Diastolic Strain Parameters are Associated with Short Term Mortality and Rehospitalization in Patients with Advanced Heart Failure

Tatar, Sefa; İcli, Abdullah; Arıbaş, Alpay; Akilli, Nazire Belgin; Akilli, Hakan; Sertdemir, Ahmet Lütfi

doi:10.36660/abc.20230670i

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Original Article • Arq. Bras. Cardiol. 121 (8) • Aug 2024 • https://doi.org/10.36660/abc.20230670i copy

Diastolic Strain Parameters are Associated with Short Term Mortality and Rehospitalization in Patients with Advanced Heart Failure

Authorship SCIMAGO INSTITUTIONS RANKINGS

Central Illustration
: Diastolic Strain Parameters are Associated with Short Term Mortality and Rehospitalization in Patients with Advanced Heart Failure

Diastolic strain echocardiography and short-term mortality in advanced HFrEF patients. HFrEF: heart failure with reduced ejection fraction; SR: strain rate; NT-ProBNP: The N-terminal prohormone of brain natriuretic peptide.

Abstract

Background

Heart failure (HF) is a leading cause of hospitalization and mortality worldwide and places a great economic burden on healthcare systems. Identification of prognostic factors in HF patients is of great importance to establish optimal management strategies and to avoid unnecessary invasive and costly procedures in end-stage patients.

Objectives

In the current study, we aimed to investigate the association between diastolic strain parameters including E/e’ SR, and short-term outcomes in advanced HF patients.

Methods

The population study included 116 advanced HF with reduced ejection fraction (HFrEF) patients. Clinical, laboratory, and echocardiographic evaluations of the patients were performed within the first 24 hours of hospital admission. Patients were followed for one month and any re-hospitalization due to worsening of HF symptoms and any mortality was recorded. The level of significance adopted in the statistical analysis was 5%.

Results

E/e’ SR was significantly higher in the patient group compared to the control group (p=0.001). During one-month follow-up, 13.8% of patients died and 37.1% of patients were rehospitalized. Serum NT-ProBNP (p=0.034) and E/e’ SR (p=0.033) were found to be independent predictors of mortality and ACEİ use (p=0.027) and apical 3C strain (p=0.011) were found to be independent predictors of rehospitalization in the patient group.

Conclusion

Findings of the current prospective study demonstrate that E/e’ SR measured by speckle tracking echocardiography is an independent and sensitive predictor of short-term mortality in advanced HFrEF patients and may have a role in the identification of end-stage HFrEF patients.

Heart Failure; Patient Readmission; Mortality

	Patient Group (n=116) Mean±SD/Median (IQR)	Control Group (n=58) Mean±SD/Median (IQR)	p
Parameters
Age (years)	67.7±12.8	68.1±11.2	0.810
Gender			0.524
Male, n (%)	71 (61.2%)	36 (62.1%)
Female, n (%)	45 (38.8%)	22 (37.9%)
CAD, n (%)			0.019
None	41 (35.3%)	35 (60.3%)
Medical	15 (12.9%)	5 (8.6%)
PTCA	39 (33.6%)	11 (19%)
CABG	21 (18.1%)	7 (12.1%)
Hypertension, n (%)	84 (72.4%)	47 (81%)	0.145
Smoking, n (%)	40 (34.5%)	15 (25.9%)	0.321
Diabetes mellitus, n (%)	52 (44.8%)	34 (58.6%)	0.06
Hyperlipidemia, n (%)	49 (42.2%)	23 (39.7%)	0.43
Stroke, n (%)	16 (13.8%)	6 (10.3%)	0.35
CKD, n (%)	53 (45.7%)	21 (36.2%)	0.151
Hemoglobin (g/dl)	12.4±2.2	12.9±2.2	0.828
Hematocrit	38.4±6.7	39.8±6.4	0.364
MCV (fL)	83.7±7.5	86.5±6.6	0.275
Platelet Count (x109/L)	246.5±96.3	252.0±78.3	0.705
Sodium (mmol/L)	138.0±3.7	138.8±3.4	0.837
Potassium (mmol/L)	4.6±0.7	4.3±0.6	0.182
GFR (ml/min)	51(29)	72(40)	0.002
Urea (mg/dl)	57(39)	40(29)	0.001
Creatine (mg/dl)	1.39(1)	0.98(1)	0.018
AST (U/L)	18(12)	17(13)	0.870
ALT (U/L)	15(14)	17(18)	0.908
WBC Count (x109/L)	9.1 (3.9)	8.3(4.5)	0.308
Echocardiography
End diastolic diameter (mm)	56.8±7.7	45.3±4.5	0.001
End systolic diameter (mm)	44.3±8.7	27.8±4.0	0.001
Left atrium (mm)	43.5±7.0	34.8±6.4	0.001
Pulmonary arterial pressur (mmHg)	35(21)	30(9)	0.001
End diastolic volume (ml)	182.8(90)	42.4(32)	0.001
End systolic volume (ml)	122.5(60)	17.3(14)	0.001
Ejection fraction (%)	30.6(11)	57.1(13)	0.001
*Apical 3C strain (%)*	-6.7±2.9	-9.3 ±3.2	0.001
*Global longitudinal strain (%)*	-7.2±2.46	-10.5±2.6	0.001
e SR, 1/s	0.34(0.4)	1.0(0.5)	0.001
a SR, 1/s	0.3(0)	1.1(1)	0.001
E/e’ SR	188.8(323.0)	54.1(21.0)	0.001

