Prediction of Adverse Outcomes in Patients with Congestive Heart

Prediction of Adverse Outcomes in
Patients with Congestive Heart Failure
Meredith Brown/ Mentor Dr. Nan Smith-Blair
Funded by Arkansas Department of Education SURF Grant (2009)
Background and Significance

Congestive heart failure (CHF) - pathological condition in
which the heart is unable to pump the necessary volume
of blood to supply the body

As the efficiency of the heart’s pumping action declines,
vital organs are unable to receive the necessary oxygen
and nutrients found in the blood, and the functioning of
these organs declines

Progression of CHF is monitored by changes in certain
lab values and vital signs: BNP, HR, BP, SaO2
Background and Significance, continued

According to the AHA 2009:

CHF in the U.S. was estimated to have cost $39.2 billion in
2010

#1 reason for hospital admissions in those over the age of 65

Once diagnosed with CHF, 52% of individuals will die within 5
years

The number of any-mention deaths from HF was about the
same in 1995 (287,000) as in 2006 (283,000)
What has been done to detect changes in
CHF patients prior to an adverse outcome?

Retrospective Models: Acute Physiology and Chronic
Health Evaluation (APACHE) and the Mortality
Probability Model (MPM)

Real time computerized surveillance systems and rapid
response teams, such as the TREX system implemented at
WRMC
Current Need for Research

Lack of literature regarding the significance of the
magnitude of change (delta change) in relation to time of
various lab values and vital signs in the prediction of
adverse outcomes in this patient population

The implications of this research are possible future real
time monitoring systems that incorporate the significance
of the magnitude of change of certain values
Purpose and Aims

To identify factors present in CHF patients prior to the
development of an adverse outcome (transfer to ICU/CCU
and/or death)

Aim 1: To determine the magnitude of change in brain natriuretic peptide
(BNP), heart rate (HR), systolic blood pressure (SBP), diastolic blood
pressure (DBP), and arterial oxygen saturation (SaO2) in patients with a
diagnosis of CHF who experience an adverse outcome during their
hospitalization.

Aim 2: To determine the magnitude of change in BNP, HR, SBP, DBP, and
SaO2 in patients with the diagnosis of CHF who did not experience an
adverse outcome during their hospitalization.
Methodology

Patient Population: all adults admitted to an urban hospital in
NWA in 2009 with the diagnosis of CHF (excluding pediatric,
hospice, trauma, and pregnant patients)

Study Design:



Study protocol approved by U of A IRB (protocol number 09-11-252) and
hospital
Retrospective review of charts using a comparable number of
patients without an adverse outcome as generated by a random
sequencer
Data collection: initial weight (WT), BNP, HR, SBP, DBP, and SaO2
upon admission and for 24 hours prior to discharge or adverse
outcome
Data Analysis

One-way ANOVA with one between-groups factor design
was used to examine possible differences upon admission
and at the point of adverse outcome/no adverse outcome
between groups 1 (no adverse outcome) and 2 (adverse
outcome)

Two-way ANOVA with repeated measures on one factor
was used to analyze Group x Time interaction and delta
change on HR, SBP, DBP, and SaO2
Demographics
 Sex


58.7% Males
41.3% Females
 Age


range 29-94
< 65 years 27%
66-79 years 42.9%
> 80 years 30.2%
 Race



2 Hispanic
1 Asian
58 Caucasian
Demographics
Variable
df
F Value
Significance
Sex
• 58.7% Males
• 41.3% Females
(1, 59)
0.04
p=.83
Age
• < 65 years 27%
• 66-79 years 42.9%
• > 80 years 30.2%
(1,59)
0.06
p=.81
Weight (Mean 85.5 kg; SD= 27.24)
• Group 1- 87.1 kg (SD 29.5kg)
• Group 2- 83.7 kg (SD 24.95 kg)
(1,59)
0.24
p=.63
RESULTS
 One-way ANOVA with one between-groups factor design
Variable
df
F Value
Significance
Heart Rate (HR)
(11,42)
0.77
p= .77
Systolic Blood Pressure (SBP)
(11,42)
0.88
p= .57
Diastolic Blood Pressure (DBP)
(10,50)
1.46
p= .18
Saturation of Oxygen in Arterial
Blood (SaO2)
(11, 77)
1.0
p= .45
Blood pH (pH)
(1,16)
1.67
p= .21
Brain Naturiuretic Peptide (BNP)
(1,42)
13.75
p< .0006**
** Level of significance p < .05
Brain Natriuretic Peptide (BNP)
*
M= 17,948.9 pg/mL
M= 5,535.7 pg/mL
*- p< .0006
Discussion: BNP

BNP = an “emergency hormone that responds immediately to
ventricular overload”

Rapid testing of BNP may be used in the future to guide
treatment of patients with decompensated CHF

Current AHA guidelines: do not yet recommend serial BNP
measurements to guide treatment

BNP affected by many variables: age, sex, weight, and renal
function

Call for further research in this area
Discussion: BNP

Anecdotally…

Group 1 = 33% of patients had slightly increased BNP
measurements over time (avg 24%)

Group 2 = 50% of patients had increased BNP measurements
over time (avg 64.6%)

One patient had a BNP of 11,264 pg/mL upon admission
(normal range is 0-100 pg/mL) that increased to 64,601 pg/mL
13 hours later

Call for continued research on the usefulness of serial BNP
measurements in predicting adverse outcomes
RESULTS


Group x Time interaction using 2-way ANOVA with
repeated measures on one factor
Variable
Df
F Value
Significance
HR
(11,42)
.77
p = .39
SBP
(11,42)
.88
p = .57
DBP
(10,50)
1.46
p = .18
SaO2
(11,77)
1.0
p = .45
No statistically significant delta changes noted in HR, SBP,
DBP, or SaO2
Discussion

Physiology of compensation (BP and HR)

Time of data entry not standardized  possible masking
of important differences

May account for the lack of any identifiable trends – does
NOT rule out the possibility of clinical significance

Multiple factors to consider
RESULTS
One-way ANOVA with one between-factors design
at the point of adverse outcome/no adverse outcome
Variable
Df
F Value
Significance
HR
(1,58)
5.587
p = .021
SBP
(1,58)
2.220
p = .142
DBP
(1,58)
1.372
p = .246
SaO2
(1,59)
2.253
p = .139
RESULTS: Heart Rate (HR)
*
*= Significance p = .021
RESULTS: Systolic Blood Pressure (SBP)
==
RESULTS: Diastolic Blood Pressure (DBP)
RESULTS: Saturation of Arterial Oxygen(SaO2)
Call for further research and possible
clinical implications

Call for more frequent monitoring of HR

Possible serial measurements of BNP to track the progression
of CHF and to predict adverse outcomes

Standardized protocol for more consistent data which could
be analyzed for earlier detection of patient deterioration

Continued efforts to identify early indicators of adverse
outcomes in CHF patients due to the high morbidity and
mortality rates
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


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