Interact CardioVasc Thorac Surg 2008;7:833-838. doi:10.1510/icvts.2008.175067
© 2008 European Association of Cardio-Thoracic Surgery
Institutional report - Cardiac general |
Utilization and outcome of coronary revascularization and valve procedures in acute heart failure – an evaluation based on the classification from the European Society of Cardiology
Stig Eggen Hermansena,b,*,
Magna Hansenb,
Marius Roaldsenb,
Stig Mullerb,
Ole-Jakob Howb and
Truls Myrmela,b
a Department of Cardiothoracic and Vascular Surgery, University Hospital North Norway, 9038 Tromsø, Norway
b Institute of Clinical Medicine, University of Tromsø, 9037 Tromsø, Norway
Received 6 January 2008;
received in revised form 10 June 2008;
accepted 11 June 2008
 The study was funded by Northern Norway Regional Health Authority.
*Corresponding author. Tel.: +47-97666411, fax: +47-77628298.
E-mail address: Stig.Eggen.Hermansen{at}unn.no (S.E. Hermansen).
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Abstract
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Early invasive treatments in patients with acute heart failure (AHF) are critical components to improve outcome. We aimed to establish if such treatments were applied according to existing guidelines and also to assess the subsequent mortality in the complete AHF population. All patients with AHF admitted to the intensive care unit/coronary care unit during the years 2003–2004 (n=302) were retrospectively reviewed and classified according to the European Society of Cardiology. Invasive revascularization was applied more frequently in patients with cardiogenic shock following acute coronary syndromes (78%, n=40) than in less severe AHF (58%, n=62, P<0.05). Only 8% (n=4) of eligible patients with acute coronary syndromes and cardiogenic shock were treated non-invasively. Valvular dysfunction was a precipitating factor for AHF in 15% (n=38). Acute mitral regurgitation was treated surgically exclusively in patients with mechanical defects. In-hospital mortality rates for less severe AHF was 12%, cardiogenic shock 46% and postcardiotomy HF 32%. Invasively treated patients had lower in-hospital mortality in both cardiogenic shock (35% vs. 70%, P=0.006) and less severe AHF (6% vs.17%, P=0.042). The study revealed an appropriate use of invasive revascularization. The high mortality in patients with severe AHF indicates that more effective treatment options are needed in eligible patients.
Key Words: Heart failure; Shock; Cardiogenic; Myocardial revascularization; Mortality; Acute coronary syndrome; Heart valve disease
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1. Introduction
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The European Society of Cardiology (ESC) introduced a first-time classification of acute heart failure (AHF) in 2005 [1]. Following this categorization, the EuroHeart Failure Survey-II (EHFS-II) was published in 2006 assessing the general AHF population in several European centers [2]. Acute coronary syndromes (ACS) and valvular dysfunction were reported to be precipitating factors in respectively 72% and 17% of patients with cardiogenic shock (CS). Less than two-thirds of these patients were revascularized (PCI or CABG) indicating an insufficient use of revascularization. The management of patients with valvular dysfunction was not described. This is an important issue, as a major question to evaluate when assessing treatment effects, is whether the invasive treatment rate and timing are optimal and compatible with recommended guidelines [1, 3, 4].
In the present study we describe all patients with AHF treated in the CCU and ICU at the University Hospital North Norway during 2003–2004, also including patients with AHF after cardiac surgery. The main purpose of the study was to analyze the use of invasive treatments, i.e. PCI, CABG and valve procedures, and to assess whether such procedures were done according to guidelines, particularly in individuals with CS. In addition, we assessed outcome to clarify to what extent the presented treatment strategy is sufficient.
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2. Methods
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The study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the Regional Ethics Committee.
All patients admitted to the ICU or CCU through the years 2003–2004 with evidence of AHF were enrolled retrospectively. Eligible patients were screened based on discharge diagnosis of ‘heart failure’, ‘myocardial infarction (MI)’ or ‘unstable angina’. Patients with AHF following major non-cardiac surgery (n=22) were excluded. The presented data were collected by the investigators from medical records using a structured case report form. Survival status and time of death for each individual patient were obtained from the Norwegian Cause of Death Registry two years after the index hospitalization.
Patients were classified into different AHF conditions based on the current ESC guidelines [1, 2]. Less severe AHF includes all AHF conditions except CS and postcardiotomy HF. Description of clinical symptoms and signs, X-ray results and attending physician's diagnosis were used for verification of heart failure and classification. Postcardiotomy HF (PC-HF) is not described in the ESC guidelines. We included patients with inadequate cardiac performance after surgery in need of inotropic and/or mechanical support lasting more than two hours. Patients with primarily infection, septic shock or other forms of high output failure were excluded.
