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 References 1. 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