Blackstone, Eugene H.

Francis, Gary S.

Jones, R.Christopher

Lauer, Michael S.

Elsevier - Publisher Connector 

Predictors of mortality in patients with heart failure and preserved systolic function in the digitalis investigation group trial 

JACC March 19,2003 ABSTRACTS - Cardiac Function and Heart Failure 2 19A 
HR each contributed significantly to the improvement in EF observed with chronic O- 
blocker treatment. Reverse remodeling (i.e., decreased end-diastolic volume) is not a 
major factor. 
Adjusted Estimates of Percentage Surviving 
9:oo a.m. 
874-3 Predictors of Mortality in Patients With Heart Failure 
and Preserved Systolic Function in the Digitalis 
Investigation Group Trial 
Patient Groups 
EF<35,SRS<15 
EF 535, SRS > 15 
EF z-35, SRS < 15 
EF >35, SRS > 15 
1 Yr 3 Yr 5 Y’ 
94.3 83.3 71.9 
93.7 77.1 58.1 
98.5 89.7 81.3 
98.3 85.8 80.0 
R. Christopher Jones, Eugene H. Blackstone. Gary S. Francis, Michael S. Lauer, The 
Cleveland Clinic Foundation, Cleveland, OH 
9:30 a.m. 
Background: Although diastolic heart failure is common, the factors that predict mortal- 
sty have not been clearly defined. 
Methods: We studied 988 patients (59% men) with documented heart failure and ejec- 
tion fraction > 45% who were enrolled and prospectively followed in the Digitalis Investi- 
gation Group (DIG) trial. During 3.1 years of follow-up, there were 231 deaths (23%). 
Results: The average age was 87210 years, and the average ejection fraction was 
Ss+_S%. There were 285 patients with diabetes (29%) and 557 with fschemlc head dis- 
ease (57%). In univariable analyses, predictors of death included older age, increasing 
serum creatinine, decreasing body mass index, and presence of diabetes (Figure shows 
quartiles or presence of these versus 3-year Kaplan-M&r death rates). 
874-5 Improvement in Global and Segmental Left Ventricular 
Contractility Following Autologous Bone Marrow Cell 
Transplantation in Humans With Severe lschemic Heart 
Failure 
Emerson C. Penn, Hans F. Dohmann, Radovan Borojevic, Hans J. Dohmann, Antonio C. 
Carvalho, Yong J. Geng, Andre Luiz S. Sousa, Guilherme V. Silva, Fernando Rangel, 
Swarm A. Silva, Isabel Rossi, Roberto Esporcatte, James T. WilIerson, Texas Head 
Institute, Houston, TX, Hospital Pro-Cardiaco, Rio de Janew Brazil 
Backgrounci Limited treatment options exist for pts with end-stage ischemic heart fail- 
ure (HF) notamenable to revascularization. We evaluated the effect of transendwardial 
(TE) delivery of autologous bone marrow mononuclear cells (BMNC) in pts with severe 
HF. 
Gender, ejection fraction, and etiology of heart failure were not predictors of death. In 
stepwise multivariable Cox regression analyses that considered 20 covariates. indepen- 
dent predictors of death were increasing creatinine (score 2 = 88, P < O.OOOl), NYHA 
class (f = 25, P < 0.0001). recent worsening heart failure (x2 = 12, P = 0.0005), older 
age (x2 = 10, P = 0.0017), body mass index (x2 = 4, P = 0.038), diabetes (x2 = 5. P = 
0.023). and use of diuretics (x2 = 4, P = 0.038). 
Conclusions: Diastolic heart failure is associated with a high death rate. Important pre- 
dictors of death include age, renal function, functional class, body mass index, and dia- 
betes. 
9:15 a.m. 
874-4 Assessment of Long-Term Outcome in a Population at 
High Risk for Coronary Artery Disease: Mortality Risk 
Associated With Ejection Fraction Differs Across 
Resting Nuclear Perfusion Findings 
Jam&on M. Bouraue. Linda K. Shaw, Eric J. Velazquez, Christopher M. O’Connor, 
Salvador Barges-Neto, Duke University Medical Center, Durham, NC 
Background: Resting myocardial perfusion studies assess myocardial viability in 
patients with heart failure. The sum rest score (SRS), a marker for perfusion abnormality 
severity at rest, provides independent prognostic information for patients at low to inter- 
mediate risk for coronary artery disease (CAD). However, its prognostic role and poten- 
tial interaction with ejection fraction (EF) in a high risk population are less well defined. 
Methods: We examined 3,275 patients at high risk for CAD who underwent cardiac cath- 
eterization and nuclear imaging within a six month interval and were followed up to 8 
years. We used Cox proportional hazards modeling to assess the relationship between 
