EL INFORME RECARTE PDF

Ventricular dilation associated with systolic dysfunction is the common endpoint of most diseases of the heart. Generally speaking, its appearance denotes a poor prognosis for the patient, with a high risk of death in the years after diagnosis. That risk continues to be high in spite of the remarkable advances that have taken place in the treatment of this syndrome. Various prognostic predictors have been described, including functional class, 5 etiology, 4,5 neurohormonal factors, 6 natremia, 7 ventricular 8 and left atrial dimensions, 9 ejection fraction, 10,11 parameters of diastolic function, right ventricular measurements and, more recently, the 6-min walking test 20,21 and end-systolic parietal stress.

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Ventricular dilation associated with systolic dysfunction is the common endpoint of most diseases of the heart. Generally speaking, its appearance denotes a poor prognosis for the patient, with a high risk of death in the years after diagnosis. That risk continues to be high in spite of the remarkable advances that have taken place in the treatment of this syndrome. Various prognostic predictors have been described, including functional class, 5 etiology, 4,5 neurohormonal factors, 6 natremia, 7 ventricular 8 and left atrial dimensions, 9 ejection fraction, 10,11 parameters of diastolic function, right ventricular measurements and, more recently, the 6-min walking test 20,21 and end-systolic parietal stress.

The multiplicity of predictors can cause confusion at the time of evaluating patients. Functional clinical assessment and the identification of markers of diastolic function by echocardiography are parameters that are easy to determine and should provide a fast and simple way to evaluate the prognosis of patients with systolic dysfunction. Parting from this hypothesis, the aim of this study was to assess the usefulness of these parameters, which were selected out of a large group of clinical and echocardiographic parameters, as predictors of the evolution of patients with left ventricular systolic dysfunction, and to understand and compare their interrelations.

Consecutive patients seen in the echocardiography laboratory of a tertiary hospital, diagnosed as systolic dysfunction with ventricular dilation in the study requested, were included for follow-up. This diagnosis was made when the left ventricular LV end-diastolic diameter was greater than 5. Data were collected from June to November The sample included 93 patients with a mean age of All the patients who were included in the study remained under the care of their regular doctors, with the treatment prescribed by them, except that angiotensin-converting enzyme inhibitors ACEI were used whenever they were tolerated.

With the previous consent of patients, telephone contact was maintained with them every three months in order to interrogate them about the follow-up variables: functional class, hospital admissions, and survival.

When the study was finalized, the clinical history of each patient included was reviewed to verify the admission data, functional evaluation of the physicians, and cause of death, as needed. In the deaths that occurred outside the hospital, details on the death were obtained from family members and the death certificate. Two patients who died of non-cardiac causes, with no relation to the disease one glioblastoma and one case of multiple injuries , were excluded from the study so all relative values were referred to a final group of 91 cases.

Parameters of functional status. Clinical and analytical parameters. The etiology was labeled as ischemic when there was evidence of ischemic heart disease in the clinical manifestations or exercise stress test, areas of evident infarction in the echo, or severe lesions in the catheterization; otherwise, the case was classified as non-ischemic.

Heart rate and blood pressure were determined at the time that the echocardiogram was made, after 5 min of rest in left lateral supine position. The rest of the clinical information was obtained by means of the interview, so only previously diagnosed diabetics were considered. Creatinine, sodium, and potassium were determined in blood samples obtained at the time of onset of the follow-up. A posteroanterior chest radiograph was made in standing position and forced inspiration.

When discrepancies were found, the disagreement was resolved by consensus. The treatment of patients in the 3 months preceding the event or study closure was recorded. All echocardiographic studies were made by the same operator, who did not know the clinical condition of the patient.

The studies of the hospitalized patients were carried out after their situation had stabilized. The echocardiographic study was made in left lateral supine position with an ATL ultramark 9 echograph Advanced Technologies Laboratories Inc.

The left cavities were measured by guiding the M-mode sector from a longitudinal parasternal section, according to the recommendations of the North American Society of Echocardiography.

The RV shortening fraction was obtained as the ratio of the difference between the previous measurements and the end-diastolic length of the short axis. In the same plane, the area of regurgitant flow through the tricuspid valve was measured as the combined area of turbulence and laminar flow. The degree of mitral insufficiency was determined by means of the proximal convergence method, as is described in detail in another article. To the right ventriculoatrial gradient obtained was added 10 mm Hg to obtain the pulmonary artery pressure.

The curve should have a clear profile to the point of maximum velocity. The statistical analysis was carried out with the SPSS 8. The follow-up endpoints considered were the presence or absence of two variables: a cardiac death, including death of cardiac origin and heart transplantation from here on, when we refer to mortality, we will be talking about cardiac death , and b cardiac event during follow-up, including death, heart transplantation, and admission for heart failure.

In the groups in which one of the endpoints was reached, the continuous variables were compared using the Student t test for independent variables. In order to evaluate the mean duration of event-free survival, Kaplan-Meier analysis was used. To analyze the relation between diverse variables and survival, univariate analysis of the Cox regression was used. The Cox regression with multiple variables was used with the conditional anterograde method to determine the independent variables.