	Mortality Group (n=16) Mean±SD/Median (IQR)	Survival Group (n=100) Mean±SD/Median (IQR)	p
Age, (years)	69.1±12.4	67.5±12.9	0.644
Gender			0.236
Male, n (%)	8 (50.0%)	63 (63.0%)
Female, n (%)	8 (50.0%)	37 (37.0%)
Total length of hospital stay (days)	7 (4-9)	7 (3-9)	0.690
Hypertension, n (%)	10 (62.5%)	74 (74%)	0.251
Diabetes mellitus, n (%)	7 (43.8%)	45 (45%)	0.573
Hyperlipidemia, n (%)	5 (31.2%)	44 (44%)	0.249
Beta blocker, n (%)	8 (50%)	75 (75%)	0.043
Diuretic, n (%)	8 (50%)	69 (69%)	0.115
ACEi, n (%)	5 (31.2%)	59 (59%)	0.036
MRA, n (%)	3 (18.8%)	34 (34%)	0.178
End diastolic diameter (mm)	52.7±8.7	57.4±7.3	0.021
End systolic diameter (mm)	42.6±9.1	44.6±8.6	0.384
Left atrium diameter (mm)	40.4±8.2	44.0±6.6	0.049
GFR (ml/min)	41 (34)	51 (20)	0.216
ProBNP (ng/L)	13800 (30747)	4860 (9174)	0.002
End diastolic volume (ml)	166.6 (138)	182.3 (76)	0.876
End systolic volume (ml)	116.4 (97)	121.2 (51)	0.719
Ejection fraction (%)	31.7 (10)	30.3 (11)	0.513
Apical 4C strain (%)	-7.5±2.4	-7.3±2.7	0.777
Apical 3C strain (%)	-6.2±2.3	-6.7 ±3.0	0.623
Apical 2C strain (%)	-7.4±4.2	-6.7±2.8	0.503
Global longitudinal strain (%)	-7.4±2.1	-7.2±2.5	0.742
E SR, 1/s	0.1 (0.3)	0.36 (0.3)	0.004
A SR, 1/s	0.3 (0.0)	0.3 (0.0)	0.774
E/e’ SR	600.0 (679.0)	184.4 (318.0)	0.009

