Clinical characteristics and outcomes of nonsteroidal anti-inflammatory drug-related heart failure in real-world Japanese practice: a retrospective cohort study.

A PROPENSITY-MATCHED COHORT STUDY TO ASSESS THE EFFECTIVENESS OF A COMMUNITY HOSPITAL BASED HEART FUNCTION CLINIC

POINT: Should New Drug Development in Heart Failure Focus on Patients Discharged From an Acute Heart Failure Admission? Lessons From Recent Studies

Summary : Lifelong exercise training maintains a youthful compliance of the left ventricle (LV), whereas a year of exercise training started later in life fails to reverse LV stiffening, possibly because of accumulation of irreversible advanced glycation end products. Alagebrium is a novel drug that breaks advanced glycation end product crosslinks and improves LV stiffness in aged animals. In this study, the authors prescribed alagebrium (200 mg daily) or placebo combined with aerobic exercise training or contact control in healthy, sedentary older individuals for 1 year. The authors evaluated overall cardiac function by the use of several modalities, including invasive pressure–volume measurements, exercise testing, and cardiac MRI before and after the training. To the authors’ knowledge, this is the first study to evaluate the effects of alagebrium and exercise training in healthy aged humans. After intervention, exercise training significantly increased exercise capacity, LV mass, and LV end-diastolic volume. Conversely, alagebrium had little effect on exercise capacity or LV geometry. However, alagebrium showed a modest improvement in LV stiffness compared with placebo. This favorable effect of alagebrium on LV stiffness was most prominent in individuals with combined alagebrium and exercise training. Conclusions : Alagebrium had no effect on hemodynamics, LV geometry, or exercise capacity in healthy, previously sedentary seniors. However, it did show a modestly favorable effect on age-associated LV stiffening.1 Summary : Maximum oxygen consumption (peak VO2) and efficiency of ventilation (VE) during exercise (VE/VCO2 slope) are known to stratify adults in heart failure for 1-year survival. On the basis of adult data, a recent American Heart Association scientific statement suggested that peak VO2<50% predicted for age and sex should be considered substantial impairment in exercise performance in children with heart disease and therefore a class I indication for heart transplant listing. This single-center study examined the association of …

Assessment of quality of care in heart failure (HF) has focused on the development and use of process of care-based performance measures. While it has been presumed that these process measures when applied in actual clinical practice are associated with improved clinical outcomes, this link has not been well-established. A recent analysis of the Organized Program to Initiate Lifesaving Treatment In Hospitalized Patients With Heart Failure (OPTIMIZE-HF) 1 registry/performance improvement program examined the relationship between current performance measures for patients hospitalized with HF and relevant patient clinical outcomes. This study found that none of the current HF performance measures were significantly associated with reduced early mortality risk and only angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use at discharge was associated with 60- to 90-day postdischarge mortality or rehospitalization. b-Blocker therapy at the time of hospital discharge, currently not an HF performance measure, was strongly associated with reduced risk of mortality and mortality/rehospitalization postdischarge. To accurately identify health care providers and hospitals providing care that is associated with more optimal clinical outcomes, additional HF performance measures as well as better methodology for identifying and validating performance measures is needed. HF is the leading cause of hospitalization in persons older than 65 years, with almost 3.6 million hospitalizations attributed to HF as the primary or a secondary discharge diagnosis each year. 2 HF patients are at substantial risk for recurrent exacerbations of symptoms requiring intervention, with up to 50% of discharged patients being rehospitalized within 6 months. An estimated 11.6% of HF patients die within 30 days and 33.1% of patients die within 1 year after their first hospitalization for HF. 3 Uniform highquality health care might reasonably be expected to reduce this burden of morbidity and mortality associated with HF. Evidence-based guidelines for the diagnosis and treatment of patients with HF have been developed. 2,4 To facilitate the measurement of and improvement in quality of care in HF, components of these guidelines have been adapted by the various organizations as performance measures. 5,6 These performance measures are based on clinical practice guidelines but are intended to be confined to those structural aspects or processes of care for which the evidence is so strong that the failure to perform them reduces the likelihood of optimal patient outcomes. 5 It is impor

