Current Status And Clinical Diagnosis Of Acute Heart Failure In Beijing Area

Acute heart failure (AHF) has brought great burden to healthcare systems all over the world with its complicated pathophysiology and dismal prognosis. In-hospital mortalities vary from 3.8% to 9.4%, and the rates of mortality and rehospitalization were 14% and 25%, respectively. Several large-scale observational studies have been conducted for the data on demographics, medical history, hemodynamics, current clinical practice, short-term and long-term outcomes of patients hospitalized for AHF. However, data on AHF patients who visited emergency department (ED) are scarce.ED plays a pivotal role in the management of AHF. Prior data suggest more than 80% of ED patients with AHF are admitted to the hospital, and a portion of patients died in ED. Furthermore, the differences in clinical characteristics, current clinical practice, and clinical outcomes between patients directly discharged from ED and patients admitted to the hospital are significant. Thus, data on AHF patients collected in the ED are more similar to the "real world" profile of acute phase in heart failure decompensation. And early diagnosis and initiation of therapy could improve the clinical outcomes of AHF patients. Therefore, it is essential to understand the clinical characteristics, current clinical practice, and outcomes of AHF patients receiving intravenous decongestive therapy including diuretics, vasodilators and inotropes/ vasopressors, and neurohormonal antagonists including angiotensin-converting enzyme inhibitors/ angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists. The profile of AHF patients with different ED dispositions including admitted to the hospital, discharge, left against medical advice and died in ED is also very important. Furthermore, we will analysis the association between the ED treatments and clinical outcomes in AHF patients.Part Ⅰ. Characteristics, current management and clinical outcomes of acute heart failure in the emergency department:a multicenter cohort registry with 1-year follow-upObjective:Acute heart failure (AHF) is a major problem for public healthcare in our country. This report aims to describe clinical characteristics, current treatments and outcomes of AHF patients in the emergency department.Methods:Beijing AHF Registry is a prospective, multicenter, observational study conducted in 14 EDs in Beijing. Data on demographics, characteristics, and outcomes in 30 days and 1 year of AHF patients were collected.Results:The study consecutively enrolled 3335 AHF patients who visited 14 EDs in Beijing from 1 January 2011 to 23 September 2012. Follow-up data on daily treatment and clinical outcomes were collected until 31 November 2013, with a response rate of 92.8%. Mean age of the enrolled patients was 67.4±15.8 years,71.9% of the patients were older then 60 years; 46.8% were women. In the total patients, coronary artery disease (43.3%), hypertensive heart disease (17.3%), cardiomyopathy (16.1%) consisted the primary etiology. Arrhythmia (44.4%), hypertension (17.3%), diabetes mellitus (30.1%) were the commonest comorbidities. Myocardial ischemia (30.2%) and upper respiratory infection (26.1%) were the leading precipitants. In the overall cohort, New York Heart Association functional class III or IV was presented by 87.7% of the patients, and the mean left ventricular ejection fraction was 44.7±14.9%. Most of the patients in the ED received intravenous treatments, including diuretics (79.3%) and vasodilators (74.9%). Fewer patients received neurohormonal antagonists, and 25.9%,31.1%and 33.7% of patients received angiotensin converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists, respectively. Percentages of ED dispositions including admitted to the hospital, discharge, left against medical advice and died were 55.5%,33.6%,7.1%, and 3.8%, respectively. All-cause mortalities at 30 days and 1 year were 15.3% and 32.3%.Conclusion:Patients with AHF were most elders in Beijing, ischemia heart disease was the primary etiology and arrhythmia was the commonest comorbidity. Traditional intravenous decongestive therapies were frequently use, whereas neurohormonal antagonists were less used in the ED. Clinical outcomes of patients with AHF in the ED were poor.Part Ⅱ. Predictors of 30-day and 1-year clinical outcomes of acute heart failure patients in BeijingObjectives:The all cause mortality rates of acute heart failure (AHF) patients at 30-day and 1-year were 