1-year Rehospitalization Research Articles

Acute Rehabilitation after Trauma: Does it Really Matter?

The impact of post-discharge rehabilitation care for the trauma patient remains poorly investigated. Here we describe the functional outcomes of trauma patients discharged to an inpatient rehabilitation facility (IRF), and compare the likelihood of discharge home, 1-year rehospitalization, and 1-year mortality between patients discharged to an IRF and a propensity score-matched cohort of patients not discharged to an IRF. The Washington State Rehabilitation Registry was used to collect data for all trauma patients discharged to an IRF between 2011 and 2012. These charts were linked to the Washington State Trauma Registry and the Comprehensive Hospital Abstract Reporting System database to obtain detailed patient, injury, and mortality data. Propensity score matching was used to identify a control group of patients who were not discharged to an IRF. Primary outcomes measures were improvement in Functional Independence Measure score with inpatient rehabilitation and the likelihood of discharge home, 1-year rehospitalization, and 1-year mortality. Nine hundred and thirty-three trauma patients were discharged to an IRF between 2011 and 2012. Total functional independence measure scores improved from 63.7 (SD 20.3) to 92.2 (SD 20.9) (p < 0.001) with care at an IRF. When patients discharged to an IRF were compared with the propensity score-matched control patients, rehabilitation was found to significantly increase the likelihood of discharge to home (odds ratio= 9.41; 95% CI, 6.80-13.01) and to decrease 1-year mortality (odds ratio= 0.60; 95% CI, 0.39-0.92). Acute trauma patients should be recognized as an underserved population that would benefit considerably from inpatient rehabilitation services after discharge from the hospital.

In-hospital and 1-year mortality associated with diabetes in patients with acute heart failure: results from the ESC-HFA Heart Failure Long-Term Registry.

The aim of this study was to evaluate the in-hospital and 1-year prognostic impact of diabetes and elevated blood glucose levels at hospital admission in patients with acute heart failure (HF). We studied a multinational cohort of 6926 hospitalized patients with acute HF enrolled in the European Society of Cardiology (ESC) and Heart Failure Association (HFA) Long-Term Registry, of whom 49.4% (n = 3422) had known or previously undiagnosed diabetes (defined as self-reported history, or medication use, or fasting glucose levels ≥7.0 mmol/L or haemoglobin A1c ≥6.5%). Compared with those without diabetes, patients with known or previously undiagnosed diabetes had higher cumulative rates of in-hospital mortality, 1-year mortality, and 1-year HF re-hospitalization that occurred independently of multiple clinical risk factors: in-hospital mortality [6.8 vs. 4.4%; adjusted hazard ratio (HR) 1.774; 95% confidence interval (CI) 1.282-2.456, P < 0.001], 1-year all-cause mortality (27.5 vs. 24%; adjusted HR 1.162; 95% CI 1.020-1.325, P = 0.024), and 1-year hospital re-admissions for HF (23.2 vs. 18.5%; adjusted HR 1.320; 95% CI 1.139-1.530, P < 0.001). Moreover, elevated admission blood glucose concentrations were powerfully prognostic for in-hospital mortality, but not for 1-year mortality or re-hospitalizations, in both patients with and without diabetes. Among patients hospitalized for acute HF, the presence of diabetes is independently associated with an increased risk of in-hospital mortality, 1-year all-cause mortality, and 1-year re-hospitalizations for HF, underscoring the need for more effective and personalized treatments of diabetes in this particularly high-risk patient population.

Long-term outcome of profound hyponatremia: a prospective 12 months follow-up study.