In order to clarify whether invasive treatment was applied according to relevant guidelines, patients with AHF following ACS and/or severe valvular pathology were assessed for type of invasive treatment given. Patients with CS not receiving recommended invasive treatment were reviewed separately to assess eligibility for invasive treatment.
2.1. Statistics
Categorical data are presented in frequencies and percentages and compared using  2-test or Fisher's exact test as appropriate. Continuous data are given as mean with standard deviation (S.D.) or median with interquartile range. Kaplan–Meier survival curves and log-rank test were used to compare cumulative mortality rates through a two-year observation period. A two-sided P-value of <0.05 was considered statistically significant.
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3. Results
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A total of 302 patients were admitted to the CCU/ICU with AHF over the two-year period (Table 1). Less severe forms of AHF were seen in 62% of the cases. CS accounted for 23% and PC-HF for 15%, representing the two most severe forms of AHF. Cardiovascular morbidities were abundant and as many as 40% had prior MI. ACS were by far the most common precipitating factors for AHF (57%), and the vast majority of these patients had evidence of AMI. Thirty percent presented with arrhythmias usually concomitant with other precipitating factors. Severe valvular dysfunction was considered a precipitating factor in 13% of all patients and 20% of CS patients.
Results of diagnostic investigations are given in Table 2. Angiography was performed in 42% of all patients and most frequently in CS patients (70%). Three-vessel disease was present in 40%. The majority of patients had a normal or moderately reduced left ventricular ejection fraction regardless of clinical class.
3.1. Invasive treatment of AHF following ACS
Invasive and supportive treatments for AHF following ACS are presented in Table 3. Revascularization was more frequent among CS patients compared to less severe AHF (78% vs. 58%, P=0.012). Patients with CS following ACS not receiving invasive revascularization during hospitalization (n=11, 22%) are presented in Table 4. An individual review revealed that only four of these patients (8%) were untreated potential candidates for coronary angiography and invasive revascularization. All were octogenarians with a history of MI or prior invasive revascularization and none survived. The presence of severe comorbidities was the reason for not performing angiography in those patients where this was technically feasible.
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Table 4 Characteristics and management of patients with cardiogenic shock following ACS not receiving invasive revascularization
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3.2. Valvular pathology
Moderate or severe mitral regurgitation (MR) was present in almost one-third of all patients (Table 2). Severe MR was observed in 13% (n=8) of CS patients and seven of these had AMI. One patient received urgent surgery due to a ruptured papillary muscle while the remaining patients were revascularized or treated conservatively. Six patients presented with severe aortic valve stenosis or aortic regurgitation. Acute valve replacement surgery was performed in three patients. Two patients were only revascularized because of concomitant AMI. One patient was not considered candidate for invasive therapy.
Severe MR was observed in 6% (n=10) and severe aortic valve dysfunction in 8% (n=13) of the patients with less severe AHF. Valvular surgery was performed during index hospitalization in only three patients with severe MR due to rupture of the papillary muscle and endocarditis.
3.3. Mortality
Mortality rates and two-year survival curves are presented in Table 5 and Fig. 1. CS had the worst prognosis with an in-hospital mortality of 46% compared to 13% in patients with less severe AHF. The majority of CS fatalities occurred within two days after admission. Two-year survival was worse for CS compared to PC-HF (log-rank P=0.004) and less severe AHF (log-rank P<0.001). No difference was observed between PC-HF and less severe AHF (log-rank P=0.064). Two-year mortality rates for hospital survivors were similar when comparing CS and less severe AHF (P=0.709), while a significantly better two-year survival was observed for the discharged PC-HF patients (P=0.009).
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Fig. 1. Kaplan–Meier survival curves for cardiogenic shock, postcardiotomy HF and less severe AHF (i.e. acute decompensated heart failure, pulmonary edema, hypertensive acute heart failure and right heart failure).
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Invasively treated patients with less severe AHF had lower in-hospital mortality compared to patients treated conservatively (6% vs. 17%, P=0.042). This was similar in the subset of patients with ACS (6% vs. 20%, P=0.028). Likewise, CS patients treated invasively had improved outcome both in the overall population (35% vs. 70%, P=0.006) and ACS subgroup (34% vs. 80%, P=0.009).
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4. Discussion
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4.1. Invasive treatment and mortality in CS
In accordance with existing guidelines, advocating an early invasive strategy there was an extensive use of invasive revascularization for patients with CS following ACS [1, 3, 5]. Conservatively treated patients were octogenarians with partly severe comorbidities or previous revascularization attempts. These aspects most likely have affected the decision toward conservative treatment and indicate an appropriate selection of patients for invasive revascularization. Early invasive revascularization seems beneficial in clinically-selected elderly patients, but this has not been confirmed in randomized trials [5–7].