15.3% and 32.2%, respectively. The cardiovascular death or readmission for heart failure rates at 30-day and 1-year were 19.1% and 46%, respectively. We aim to analysis the predictors of these primary outcomes of patients with AHF in emergency department (ED).Methods:The primary clinical outcomes in the Beijing AHF Registry study were all cause mortality at 30-day and 1-year, and the cardiovascular death or readmission for heart failure at 30-day and 1-year. Univariate and multivariate Cox regression models and stepwise selection techniques were applied to analyze predictors of the primary clinical outcomes in AHF patients.Results:Older age, New York Heart Association functional class Ⅲ or Ⅳ, precipitant of myocardial ischemia, orthopnea at admission, higher blood urea nitrogen, and brain natriuretic peptide (BNP)≥ 500 pg/ml or N terminal pro BNP≥1000 pg/ml were independently associated with increased risks of four clinical outcomes. Whereas higher diastolic blood pressure and sodium concentration, ED prescriptions of angiotensin converting enzyme inhibitors/angiotensin receptor blockers and calcium antagonists were independently associated with decreased risks of four primary clinical outcomes. Additionally, etiology of prior myocardial infarction, decreased heart rate, ED prescription of intravenous vasodilators were protective factors of 30-day clinical outcomes. And higher body mass index, oral diuretics, beta-blockers and nitrates in ED or during the follow-up period were protective factors of 1-year clinical outcomes.Conclusion:These predictors of primary clinical outcomes in AHF patients were important for our clinical practice and researches.Part Ⅲ. Comparison of clinical characteristics, current practice and outcomes between new-onset acute heart failure and worsening chronic heart failureObjective:Comparing the clinical characteristics, current practice and outcomes between new-onset acute heart failure (AHF) and worsening chronic heart failure (HF), as well as the association between time-course and clinical outcomes in AHF patients.Methods:3335 patients from the Beijing AHF Registry study were included in this analysis. HF was classified as new-onset HF in the absence of a history of HF, or as worsening chronic HF if a previous diagnosis or hospitalization for HF was either documented or reported by the patient. The data were reported as mean ± standard deviation for the continuous variables or as numbers (percentages) for the categorical variables. Overall tests of any differences in patient characteristics and management were compared using the Pearson chi-square (x2) test for categorical variables and the Mann-Whitney U-test for continuous variables to estimate the differences between subgroups. We estimated outcomes using the Kaplan-Meier method and tested for differences between the subgroups using the log-rank test. Univariate and multivariate Cox regression models were used to reveal the relationships between new-onset HF and clinical endpoints.Results:Patients with new-onset HF accounted for 50% of the overall cohort. Compared to the patients with worsening chronic HF, patients with new-onset HF were older, more acute myocardial infarction and hypertensive heart disease etiology and less other cardiovascular disease etiology, with higher systolic and diastolic blood pressure and lower blood urea nitrogen concentration. Patients with new-onset HF received more treatments in the emergency department and during the follow-up period then patients with worsening chronic HF. The event rates of 1-year all cause mortality (29.6% vs.35%, P=0.0028) and 1-year cardiovascular death or readmission for heart failure (42.8% vs.49.3%, P=0.0005) were lower in the subgroup of new-onset HF. However, new-onset HF didn’t independently predict better survival [adjusted for clinical characteristics and treatments, hazard ratio (HR) =0.911,95% confidential interval (CI):0.804-1.033, P= 0.1465] or decreased events (adjusted for predictors of outcomes:HR= 0.9,95% CI:0.809-1.002, P= 0.054) in AHF patients.Conclusion:The clinical profiles between subgroups of new-onset HF and worsening chronic HF were different, and patients with new-onset HF showed decreased mortality and event rates in 1 year. But the time-course of HF was not independently associated with clinical outcomes.Part Ⅳ. Differences in clinical characteristics, current practice and outcomes between patients with a preserved and a reduced left ventricular functionObjective:Comparing the