As we approach the end of the first decade of the 21st century, it is evident that the epidemic of heart failure has not abated, nor have concerns about the quality of care received by patients with this condition. Recent data from the American Heart Association1 and the Centers for Disease Control and Prevention2 reaffirm that the number of patients hospitalized with heart failure has grown steadily over the past 30 years. With aging of the US population, this trend will undoubtedly continue, but it is also noteworthy that the increase in heart failure hospitalizations over the past few decades is not limited to the Medicare population.2 Moreover, the outcome of heart failure patients after hospital discharge is not improving. Despite evidence-based guidelines, performance measures, quality improvement programs, and public reporting of hospital-level performance data, the number of patients dying or readmitted to hospitals within 30 days of hospital discharge has not declined3–6 and is equivalent in patients with depressed and those with preserved left ventricular systolic function.7 Hospital readmission is expensive and contributes to the increasing economic burden of heart failure, but this is often a preventable event. However, the characteristics of patients who will require rehospitalization have not been identified,5 and it is impossible to predict which patients will be readmitted. In many cases it is not the patient, but the healthcare system involving multiple providers and transitions of care, that makes the conditions ripe for high readmission rates. Article See p 29 The fundamental first step in identifying and correcting gaps in healthcare quality is setting standards of care through development of evidence-based clinical practice guidelines. From quality indicators emphasized in guidelines, clinical performance measures can be derived to evaluate the quality of care provided by hospitals and by individual practitioners. …

The relationship between the Charlson comorbidity index (CCI) and short-term readmission is as yet unknown. Therefore, we aimed to investigate whether the CCI was independently related to short-term readmission in patients with heart failure (HF) after adjusting for other covariates. From December 2016 to June 2019, 2008 patients who underwent HF were enrolled in the study to determine the relationship between CCI and short-term readmission. Patients with HF were divided into 2 categories based on the predefined CCI (low < 3 and high > =3). The relationships between CCI and short-term readmission were analyzed in multivariable logistic regression models and a 2-piece linear regression model. In the high CCI group, the risk of short-term readmission was higher than that in the low CCI group. A curvilinear association was found between CCI and short-term readmission, with a saturation effect predicted at 2.97. In patients with HF who had CCI scores above 2.97, the risk of short-term readmission increased significantly (OR, 2.66; 95% confidence interval, 1.566-4.537). A high CCI was associated with increased short-term readmission in patients with HF, indicating that the CCI could be useful in estimating the readmission rate and has significant predictive value for clinical outcomes in patients with HF.

Section 11: Evaluation and Management of Patients With Heart Failure and Preserved Left Ventricular Ejection Fraction

Mortality and Morbidity Following Heart Failure Hospitalization in Adults With and Without Congenital Heart Disease.

Readmission after hospitalization for heart failure (HF) has received increasing attention due to the significant burden it places on patients and payers.[1][1]–[2][2] Among Medicare beneficiaries, readmission within 30 days following heart failure hospitalization approaches 25%.[2][2] Even after

