Risk stratification in a Brazilian hospital-based cohort of 1220 outpatients with heart failure: role of Chagas' heart disease
Introduction
Heart failure is a significant major public health problem worldwide [1]. There is a wide variation in the prognosis of symptomatic patients after the diagnosis of heart failure, which may be related to epidemiological, clinical and methodological characteristics of different studies.
Epidemiological characteristics influence prognosis [2], [3] and contribute to different survival experiences in population-based studies [4], [5], [6], [7], in hospital-based series [8], [9], [10], [11], [12] or in protocols of drug therapy [13], [14], [15], [16], [17], [18]. In addition, etiologies of heart failure [9], [12], [19], [20], severity of the disease [21] and some characteristics of medical treatment [22], [23] depend on peculiarities of local clinical settings. Further, criteria for patients' inclusion, as well as numbers of patients in the series [8], [11], [24], [25], are also heterogeneous.
Decisions regarding therapy, including surgical treatment of heart failure or heart transplantation, are to be made on the basis of knowledge of the long-term prognosis of affected patients. We hypothesized that variables elicited during clinical evaluation of outpatients might be identified and structured in models that would be of help in identifying patients at higher risk of dying. Specifically, we were interested in testing a sequence of a noninvasive as well as an invasive strategy previously published [19] that would assist us in identifying prognostic factors to guide decisions in therapy. In addition, there are few recently published large series of patients with heart failure that includes a significant proportion of patients with Chagas' heart disease in a single institution.
We performed this study to identify risk factors of mortality in a large series of outpatients with severe heart failure, including a significant proportion of patients with Chagas' heart disease, which were routinely submitted to angiotensin converting enzyme inhibitors therapy followed up in the 1990s in a single institution.
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Patients
Patients (1220) with heart failure in functional classes III and IV of the New York Heart Association were studied from April 1991 to November 2000. The mean age of the patients was 45.5 years, standard deviation 11.0 (range 13–72 years); 952 (78%) were men and 268 (22%) were women. The mean duration of symptoms before entry in the study was 47.9 months, with a standard deviation of 48.1 months.
Inclusion criteria
Patients with age less than 75 years, diagnosis of symptomatic heart failure in functional class III
Clinical characteristics
The clinical characteristics are presented in Table 1 relative to the etiologies of heart failure and in Table 2 relative to survival, nonsurvival, heart transplantation and other surgical interventions in the follow-up.
There was male predominance in every etiology of heart failure studied; the mean age was less than 51.7±8.3 years and the mean left ventricular ejection fraction by radionuclide ventriculography was 22.1±7.9%. Invasive cardiac catheterization studies were performed in 357
Discussion
We studied a Brazilian cohort of outpatients with heart failure of different etiologies, including Chagas' heart disease with the aim of evaluating prognostic factors to support decisions regarding medical or surgical treatment of heart failure. In previous reports, patients with Chagas' heart disease were absent [8], [9], [11], [12], the degree of ventricular dysfunction has not always been estimated [21], and some studies were performed before availability of widespread therapy with
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