The variables that could only be measured in certain situations were not included. For example, systolic pulmonic pressure was not used because it requires the existence of tricuspid insufficiency and its inclusion would lead to population selection. The selection of some of the cutoff points that appear in the results was made with ROC curves, as will be described. A value of P P The patients in the sample had a mean age of The group was composed of The cause was considered ischemic in The EF was The mean follow-up time of the patients was Two patients underwent heart transplantation 2.

Seventeen patients suffered a single episode of heart failure that required hospital admission Considering all admissions, transplantations, and deaths, 58 patients A comparison of the mean values of the continuous variables between the patients who remain alive and those who suffered cardiac death is shown in Table 1.

Only the variables with the most significant differences are shown. The most statistically significant differences were found in the results of the walking test, all the parameters of diastolic function, and the left atrial dimensions, all of which had P values close to. There were also differences in the plasma creatinine values, RV end-diastolic diameter, and systolic pulmonic pressure.

The EF was smaller in patients with cardiac death, although this was non-significant. The results were very similar when the same parameters were compared between the groups with and without events. The analysis of categorical variables disclosed no differences in coronary risk factors smoking habit, diabetes, sex between patients with cardiac mortality and survivors.

There were differences in the functional class, history of heart failure, presence of a radiographic infiltrate, and degree of mitral and tricuspid insufficiency Table 2.

When the presence or absence of events was considered, the differences were similar, except for etiology. Univariate Cox regression analysis was performed to assess the influence of a number of variables on survival. The most significant results are shown in Table 3. The results were practically the same when cardiac death or total events were considered as endpoints.

None of the epidemiological parameters achieved statistical significance when included in the regression equation age, sex, smoking habit, alcohol use, etiology, diabetes. In Figures 1 to 5 are shown the Kaplan-Meier survival curves for the variables with the most significant clinical and statistical results.

The figures also show the survival table for cardiac death and events. Likewise, patients with deceleration times of less than m lived less time 17 versus 26 or more months; Figure 4. In this case, the cutoff points were assessed with ROC curves and were adjusted to the hundredths. The evolution was worse in patients with atrial diameters of more than 5 cm 20 versus 28 months or more; Figure 5.

Kaplan-Meier survival curves for cardiac mortality in relation to ejection fraction EF. The difference was not significant for event-free survival. Kaplan-Meier survival curves for cardiac mortality according to functional class FC.

Kaplan-Meier survival curves fo r cardiac mortality in relation to distance walked. The following table shows how survival and event-free survival get worse as the distance that patients are capable of walking decreases. Kaplan-Meier survival curves for cardiac mortality in relation to deceleration time. The adjacent table shows how survival and event-free survival worsen as the E-wave deceleration time decreases. Kaplan-Meier survival curves for cardiac mortality in relation to left atrial diameter.

The following table shows how survival and event-free survival worsen as the size of the atrium increases. In our study, functional class was the only independent predictor of cardiac mortality, although it was replaced by the distance covered in the walking test in view of the fact that patients incapable of carrying out the test walked less than m.

The echocardiographic parameters, although of great prognostic value, did not provide information in addition to that obtained with the functional class or walking test. When only the echocardiographic parameters were assessed, the only independent predictors were E-wave deceleration time and left atrial dimensions, the rest of the echocardiographic variables being excluded.

In the last 10 years, studies have been published on the prognostic value of various clinical and echocardiographic parameters in LV systolic dysfunction. The interest of our work lay in determining the predictors of prognosis in a simpler, more powerful, and independent way. This can help to organize diagnostic protocols for the selection of parameters, as well as to determine which protocols can replace others that cannot be obtained, in spite of their interest.

Functional class is and has been the fundamental reference criterion for classifying patients with systolic dysfunction and deciding on their therapy, especially with regard to performing heart transplantation in class IV patients. In that sense, a clear discrimination between patients in classes II and III was found that other studies have not demonstrated. The walking test is a way to objectively assess functional capacity.

Although it has been demonstrated that, in absence of analysis of oxygen consumption, it is less related with the evolution of patients, it also has been observed that the fit between oxygen consumption and distance walked correlated with accuracy in patients with a depressed functional capacity. It is noteworthy that an objective test was less useful than a subjective one. An explanation could be that only 1 in 6 patients in class IV could carry out the test.

When class IV was excluded from the analysis, the walking test was a more powerful predictor of event-free survival than functional class. For patients in class IV, the impossibility to carry out the test would be a finding of poor prognosis.

Our study emphasizes the prognostic importance of clinical data that are easily obtained, such as a history of admission for heart failure or the radiological findings of pulmonary congestion, and recalled the value of others, such as plasma creatinine and the hyponatremia, that have been described previously.

The only study that analyzed patients in atrial fibrillation found no differences in their prognosis. Nevertheless, in the study of patients with systolic dysfunction, other parameters aside from the degree of dysfunction were more relevant prognostic indicators. In fact, in our sample, the degree of systolic dysfunction, as measured by the EF, had less predictive value than the parameters of diastolic function or functional status, and were excluded by these parameters in multivariate studies.

The parameters of diastolic dysfunction were closely related with survival, principally left atrial pressure, which masks many data related with ventricular relaxation. In our experience, the speed of propagation of the E wave measured with color M was unrelated to the prognosis of patients with systolic dysfunction, 41 although this parameter was not included in this study.

The prognostic value of other, more recent, parameters is not known, such as tissue Doppler of the mitral annulus.

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