Monday, 1 September 2008 - European Heart Journal

270 Prognostic predictors in acute heart failure / Restenosis: is there an alternative to drug-eluting stents?
the degree of oedema showed no correlation to the duration of dyspnea prior to
presentation (r=-0.168, p=0.393).
Conclusion: Lower extremity oedema in ADHF is not primarily caused by an
elevation of the hydrostatic pressure as depicted by the CVP but might mirror
disease severity depicted by BNP levels. Interestingly, the extent of lower oedema
can not be used as a bedside measurement of disease severity.
1782 Prognostic value and changes in renal function in
patients admitted with acute heart failure - results from
the EVEREST program
J. Blair 1 , J.C. Burnett2 ,M.A.Konstam3 , L. Grinfield4 , A.P. Maggioni5 ,
K. Swedberg6 ,J.E.Udelson3 , F. Znnad7 ,T.Cook8 , M. Gheorghiade1 on behalf of the EVEREST investigators. 1Northwestern University, Internal
Medicine, Division of Cardiology, Chicago, United States of America; 2Mayo Clinic, Rochester, United States of America; 3Tufts New England Medical Center,
Boston, United States of America; 4Hospital Italiano, Buenos Aires, Argentina;
5 6 Associazione Nazionale Medici Cardioligi, Florence, Italy; Sahlgrenska
University Hospital/Oestra, Gothenburg, Sweden; 7INSERM, Nancy, France;
8University of Wisconsin, Madison, United States of America
Introduction: The prognostic value of admission and changes in renal function
has not been well studied in patients admitted with acute heart failure.
Methods: EVEREST was a prospective, international, placebo controlled trial
evaluating the effects of tolvaptan, an oral vasopressin antagonist, in pts admitted
with worsening heart failure and LVEF £ 40%. Pts with a Cr > 3.5 mg/dL or on
hemodialysis were excluded. Pts were receiving standard medical therapy including
ACE inhibitors/ARBs, beta blockers, and diuretics. The 4133 enrolled patients
were grouped into quartiles of baseline BUN, Cr, eGFR, and BUN/Cr ratio, and
outcomes for each quartile were reported. BUN and Cr levels were obtained during
hospitalization and over the course of the study (median 9.9 months)
Results: After adjustment for non-renal baseline characteristics (age, race, SBP,
EF, beta blocker use, geographic region, BNP, and QRS), all four measures of
renal function were highly predictive of 3-month and 1-year mortality (p 24 mg/dL) was 47% on admission,
53% at discharge, and 39% at one year. Similarly, the percentage of pts with
abnormal Cr (>1.1 mg/dL) was 39% on admission, 41% at discharge, and 39%
at one year.
One Year Unadjusted Mortality
Quartile BUN Cr eGFR BUN/Cr
Range Mortality Range Mortality Range Mortality Range Mortality
1 ≤20 16.3% ≤1.0 16.8% >75 16.4% ≤17 19.7%
2 21-26 17.4% 1.0-1.3 21.1% 59-75 21.1% 18-21 21.7%
3 27-35 27.2% 1.4-1.6 29.6% 44-58 26.1% 22-25 24.6%
4 >35 42.8% >1.6 40.3% ≤44 39.2% >25 37.2%
Conclusion: In pts admitted with acute heart failure and reduced LVEF, baseline
renal dysfunction is common, tended to worsen during hospitalization, and is an
independent predictor of short- and long- term mortality.
1783 The presence of an S3 is associated with an increase
rate of all- cause-mortality after one year
M. Potocki, T. Breidthardt, T. Klima, M. Noveanu, T. Reichlin, K. Laule,
C. Stelzig, T. Boldanova, M. Christ, C. Mueller. University Hospital,
Internal Medicine, Basel, Switzerland
Purpose: The S3 heart sound has been shown to be diagnostic in patients presenting
with acute decompensated heart failure (ADHF). We investigated the utility
of the S3 heart sound to predict one year all-cause-mortality in patients presenting
with dyspnea to the emergency department (ED).
Methods: We analyzed the data of 287 consecutive patients with dyspnea enrolled
from April 2006 to March 2007 in our emergency department. The patients
received a clinical evaluation with an S3 evaluation by Audicor ® (Inovise Medical,
Inc, Portland, USA). The diagnosis of ADHF was adjudicated by two independent
cardiologists using all available clinical data including BNP.
Results: Audicor ® results were available in 275 patients. The mean age was
74±12 years and 52% were male. The median follow-up time was 372 days
[IQR 153-430 days]. Hypertension, coronary artery disease, chronic kidney disease
and diabetes was present in 183 (67%), 75 (27%), 72 (26%) and 51 (19%).
ADHF was the adjudicated final diagnosis in 145 patients (53%). Median BNP levels
were significantly higher in patients with an S3 compared to patients without
S3 detection (1081 vs. 263pmol/L, p < 0.001). In the Kaplan-Meier and log-rank
analyses, those patients with an S3 detected had a significantly higher one year
mortality compared to the patients without an S3 (37% vs. 23%, p = 0.046). The
sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy
of an electronic S3 for detection of ADHF were 26%, 92%, 79%, 53% and
57% and for an S3 detected by physician auscultation 9%, 99%, 93%, 49% and
52%. The odds ratio for one year mortality was 2.02 (p = 0.036) for the electronic
detection of an S3, whereas S3 detection by physician failed to reach statistically
significance.
Conclusions: The presence of an electronically detected S3 is a significant predictor
of one year mortality in patients presenting with dyspnea to the emergency
department. The detection of S3, both by auscultation or by electronical devices,
is highly specific for the diagnosis of ADHF and may improve early diagnostic
accuracy in the emergency department.
RESTENOSIS: IS THERE AN ALTERNATIVE TO
DRUG-ELUTING STENTS?
1784 Oral cilostazol prevents restenosis and repeat
revascularization after percutaneous coronary
stenting: A meta-analysis of 15 randomized trials and
4897 patients
G. Biondi-Zoccai1 ,C.Moretti1 , M. Lotrionte2 , P. Agostoni3 ,F.Sciuto1 ,
P. Omede1 , A. Abbate4 ,G.Trevi1 , I. Sheiban1 . 1Turin, Italy; 2Rome, Italy; 3Antwerp, Belgium; 4Richmond, United States of America
Purpose: Drug-eluting stents reduce the risk of restenosis after percutaneous
coronary intervention (PCI), but may pose a risk of thrombosis. Cilostazol, an oral
antiplatelet agent with pleiotropic effects including inhibition of neointimal hyperplasia,
could hold the promise of preventing both restenosis and thrombosis. We
systematically reviewed randomized clinical trials on the angiographic and clinical
impact of cilostazol after percutaneous coronary stenting.
Methods: Pertinent randomized trials were searched in BioMedCentral, CEN-
TRAL, clinicaltrials.gov, EMBASE, and PubMed (January 2007). Co-primary
end-points were binary angiographic restenosis and repeat revascularization,
abstracted and pooled by means of random-effect relative risks (RR). Small
study/publication bias was appraised with multiple methods.
Results: A total of 15 randomized clinical trials were included (4897 patients,
2453 randomized to oral cilostazol for 1-6 months, and 2444 randomized to control
therapy or placebo), with median follow-up of 6 months. Pooled analysis
showed that cilostazol was associated with statistically significant reductions in binary
angiographic restenosis (18.8% for cilostazol vs 26.8% for control, RR=0.60
[0.49-0.73], p