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60 Cardio Diabetes Medicine 2017

ations of fluid and electrolyte homeostasis are very 5. Left ventricular end-systolic diameter
important in the pathophysiology of chronic HF. Re- 6. Left ventricular hypertrophy by ECG
cent data highlight the value of impaired renal func-
tion as a marker for increased risk of progression and 7. Increased age.
death in chronic heart failure. Hillege et al., in a ret- 8. Calculated eGFR
rospective analysis showed that creatinine clearance
derived from serum creatinine, body weight, and age In multivariate analysis, reduced SDNN and serum
is the most powerful predictor of all-cause mortality sodium and creatinine remained independent and
in patients LVEF< 49$ and NYHA functional class specific predictors of progressive HF irrespective of
III to IV symptoms.Dries et al. (1), in a retrospective the EF and etiology of Chronic HF. They could iden-
analysis of the Studies of Left Ventricular Dysfunc- tify patients with relatively mild disease who are at
tion (SOLVD) database, demonstrated that moderate high risk of death specifically due to progressive
renal insufficiency is an independent predictor of all- HF over a five-year period. 24-h frequency-domain
cause mortality and progressive heart failure.Each measurements of HRV did not provide additional
10 μmol/l increment of creatinine level increases the prognostic information over the simple time-domain
risk of a progressive HF death by ∼14%.Thus, it ap- measurement SDNN.
pears that renal dysfunction per se may contribute
to HF progression. The mechanisms underlying this DIAGNOSTIC WORKUP FOR PROGRESSIVE HEART
detrimental cardiorenal interaction warrant further in- FAILURE
vestigation.
1. Symptoms and signs of heart failure: A detailed
INDEPENDENT PREDICTORS OF DEATH history symptoms and signs of HF need to be
SPECIFIC TO PROGRESSIVE HF assessed, every visit, with particular attention to
evidence of congestion to monitor a patient’s re-
In ambulant outpatients with chronic HF, low serum sponse to treatment and stability over time. Per-
sodium and low SDNN (Standard deviation of all nor- sistence of symptoms despite treatment usually
mal-to-normal RR intervals) and high serum creati- indicates the need for additional therapy. Wors-
nine identify patients at increased risk of death due ening of symptoms suggests progressive heart
to progressive HF. Identifying patients at risk of death failure, and merits prompt medical attention.
specifically from progressive HF may help to tailor
further investigation or therapy to prevent death and 2. Natriuretic peptides: Elevated natriuretic peptides
hospitalization from progressive heart failure. (NPs) help establish an initial working diagnosis,
identifying those who require further cardiac
The United Kingdom Heart Failure Evaluation and investigation. The upper limit of normal in the
Assessment of Risk Trial (UK-HEART) was prospec- non-acute setting for B-type natriuretic peptide
tively designed to assess the variables that specifi- (BNP) is 35 pg/mL and for N-terminal pro-BNP
cally identify patients at increased risk of death due (NT-proBNP) is 125 pg/mL. In the acute setting,
to progressive HF. The following parameters were higher values should be used [BNP < 100 pg/
considered; Time-domain analyses of HRV, Fre- mL, NT-proBNP< 300 pg/mL and mid-regional
quency-domain HRV analyses, Multifrequency bio- pro A-type natriuretic peptide (MR-proANP) < 120
electrical impedance analysis [noninvasive estimate pmol/L] as upper limits of normal. Diagnostic val-
overload of extracellular water/ total body water], ues apply similarly to HFrEF and HFpEF; on aver-
ECG variables, Echo parameters, Chest X ray, clin- age, values are lower for HFpEF than for HFrEF.
ical variables etc. With these exclusionary cut-points, the negative
of all the parameters assessed, eight variables pro- predictive values are high (0.94–0.98) but the
vided independent prognostic information that iden- positive predictive values are lower both in the
tified patients at increased risk of death from any non-acute and acute setting (0.44–0.67). NPs are
cause thus recommended more for ruling-out HF, than
to establish the diagnosis.
1. SDNN
3. Electrocardiogram. An abnormal (ECG) increases
2. Reduced Serum sodium and creatinine, the likelihood of the diagnosis of HF, but has low

3. Increased Cardiothoracic ratio specificity. HF is unlikely in patients presenting
with a completely normal ECG (sensitivity 89%).
4. Non-sustained ventricular tachycardia
Some abnormalities on the ECG provide informa-

GCDC 2017