The patient, W.L., is a 62-year-old white man with a history of hypertension, hypercholesterolemia, and an anterior Q-wave myocardial infarction 3 years ago. He has had 2 admissions for heart failure in the past 6 months. He was last discharged 2 months ago on aspirin 325 mg daily, simvastatin 40 mg daily, enalapril 10 mg BID, metoprolol XL 100 mg daily, digoxin 0.25 mg daily, and furosemide 120 mg BID. Over the past month, he has noted some increasing dyspnea on exertion and occasional episodes of paroxysmal nocturnal dyspnea but has not had any increase in peripheral edema or body weight. His left ventricular ejection fraction on discharge from the hospital 2 months ago was 26%, with evidence of a large anterior akinetic area but without evidence of inducible myocardial ischemia on dobutamine echocardiography. His laboratory data today included a hematocrit of 41%, serum creatinine 1.1 mg%, potassium 4.1 meq/L, fasting blood sugar 108 mg%, LDL cholesterol 92 mg/dL, HDL cholesterol 45 mg/dL, triglycerides 188 mg/dL, serum digoxin level 1.2, and brain natriuretic peptide (BNP) (Biosite) 508. ECG revealed evidence of an old anterior myocardial infarction, and chest x-ray showed cardiomegaly with some increase in pulmonary vascularity. At this time, would you suggest any change in his medical regimen? Angiotensin-converting enzyme (ACE) inhibition and β-blockade have been shown effective in improving survival in patients with systolic left ventricular dysfunction (SLVD) resulting from both ischemic and nonischemic cardiomyopathy; they are indicated in all patients with heart failure (HF) caused by SLVD unless contraindicated or not tolerated. Although they improve the symptoms of HF, loop diuretics and digoxin have not been shown to reduce mortality rate. There is, however, increasing evidence that aldosterone blockade is effective in reducing mortality and morbidity rates in patients with HF caused by SLVD that is associated …

Section 6: Nonpharmacologic Management and Health Care Maintenance in Patients With Chronic Heart Failure

Successes and failures of current treatment of heart failure

Heart failure is a deadly disease that has reached epidemic proportions in industrialized countries. Patients living with heart failure carry a heavy burden in terms of morbidity. Many patients require repeated hospitalizations for cardiovascular problems, especially for episodes of worsening heart failure. In fact, heart failure is one of the most important causes of hospital admissions in the United States, accounting for over 2.5 million admissions per year. Once hospitalized, patients with heart failure have an increased risk of recurrent hospitalizations and death. Approximately 30% to 40% of patients are readmitted within 6 months of an index hospitalization. Angiotensin-converting enzyme (ACE) inhibitors, digitalis, and spironolactone decrease the risk of hospitalization in heart failure patients; however, the annual rate of hospital admission for worsening heart failure has remained high.1–3⇓⇓ See p 2194 Given these challenges, clinical trials conducted in the mid 1990s that demonstrated that β-blocker therapy in addition to ACE inhibitors and digitalis reduces the risk of hospitalization in heart failure patients by about 20% to 30% represented remarkable progress. These beneficial effects of β-blocking agents on morbidity were recognized well before favorable effects on survival were unequivocally established (Table). In some, but not all, trials, the clinical benefits of β-blocker treatment included improved heart failure symptoms as assessed by physicians and patients. View this table: Large-Scale Clinical Trials Reporting β-Blocker Effects on Heart Failure Morbidity Previous trials addressing the effects of β-blockers on morbidity have been conducted in patients …

The aim of this study was to clarify whether worsening of independence in activities of daily living (ADL) and also difficulties in ADL are triggered by hospitalization in older patients with heart failure (HF) and whether difficulties in ADL can predict readmission for HF regardless of independence in ADL in these patients. We enrolled 241 HF patients in the present multi-institutional, prospective, observational study. The patients were divided according to age into the non-older patient group (<75 years, n = 137) and the older patient group (≥75 years, n = 104). The Katz index and the Performance Measure for Activities of Daily Living-8 (PMADL-8) were used to evaluate independence and difficulties in ADL, respectively. The endpoint of this study was rehospitalization for HF. Independence as indicated by the Katz index at discharge was significantly lower than that before admission only in the older patient group, and the value of the PMADL-8 at discharge was significantly higher than that before admission (P < 0.001). In all patients, after adjusting for the Katz index and other variables, PMADL-8 score was a significant predictor of rehospitalization for HF (hazard ratio 1.50; 95% confidence interval 1.07-2.13; P = 0.021). Worsening of both independence and difficulties in ADL was triggered by hospitalization in older HF patients, and difficulties in ADL were relevant factors for risk of rehospitalization regardless of independence in ADL. These findings indicate the importance of preventing not only decreased independence but also increased difficulties in ADL during and after hospitalization.

Monitoring Is Key to Heart Failure in Elders