Hyponatremia is the most common electrolyte abnormality in hospitalized patients and given its impact on mortality and morbidity, a relevant medical condition. Nevertheless, little is known about factors influencing long-term outcome. This is a prospective observational 12-month follow-up study of patients with profound hyponatremia (≤125 mmol/L) admitted to the emergency department of two tertiary care centers between 2011 and 2013. We analyzed the predictive value of clinical and laboratory parameters regarding the following outcomes: 1-year mortality, rehospitalization and recurrent profound hyponatremia. Median (IQR) initial serum sodium (s-sodium) level of 281 included patients was 120 mmol/L (116-123). During the follow-up period, 58 (20.6%) patients died. The majority (56.2%) were rehospitalized at least once. Recurrent hyponatremia was observed in 42.7%, being profound in 16%. Underlying comorbidities, assessed by the Charlson Comorbidity Index, predicted 1-year mortality (odds ratio (OR) 1.43, 95% confidence interval (CI) 1.25-1.64, P < 0.001). Furthermore, 's-sodium level at admission' (OR 1.14, 95% CI 1.01-1.29, P = 0.036) and 'correction of hyponatremia' defined as s-sodium ≥135 mmol/L at discharge were associated with mortality (OR 0.47, 95% CI 0.23-0.94, P = 0.034). Mortality rate fell with decreasing baseline s-sodium levels and was lower in the hyponatremia category ≤120 mmol/L vs >120 mmol/L (14.8% and 27.8%, P < 0.01). Patients with s-sodium level ≤120 mmol/L were more likely to have drug-induced hyponatremia, whereas hypervolemic hyponatremia was more common in patients with s-sodium >120 mmol/L. Hyponatremia is associated with a substantial 1-year mortality, recurrence and rehospitalization rate. The positive correlation of s-sodium and mortality emphasizes the importance of the underlying disease, which determines the outcome besides hyponatremia itself.

Impact of Preoperative Chronic Kidney Disease in 2,531 High-Risk and Inoperable Patients Undergoing Transcatheter Aortic Valve Replacement in the PARTNER Trial

Although preoperative renal dysfunction (RD) is associated with increased mortality and morbidity after surgical aortic valve replacement, its impact on clinical outcomes after transcatheter aortic valve replacement (TAVR) is less defined. TAVR patients in the PARTNER (Placement of Aortic Transcatheter Valves) trial with a calculable glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease equation were included. Patients were divided into three groups: GFR >60 mL/min (none/mild RD), GFR 31 to 60 mL/min (moderate RD), and GFR ≤30 mL/min (severe RD). Operative characteristics and clinical outcomes were analyzed. Cox regression models were used to determine multivariable predictors of 1-year all-cause mortality. A total of 2,531 inoperable or high surgical risk patients from the PARTNER trial and continued access registries had a calculable GFR level: 767 (30%) had normal renal function or mild RD, 1,473 (58%) had moderate RD, and 291 (12%) presented with severe RD. The mean Society of Thoracic Surgeons Predicted Risk of Mortality for the cohort was 11.5%, and it was highest in those with severe RD (13.8%). Patients with severe RD were more often women with a higher prevalence of diabetes. Patients with severe RD had the highest incidence of 30-day and 1-year all-cause mortality and rehospitalization. The 30-day rate of death from any cause was 10.7% in the severe RD group versus 6.0% in the moderate and mild RD groups (p= 0.01). The 1-year rate of death from any cause was 34.4% in the severe RD group versus 21.5% in the moderate RD and 20.8% in the none/mild RD groups (adjusted hazard ratio [HR] 2.24, p<0.0001 for severe versus none/mild; adjusted HR 1.14, p= 0.24 for severe versus moderate). Other significant predictors of 1-year all-cause mortality included lower body mass index, frailty, the transapical approach, a lower ejection fraction, oxygen-dependent chronic obstructive pulmonary disease, liver disease, and male sex. Preoperative severe RD is a significant predictor for 1-year mortality in TAVR patients. Careful risk stratification by the heart team is required in patients with severe preprocedural RD.

A prospective multicenter cohort study of frailty in younger critically ill patients.

