Ischemic Electrocardiographic Abnormalities and Prognosis in Decompensated Heart Failure

Abstract

Background— Identification of coronary ischemia may enable targeted diagnostic and therapeutic strategies for acute heart failure. We determined the risk of 30-day mortality associated with ischemic ECG abnormalities in patients with acute heart failure. Methods and Results— Among 8772 patients (53.4% women, median 78 years [Q1, Q3: 68,84]) presenting with acute heart failure to 86 hospital emergency departments in Ontario, Canada, Q-waves, T-wave inversion, or ST-depression were present in 51.8% of subjects. However, presence of ST-depression was the only finding associated with 30-day mortality with adjusted odds ratio 1.24 (95% confidence interval [CI], 1.02–1.50). Using continuous net reclassification improvement, addition of ST-depression to the Emergency Heart failure Mortality Risk Grade model reclassified 16.9% of patients overall, and 29.3% of those with a history of ischemic heart disease (both P <0.001). By adding ST-depression to the model, the Emergency Heart failure Mortality Risk Grade was extended to predict 30-day death with high discrimination ( c -statistic 0.801), with 0.57% mortality rate in the lowest risk decile. Adjusted odds ratios for 30-day mortality were 2.81 (95% CI, 1.48–5.31; P =0.002) in quintile 2, 7.41 (95% CI, 4.13–13.30; P <0.001) in quintile 3, and 14.47 (95% CI, 8.20–25.54; P <0.001) in quintile 4 compared with the lowest risk quintile. When the highest risk quintile was subdivided into 2 equally sized risk strata (deciles 9 and 10), the adjusted odds ratios for 30-day mortality were 27.20 (95% CI, 15.33–48.27; P <0.001) in decile 9 and 58.96 (95% CI, 33.54–103.65; P <0.001) in highest risk decile 10. Conclusions— Presence of ST-depression on the ECG reclassified risk of 30-day mortality in patients with acute heart failure, identifying both high- and low-risk subsets.

Prognostic impact of comorbidities in hospitalized patients with acute exacerbation of chronic heart failure

“…Moreover, as reported by Beohar et al [30] exhaustion of the mechanisms of coronary autoregulation may contribute to compromise coronary perfusion in acute HF and CHD, making the myocardium particularly vulnerable to decreased perfusion pressure and/or increased demand. In a study of 8772 patients with acute HF, ST segment depression at presentation was associated with increased 30-day mortality primarily among patients with ischemic HF, [31]. Notably, the frequency of elevated troponin values in patients with ST-segment depression was N2-fold higher than in those without ST-segment depression.…”

Insights into the importance of the electrocardiogram in patients with acute heart failure

“…The prevalence of atrial fibrillation in the present study was 36%, which is comparable to other studies that report a prevalence ranging between 22% and 37%. [11][12][13][14]30 . The present study suggests that while atrial fibrillation is associated with rehospitalization, it is not an independent predictor of mortality.…”

“…From June 2009 to November 2012, 937 patients with suspected decompensated AHF and de novo AHF were prospectively enrolled at four Canadian hospital EDs into the Acute Heart Failure—Emergency Management (AHF‐EM) cohort. Details of this protocol have been published previously . Briefly, patients with a diagnosis of AHF were approached and provided written informed consent.…”

“…Up to 5‐year survival data were available; median duration of follow‐up was 25.7 months. Clinical outcomes were captured in administrative data and supplemented with direct contact with the patient, as described previously . Ejection fraction was extrapolated from the last available echocardiogram.…”

Patient engagement in a trial testing a new strategy of care for acute heart failure

“…In the intervention arm, patients are stratified using the Emergency Heart Failure Mortality Risk Grade (EHMRG) score for their simultaneous risk of 7-and 30-day mortality in the emergency department. 3,4 Early discharge home or the standard care pathway of hospital admission are recommended based on the EHMRG score. Patients who are discharged early are eligible for follow-up in the Rapid Ambulatory Program for Investigation and Diagnosis of Heart Failure (RAPID-HF) transitional care clinic.…”