Objective To determine among community patients with heart failure (HF), whether pulmonary artery systolic pressure (PASP) assessed by Doppler echocardiography was associated with death and improved risk prediction over established factors, using the integrated discrimination improvement (IDI) and net reclassification improvement (NRI). Background While several studies have focused on idiopathic pulmonary arterial hypertension, less is known about pulmonary hypertension among patients with HF, particularly on its prognostic value in the community. Methods Olmsted County residents with HF between 2003 and 2010 prospectively underwent assessment of ejection fraction (EF), diastolic function, and PASP by Doppler echocardiography. Results PASP was recorded in 1049 of 1153 patients (mean age 76±13, 51% women). Median PASP was 48 mmHg (25th-75th percentile, 37.0-58.0). There were 489 deaths after a follow-up of 2.7±1.9 years. There was a strong positive graded association between PASP and mortality. Increasing PASP was associated with an increased risk of death (HR 1.45, 95%CI 1.13-1.85 for tertile 2; HR 2.07, 95%CI 1.62-2.64 for tertile 3, versus tertile 1), independently of age, sex, comorbidities, EF and diastolic function. Adding PASP to models including these clinical characteristics resulted in an increase in the c-statistic from 0.704 to 0.742 (p=0.007), an IDI gain of 4.2% (p<0.001), and an NRI of 14.1% (p=0.002), indicating that PASP improved prediction of death over traditional prognostic factors. All results were similar for CV death. Conclusion Among community patients with HF, PASP strongly predicts death and provides incremental and clinically relevant prognostic information independently of known predictors of outcomes.

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Objective To evaluate the risk of cancer in patients with heart failure (HF) compared to community controls and its impact on outcome. Background HF is associated with excess morbidity and mortality. Non-cardiac causes of adverse outcomes in HF are increasingly recognized but not fully characterized. Methods In a case-control study, we compared history of cancer among community subjects newly diagnosed with HF from 1979–2002 to age-, sex-, and date-matched community controls without HF (961 pairs). Individuals without cancer at index (596 pairs) were followed for cancer in a cohort design, and the survival of HF patients who developed cancer was assessed. Results Before index, 22% of HF cases and 23% of controls had a history of cancer (odds ratio 0.94; 95% CI 0.75–1.17). During 9,203 person-years of follow-up [mean (SD), 7.7 (6.4) years], 244 new cancer cases were identified; HF patients had a 68% higher risk of developing cancer [hazard ratio (HR) 1.68; 95% CI 1.13–2.50] adjusted for body mass index, smoking and comorbidities. The HRs were similar for men and women with a trend toward a stronger association among subjects ≤75 years (P=0.22) and during the most recent time period (P=0.075). Among HF cases, incident cancer increased the risk of death (HR 1.56; 95% CI 1.22–1.99) adjusted for age, sex, year and comorbidities. Conclusions HF patients are at increased risk of cancer, which appears to have increased over time. Cancer increases mortality in HF underscoring the importance of non-cardiac morbidity and of cancer surveillance in the management of HF patients.

Objectives The aim of this study was to determine the prevalence of frailty in a community cohort of patients with heart failure (HF) and to determine whether frailty is associated with healthcare utilization. Background Frailty is associated with death in patients with HF, but its prevalence and impact on healthcare utilization in patients with HF are poorly characterized. Methods Residents of Olmsted, Dodge, and Fillmore counties in Minnesota with HF between October 2007 and March 2011 were prospectively recruited to undergo frailty assessment. Frailty was defined as 3 or more of the following: unintentional weight loss, exhaustion, weak grip strength, and slowness and low physical activity measured by the SF-12 physical component score. Intermediate frailty was defined as 1 or 2 components. Negative binomial regression was used to examine the association between outpatient visits and frailty; Andersen-Gill models were used to determine if frailty predicted emergency department (ED) visits or hospitalizations. Results Among 448 patients (mean age 73 ± 13 years, 57% men), 74% had some degree of frailty (19% frail, 55% intermediate frail). Over a mean follow-up period of 2.0 ± 1.1 years, 20,164 outpatient visits, 1,440 ED visits, and 1,057 hospitalizations occurred. After adjustment for potential confounders, frailty was associated with a 92% increased risk for ED visits and a 65% increased risk for hospitalizations. The population-attributable risk associated with any degree of frailty was 35% for ED visits and 19% for hospitalizations. Conclusions Frailty is common among community patients with HF and is a strong and independent predictor of ED visits and hospitalizations. Because frailty is potentially modifiable, it should be incorporated in the clinical evaluation of patients with HF.

Background Frailty is recognized as an important prognostic indicator in heart failure. There has been interest in understanding whether pre-operative frailty is associated with worse outcomes after destination left ventricular assist device (LVAD). Methods Patients undergoing destination LVAD at the Mayo Clinic in Rochester, Minnesota from February 2007 to June 2012 were included. Frailty was assessed using the Deficit Index (31 impairments, disabilities, and comorbidities) and defined as the proportion of deficits present. We divided patients based on tertiles of the Deficit Index (>0.32= frail, 0.23–0.32= intermediate frail, <0.23= not frail). Cox proportional hazard regression models were used to examine the association between frailty and death. Patients were censored at death or last follow-up through October 2013. Results Among 99 patients (mean age 65 years, 18% female, 55% ischemic HF), the Deficit Index ranged from 0.10 to 0.65 (mean 0.29). After a mean follow-up of 1.9 ±1.6 years, 79% had been rehospitalized (range 0–17 hospitalizations, median 1 per person) and 45% had died. Compared to those who were not frail, patients who were intermediate frail (adjusted HR 1.70, 95% CI 0.71–4.31) and frail (HR 3.08, 95% CI 1.40–7.48) were at increased risk for death (p for trend=0.004). The mean (SD) days alive out of hospital the first year after LVAD was 293 (107), 266 (134), and 250 (132) in those who were not frail, intermediate frail, and frail, respectively. Conclusions Frailty pre-destination LVAD is associated with increased risk of death, and may represent an important patient selection consideration.