clinical characteristics, current practice and outcomes between patients with heart failure and preserved ejection fraction (HFpEF) and patients with heart failure and reduced ejection fraction (HFrEF), as well as the association of preserved systolic function with clinical outcomes in acute heart failure (AHF) patients.Methods:2083 patients from the Beijing AHF Registry study with available echocardiographic left ventricular ejection fraction (LVEF) value were included in this analysis. HFpEF was defined as LVEF≥ 45% and HFrEF was defined as LVEF < 45%. The data were reported as mean ± standard deviation for the continuous variables or as numbers (percentages) for the categorical variables. Overall tests of any differences in patient characteristics and management were compared using the Pearson chi-square (x2) test for categorical variables and the Mann-Whitney U-test for continuous variables to estimate the differences between subgroups. We estimated outcomes using the Kaplan-Meier method and tested for differences between the subgroups using the log-rank test. Univariate and multivariate Cox regression models were used to reveal the relationships between HFpEF and primary clinical endpoints.Results:In the 2083 patients,1035 (49.7%) patients was classified as HFrEF, and 1048 (50.3%) was classified as HFpEF. Patients with HFpEF were older, more women, with less prior myocardial infarction and cardiomyopathy etiology and more hypertensive heart disease, vavular heart disease, chronic obstructive pulmonary disease etiology (COPD), with more comorbidities including stroke, COPD, chronic renal dysfunction and atrial fibrillation. Patients with HFpEF received significantly less ED therapies including intravenous vasodilators, intravenous inotropes/ vasopressors, oral diuretics, beta-blockers, angiotensin-converting enzyme inhibitors/ angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists, nitrates, digoxin, aspirin and statin comparing with patients with HFrEF. The primary clinical endpoints of two subgroups were similar. While the rate of all cause mortality and readmission in HFpEF subgroup was higher than HFrEF (30 days: 29.2% vs.23.7%, P= 0.0037; 1 year:62% vs.57.9%, P= 0.0291).Conclusion:Patients with HFpEF were older, associated with various etiologies, comorbidities, insufficient treatments, and higher event rates.Part Ⅴ. Intravenous decongestive therapy in emergency department and its association with clinical outcomes in acute heart failure patientsObjective:The intravenous decongestive therapies including diuretics, vasodilators and inotropes/vasopressors were frequently used in acute heart failure (AHF) patients from Beijing AHF Registry study, but with limited evidence in prognostic benefit of AHF patients. We detected the associations of these therapies with outcomes in AHF patients.Methods:3335 patients from the Beijing AHF Registry study were included in this analysis. The data were reported as mean ± standard deviation for the continuous variables or as numbers (percentages) for the categorical variables. Overall tests of any differences in patient characteristics and management were compared using the Pearson chi-square (x2) test for categorical variables and the Mann-Whitney U-test for continuous variables to estimate the differences between subgroups. We estimated outcomes using the Kaplan-Meier method and tested for differences between the subgroups using the log-rank test. Univariate and multivariate Cox regression models were used to reveal the relationships between intravenous decongestive therapies and clinical endpoints.Results:The commonest intravenous decongestive therapy prescribed in the ED was combination of diuretics and vasodilators (40.7%), and the second commonest was the combination of diuretics, vasodilators and inotropes/ vasopressors (23.7%). The baseline characteristics varied in different therapy cohorts. Intravenous diuretics independently increased the risk of 1-year all cause mortality or readmission [hazard ratio (HR):1.212; 95% confidential interval (CI):1.048-1.402; P=0.0094], but was not associated with all cause mortality rates. Intravenous vasodilators was independently associated with decreased risks of 30-day all cause mortality (HR:0.65; 95% CI:0.533-0.792; P<.0001),1-year all cause mortality (HR:0.695; 95% CI: 0.581-0.8312; P<.0001), and 30-day cardiovascular death or readmission for heart failure (HR:0.848; 95% CI:0.736-0.979; P=0.0242). While intravenous inotropes/ vasopressors showed no