Parameters	Univariate analysis		p	Multivariate analysis		p
Parameters	OR	95% CI	p	OR	95% CI	p
*Beta blocker, n (%)**	3.0	1.019-8.829	0.046	2.753	0.824-9.203	0.100
*Diuretic, n (%)**	2.226	0.765-6.474	0.142	0.861	0.157-4.714	0.863
*ACEi, n (%)**	3.166	1.023-9.798	0.046	1.356	0.306-5.998	0.688
MRA, n (%)	2.232	0.595-8.372	0.234	-	-	-
*End diastolic diameter (mm)**	0.916	0.850-0.988	0.024	0.956	0.866-1.055	0.369
End systolic diameter (mm)	0.972	0.913-1.036	0.381	-	-	-
LVEF (%)	0.983	0.927-1.043	0.569	-	-	-
*Left atrium diameter (mm)**	0.927	0.858-1.001	0.053	0.925	0.851-1.004	0.064
*ProBNP (ng/L)**	1.000	1.000-1.000	0.029	1.000	1.000-1.000	0.034
E/e’ SR*	1.001	1.000-1.001	0.048	1.001	1.000-1.001	0.033

	Rehospitalization Group (n=43) Mean±SD/Median (IQR)	Non-rehospitalization Group (n=73) Mean±SD/Median (IQR)	p
Age, (years)	66.5±11.9	68.4±13.3	0.452
Gender			0.845
Male, n (%)	27 (62.8%)	44 (60.3%)
Female, n (%)	16 (37.2%)	29 (39.7%)
Total length of hospital stay (days)	6 (3-9)	7 (3-9)	0.662
Hypertension, n (%)	34 (79.1%)	50 (68.5%)	0.155
Diabetes mellitus, n (%)	24 (55.8%)	28 (38.4%)	0.551
Hyperlipidemia, n (%)	19 (44.2%)	30 (41.1%)	0.447
Beta blocker, n (%)	33 (76.7%)	50 (68.5%)	0.231
Diuretic, n (%)	32 (74.4%)	45 (61.6%)	0.114
ACEi, n (%)	29 (67.4%)	35 (47.9%)	0.032
MRA, n (%)	17 (39.5%)	20 (27.4%)	0.126
End diastolic diameter (mm)	57.1±7.1	56.5±8.0	0.686
End systolic diameter (mm)	44.1±8.7	44.5±8.7	0.824
Left atrium diameter (mm)	44.4±7.1	43.0±6.6	0.292
GFR (ml/min)	47.0 (17.0)	51.5 (34.0)	0.224
ProBNP (ng/L)	5560 (8721)	7368 (15593)	0.554
End diastolic volume (ml)	196.8 (92)	169.8 (78)	0.154
End systolic volume (ml)	129.9 (64)	117 (48)	0.117
Ejection fraction (%)	33 (11)	30 (11)	0.268
*Apical 4C strain (%)*	-6.7±2.4	-7.63±2.7	0.116
*Apical 3C strain (%)*	-5.57±2.7	-6.7 ±3.0	0.010
*Apical 2C strain (%)*	-6.4±2.9	-6.9±2.9	0.457
*Global longitudinal strain (%)*	-7.0±2.6	-7.4±2.36	0.462
E SR, 1/s	0.37 (0.3)	0.32 (0.4)	0.817
A SR, 1/s	0.32 (0)	0.3 (0)	0.765
E/e’ SR	178.3 (305)	221.8 (473)	0.470

Parameters	Análise univariada		p	Análise multivariada		p
Parameters	OR	95% CI	p	OR	95% CI	p
Hipertensão, n (%)	0.575	0.237-1.395	0.221	-	-	-
*Diurético, n (%)**	0.552	0.240-1.269	0.162	0.756	0.269-2.218	0.597
*ECAİ, n (%)**	0.445	0.203-0.976	0.043	2.525	1.111-5.738	0.027
*ARM, n (%)**	0.577	0.260-1.283	0.177	0.832	0.317-2.186	0.709
Volume diastólico final (ml)	1.003	0.997-1.009	0.264	-	-	-
Volume sistólico final (ml)	1.005	0.997-1.012	0.247	-	-	-
FEVE (%)	0.969	0.923-1.016	0.192	-	-	-
*Strain apical 3C (%)**	1.138	1.023-1.265	0.017	1.154	1.033-1.288	0.011
*Strain apical 4C (%)**	1.119	1.008-1.241	0.035	1.039	0.898-1.202	0.609

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