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CLINICAL RESEARCH: ECHOCARDIOGRAPHY AND HEART FAILURE

Echocardiographic predictors of morbidity and mortality in patients with advanced heart failure

The Beta-blocker Evaluation of Survival Trial (BEST)

Paul A. Grayburn, MD^_*,_*, Christopher P. Appleton, MD, Anthony N. DeMaria, MD, Barry Greenberg, MD, Brian Lowes, MD, Jae Oh, MD^||, Jonathan F. Plehn, MD^¶, Peter Rahko, MD^#, Martin St. John Sutton, MD^_**, Eric J. Eichhorn, MD^_* the BEST Trial Echocardiographic Substudy Investigators

^_* Echocardiographic Core Laboratory, Baylor University Medical Center, Dallas, Texas
Mayo Clinic Scottsdale, Scottsdale, Arizona
University of California, San Diego, San Diego, California
University of Colorado, Denver, Colorado
^|| Mayo Clinic Rochester, Rochester, Minnesota
^¶ National Heart, Lung, and Blood Institute, Washington, DC
^# University of Wisconsin, Madison, Wisconsin
^_** University of Pennsylvania, Philadelphia, Pennsylvania

Manuscript received October 11, 2004; revised manuscript received December 3, 2004, accepted December 20, 2004.

^_* Reprint requests and correspondence: Dr. Paul A. Grayburn, Baylor Heart and Vascular Institute, Baylor University Medical Center, 621 North Hall Street, Dallas, Texas 75226 (Email: paulgr{at}baylorhealth.edu).

OBJECTIVES: The aim of this study was to determine echocardiographic predictors of outcome in patients with advanced heart failure (HF) due to severe left ventricular (LV) systolic dysfunction in the Beta-blocker Evaluation of Survival Trial (BEST).

BACKGROUND: Previous studies indicate that echocardiographic measurements of LV size and function, mitral deceleration time, and mitral regurgitation (MR) predict adverse outcomes in HF. However, complete quantitative echocardiograms evaluating all of these parameters have not been reported in a prospective randomized clinical trial in the era of modern HF therapy.

METHODS: Complete echocardiograms were performed in 336 patients at 26 sites and analyzed by a core laboratory. A Cox proportional-hazards regression model was used to determine which echocardiographic variables predicted the primary end point of death or the secondary end point of death, HF hospitalization, or transplant. Significant variables were then entered into a multivariable model adjusted for clinical and demographic covariates.

RESULTS: On multivariable analysis adjusted for clinical covariates, only LV end-diastolic volume index predicted death (events = 75), with a cut point of 120 ml/m². Three echocardiographic variables predicted the combined end point of death (events = 75), HF hospitalization (events = 97), and transplant (events = 9): LV end-diastolic volume index, mitral deceleration time, and the vena contracta width of MR. Optimal cut points for these variables were 120 ml/m², 150 ms, and 0.4 cm, respectively.

CONCLUSIONS: Echocardiographic predictors of outcome in advanced HF include LV end-diastolic volume index, mitral deceleration time, and vena contracta width. These variables indicate that LV remodeling, increased LV stiffness, and MR are independent predictors of outcome in patients with advanced HF.

Abbreviations and Acronyms   BEST = Beta-blocker Evaluation of Survival Trial   CHF = congestive heart failure   EROA = effective regurgitant orifice area   HF = heart failure   LV = left ventricle/ventricular   LVEF = left ventricular ejection fraction   MR = mitral regurgitation   NYHA = New York Heart Association   SAVE = Survival And Ventricular Enlargement trial   SOLVD = Studies Of Left Ventricular Dysfunction trial   Val-HeFT = Valsartan in Heart Failure Trial

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