effects on the clinical outcomes in AHF patients.Conclusion:ED prescription of intravenous vasodilators is associated with better clinical outcomes in AHF patients.Part Ⅵ. Neurohormonal antagonist therapy in emergency department and its association with clinical outcomes in acute heart failure patientsObjective:The neurohormonal antagonist therapy including angiotensin-converting enzyme inhibitors (ACEI)/ angiotensin receptor blockers (ARB), beta-blockers and mineralocorticoid receptor antagonists (MRA) was evidenced to improved the outcomes of patients with heart failure, but infrequently used in acute heart failure patients from the Beijing AHF Registry study.Methods:3335 patients from the Beijing AHF Registry study were included in this analysis. The data were reported as mean ± standard deviation for the continuous variables or as numbers (percentages) for the categorical variables. Overall tests of any differences in patient characteristics and management were compared using the Pearson chi-square(x2) test for categorical variables and the Mann-Whitney U-test for continuous variables to estimate the differences between subgroups. We estimated outcomes using the Kaplan-Meier method and tested for differences between the subgroups using the log-rank test. Univariate and multivariate Cox regression models were used to reveal the relationships between neurohormonal antagonists therapy and clinical endpoints.Results:Nearly half (49.4%) of the overall patients did not receive any of the neurohormonal antagonists. The mostly used therapy was combination of ACEI/ARB, beta-blocker and MRA (10.8%), the second commonly used therapy was MRA alone (9.6%). The baseline characteristics varied in different therapy cohorts. ED prescription of ACEI/ARB independently associated with decreased risk of 30-day all cause mortality [hazard ratio (HR):0.59; 95% confidential interval (CI):0.427-0.815; P=0.0014] and 30-day cardiovascular death or readmission for heart failure (HR: 0.643; 95% CI:0.51-0.812; P=0.0002). ED prescription of beta-blocker independently decreased 30-day all cause mortality (HR:0.657; 95% CI:0.498-0.865; P=0.0028). ED prescription of MRA was independently in relationship with reduced 30-day all cause mortality (HR:0.778; 95% CI:0.605-0.999; P=0.0493) risk.Conclusion:AHF patients could benefit from ED prescription of neurohormonal antagonists.Part Ⅶ. Characteristics, clinical practice and outcomes in acuteheart failure patients with different emergency department dispositionsObjective:Of the entire patients in the Beijing AHF Registry study,55.5% were admitted to the hospital,33.6% were directly discharge home,7.7% left against medical advice, and 3.8% died in emergency department (ED). This report was to describe the characteristics, clinical practice and outcomes in acute heart failure (AHF) patients with different ED dispositions.Methods:3335 patients from the Beijing AHF Registry study were included in this analysis. The data were reported as mean ±standard deviation for the continuous variables or as numbers (percentages) for the categorical variables. Overall tests of any differences in patient characteristics and management were compared using the Pearson chi-square (x2) test for categorical variables and the Mann-Whitney U-test for continuous variables to estimate the differences between subgroups. We estimated outcomes using the Kaplan-Meier method and tested for differences between the subgroups using the log-rank test.Results:The baseline characteristics varied in different ED disposition cohorts. Patients directly discharged home received the most sufficient treatment in the ED, and had best survival in 1 year. Comparing with the patients directly discharged home, patients admitted to the hospital received less treatment in the ED and had higher mortality rate in 1 year (30.7% vs.24.8%, P<.0001). Patients left against medical advice received even less treatments in the ED, and had the highest mortality rate in 1 year (43.3%). In addition, patients died in the ED presented with various comorbidities, the most severe symptoms and signs, and unstable hemodynamic statuses. However, these patients received insufficient intravenous decongestive therapies.Conclusion:The all cause mortality rate was high in the ED, patients with different ED disposition significantly varied in clinical characteristics, management and outcomes. We should explore and estimate the risk stratification of AHF in the ED to improve the outcomes in these patients.