EF and SRS after adjusting for significant clinical characteristics. 
Results: A significant interaction (p=O.O30) was found between the nuclear SRS and EF. 
Each 10% decrease in EF for patients with a low risk SRS of 1 provided a 29% increase 
m mortality risk (p=O.OOl, hazard ratio (HR) =1.29. 95% confidence interval (Cl) 1.19- 
1.40). while those wth a hfgh risk SRS of 8 (cohort 75” percentile) had a 37% increase 
(p=O.OOl, HR 1.37, 95% Cl 1.23-l .52). Adjusted survival estimates across SRS levels 
and EF groups were obsewed (see table). 
Conclusion: Resting perfusion studies significantly Impact the interpretation of mortality 
risk associated with changes in resting EF. This clinical interaction should be taken into 
account when nuclear perfusion imagmg is performed to assess prognosis and viability in 
the low EF populabon. 
Methods Ten pts (58 f 11 yrs, 7 males) with severe LV dysfunction (EF 19 + 10 %) and 
were included. Bone marrow (50ml) was aspirated and BMNCs were isolated. TE injec- 
tions were performed using the Myo-Star catheter (NOGA, Biosense) to target hibemat- 
ing myocardium guided by electromechanical mapping (EMM). Pts were evaluated by 
a)angiography (LVEF) b) EMM (mean values of linear local shortening (LLS) and unlpo- 
lar voltage (UniV)) and c)echo (wall motion score index). LVEF and treated vs. non- 
treated segments were analyzed before and 18 wks after the procedure. Student’s paired 
T-test was utilized. 
Resultr On angiography LVEF increased from 19*9% to 24~12% (p=O.O05). A total of 
18 myocardial segments were injected (2kO.7 per pt). On EMM the mean LLS values in 
the treated areas increased from 5.7*3.7% to 10.8*3.5 % (p=O.O05) UniV values of the 
treated segments did not vary significantly after cell therapy (from 10.5 r 3.5 to 10.3 * 2.7 
mV; p=O.8). 
By echocardiography the wall motion score index decreased from 2.0 * 0.7 to 1.8 * 0.8 
(p=O.OOOS) in the treated segments and from 1.9*0.3 to 1.7r0.2 (p=O.Ol) in the non- 
treated segments. 
Conclusion In this small number of pts there was an overall lmprovent in LVEF by 
angiography following TE injection of BMNC at 18wk follow-up. There was improvement 
in segmental contractility in the treated areas by both echocardiographic and EMM crite- 
ria. Future studies are needed to further clarify the role of stem-cell therapy m the treat- 
ment of severe HF. 
9:45 a.m. 
874-6 The Association of Left Ventricular Ejection Fraction, 
Mortality, and Cause of Death in Stable Patients With 
Heart Failure 
Jeptha P. Cur&., Seth I. Sokol. Yongfei Wang, Saif S. Rathote, Dennis T. Ko, Farid 
Jadbabaie, Edward L. Portnay, Stephen J. Marshalko, Martha J. Radford, Harlan M. 
Krumholz, Yale University School of Medicine, New Haven, CT 
Background Left ventricular ejection fraction (LVEF) IS used as a predictor of prognosis 
in heart failure (HF) patients. but the manner in which the associatton of LVEF, mortality, 
and cause of death vanes across the full spectrum of LVEF is incompletely understood. 
Methods and Results: We examined the association of LVEF and outcomes in 7788 
patients enrolled in the Digitalis Investigation Group trial. With mean follow-up of 37 
months, mortality was substantial in all LVEF groups (range LVER15%: 51.7%, >55: 
23.5%). Among pabents with LVEK45%. mortality rates decreased in a near linear fash- 
ion across successively higher LVEF groups (LVEM15%: 51.7%; LVEF 38-45%. 25.8%; 
PcO.OOl), but mortality was comparable in LVEF groups above 45% (LVEF 48.55%: 
23.3%, LVEF>55%: 23.5%; P=O.25). In multivariable analysis, the magnitude of the 
association was reduced (LVERlS%: HR 1.84. Cl 1.54-2.18; 18-25%: HR 1.47, Cl 1.30. 
1.85; 28.35%: HR 1.13, Cl 1.01.1’.28; 38-45%: referent; 48-55%: HR 0.91, Cl 0.78-1.09; 
~-55%: HR 0.89, Cl 0.71-l .lO). Patients with lower LVEF were at increased risk of death 
due to arrhythmia and worsening HF, but these wars leading causes of death in all LVEF 
groups. 
Conclusions Annual mortality was more than 5.5% in all LVEF groups, but lower LVEF 


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Predictors of mortality in patients with heart failure and preserved systolic function in the digitalis investigation group trial

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