4 3 2 1 0 *** 4.0 4.0 7.9 Unadjusted 6.3 DHF SHF Global Unadjusted OR 0.43 (0.2-0.84) Unadjusted OR 0.48 (0.3-0.7) Adjusted DHF/SHF OR 0.4 (0.2-0.78) *** p < 0,001
Conclusions Heart failure without reduced ejection fraction, commonly considered as diastolic heart failure, accounts for almost one third to 40% of HF admissions in a network of CCU in Argentina. Patients with DHF are older, more often females, with more history of hypertension, atrial fibrillation and less history of coronary heart disease. Shock and global heart failure were more common in SHF p and isolated pulmonary congestion, particularly acute pulmonary edema was more common in DHF.
Conclusions Critical care stay length was similar in both groups, as was clinical treatment at discharge. Hospital mortality in the univariate and multivariate analysis was lower in DHF patients. Heart failure without reduced ejection fraction is a significant part of the burden of hospitalizations for HF in Argentina. Epi/Cardio Registry is a valuable tool to explore the trend in hospitalizations and clinical evolution in a network of CCU.
Use of inotropics IV inotropics 21,6% Other comb 12% Dopamine- Dobutamine 27% Dopamine 24% Milrinone 0% Levosimendan 2% Dobutamine 35%