A reported invasive revascularization frequency in EHFS-II around two-thirds of CS patients and 43% in the GRACE registry, indicates a restrictive utilization of invasive revascularization compared to existing guidelines [2, 5]. In contrast, 78% of CS patients in our survey received revascularization. We did not, however, observe a more satisfactory in-hospital outcome compared to the EHFS-II. One possible explanation could be that the beneficial effects of aggressive revascularization are only apparent long-term. Mortality rates for CS of any cause in our material were comparable with early and long-term mortality found in the EFICA study of severe AHF [8].
Compared to other patient materials, the use of surgery (24%) was high in CS due to ACS [2, 5, 7]. The role of CABG in the acute phase of STEMI and CS is somewhat unclear. The AHA/ACC guidelines state that CABG should be used if there is a suitable anatomy (main stem, three-vessel disease) and PCI fails to adequately reperfuse the myocardium or cannot be done [9]. Importantly, approximately 40% of the patients revascularized early in the SHOCK trial were treated with CABG with no higher mortality than patients treated by PCI [10]. Also, the two interventions seem to be comparable in high-risk populations [11]. By attacking the culprit lesions only, there is a risk of inadequate revascularization in some of these patients [12]. Potentially, the rather disappointing effects of revascularization could be improved by allocating more patients to early complete revascularization by CABG as the majority of CS patients presented with multi-vessel disease.
The presence of severe MR (13%) was comparable with the findings in EHFS-II. This was secondary to left ventricular dysfunction in the majority of patients and treated with revascularization or conservative treatment only. In contrast, close to half of the patients with severe MR received valvular surgery in the SHOCK trial registry [13]. The proportion of these patients with MR secondary to left ventricular dysfunction vs. acute mechanical dysfunction (e.g. papillary muscle rupture), is not reported. This could potentially explain the difference in the management of these patients. In addition, there is no definite evidence guiding the choice between revascularization and stabilization vs. prompt valve repair or replacement when MR follows left ventricular dilatation in AHF.
The use of mechanical circulatory assistance (IABP) was surprisingly low despite being a recommended therapy for CS in particular. A potential under-utilization of IABP was also apparent in EHFS-II (31%) and the NRMI registry (39%) [2, 7]. Since this survey, we have instituted IABP as a routine modality in CS.
4.2. Invasive treatment and mortality in less severe AHF
Less severe forms of AHF have received much less attention than CS with regard to invasive revascularization. The revascularization frequency observed in our study (58%) was substantially higher than reported from both the NRMI and GRACE registries (20–36%) [14, 15]. Despite similar in-hospital mortality rates of 14%, the reported long-term survival in the GRACE registry was better. This reflects the strikingly high intermediate-term mortality for hospital survivors observed in our patients. A selection of CCU/ICU patients and not the general AHF population, could explain this difference. Mortality rates for less severe AHF of any cause were also a lot higher than reported in EHFS-II, but comparable to the findings in the EFICA study on ICU/CCU patients [2, 8].
Severe valvular dysfunction was less frequent in less severe AHF compared to CS, mostly due to a difference in the presence of MR. Surgical treatment of acute MR was only performed in the setting of acute papillary muscle rupture or dysfunction and endocarditis.
The dismal long-term prognosis for patients with less severe AHF underlines the need for close surveillance after discharge in this CCU/ICU treated population.
4.3. Postcardiotomy HF
PC-HF constituted a significant part of the AHF population treated in the CCU/ICU. Short-term prognosis was dismal compared to less severe AHF, but better than for CS. Two-year mortality for hospital survivors was, however, substantially better compared to any of the other AHF conditions. These patients are all treated with complete surgical correction, and for logistical reasons, always receive a high level of medical attention and surveillance making early application of appropriate therapy possible.
4.4. Study limitations
The single center retrospective design increases the risk of missing patients eligible for inclusion, has a potential for selection bias and limits generalization of the results. Data on previous medical history are also likely to be under-reported because they are obtained in a clinical setting. Importantly, the exact timing of revascularization could not be assessed accurately for our patients.
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5. Conclusion
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The AHF patients were mainly treated according to relevant guidelines. However, the mortality for these patients is still high, and more effective treatment options, like assist devices, are needed in eligible patients.
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Acknowledgements
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The authors thank H. Wang and T. Næsheim.
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Abstract
1. Introduction