BackgroundFrailty is a multidimensional syndrome characterized by loss of physiologic and cognitive reserve that heightens vulnerability. Frailty has been well described among elderly patients (i.e., 65 years of age or older), but few studies have evaluated frailty in nonelderly patients with critical illness. We aimed to describe the prevalence, correlates, and outcomes associated with frailty among younger critically ill patients.MethodsWe conducted a prospective cohort study of 197 consecutive critically ill patients aged 50–64.9 years admitted to intensive care units (ICUs) at six hospitals across Alberta, Canada. Frailty was defined as a score ≥5 on the Clinical Frailty Scale before hospitalization. Multivariable analyses were used to evaluate factors independently associated with frailty before ICU admission and the independent association between frailty and outcome.ResultsIn the 197 patients in the study, mean (SD) age was 58.5 (4.1) years, 37 % were female, 73 % had three or more comorbid illnesses, and 28 % (n = 55; 95 % CI 22–35) were frail. Factors independently associated with frailty included not being completely independent (adjusted OR [aOR] 4.4, 95 % CI 1.8–11.1), connective tissue disease (aOR 6.0, 95 % CI 2.1–17.0), and hospitalization within the preceding year (aOR 3.3, 95 % CI 1.3–8.1). There were no significant differences between frail and nonfrail patients in reason for admission, Acute Physiology and Chronic Health Evaluation II score, preference for life support, or treatment intensity. Younger frail patients did not have significantly longer (median [interquartile range]) hospital stay (26 [9–68] days vs. 19 [10–43] days; p = 0.4), but they had greater 1-year rehospitalization rates (61 % vs. 40 %; p = 0.02) and higher 1-year mortality (33 % vs. 20 %; adjusted HR 1.8, 95 % CI 1.0–3.3; p = 0.039).ConclusionsPrehospital frailty is common among younger critically ill patients, and in this study it was associated with higher rates of mortality at 1 year and with rehospitalization. Our data suggest that frailty should be considered in younger adults admitted to the ICU, not just in the elderly. Additional research is needed to further characterize frailty in younger critically ill patients, along with the ideal instruments for identification.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1338-x) contains supplementary material, which is available to authorized users.

Nonalcoholic Fatty Liver Disease Is Associated With Higher 1-year All-Cause Rehospitalization Rates in Patients Admitted for Acute Heart Failure.

Repeat hospitalization due to acute heart failure (HF) is a global public health problem that markedly impacts on health resource use. Identifying novel predictors of rehospitalization would help physicians to determine the optimal postdischarge plan for preventing HF rehospitalization. Nonalcoholic fatty liver disease (NAFLD) is an emerging risk factor for many heart diseases, including HF. We assessed whether NAFLD at hospital admission predicts 1-year all-cause rehospitalization in patients with acute HF.We enrolled all patients consecutively admitted for acute HF to our General Medicine Division, from January 2013 to April 2014, after excluding patients with acute myocardial infarction, severe heart valve diseases, malignancy, known liver diseases, and those with volume overload related to extracardiac causes. NAFLD was diagnosed by ultrasonography and exclusion of competing etiologies. The primary outcome of the study was the 1-year all-cause rehospitalization rate.Among the 107 patients enrolled in the study, the cumulative rehospitalization rate was 12.1% at 1 month, 25.2% at 3 months, 29.9% at 6 months, and 38.3% at 1 year. Patients with NAFLD had markedly higher 1-year rehospitalization rates than those without NAFLD (58% vs 21% at 1 y; P < 0.001 by the log-rank test). Cox regression analysis revealed that NAFLD was associated with a 5.5-fold increased risk of rehospitalization (adjusted hazard ratio 5.56, 95% confidence interval 2.46–12.1, P < 0.001) after adjustment for multiple HF risk factors and potential confounders.In conclusion, NAFLD was independently associated with higher 1-year rehospitalization in patients hospitalized for acute HF.

Abstract WP312: The Association of Chronic Kidney Disease (CKD) With 30-day and 1-year Post Ischemic Stroke Mortality and Rehospitalization: Get With the Guidelines (GWTG) Stroke

Background: The extent to which CKD is associated with 30-day and 1-year post ischemic stroke mortality and rehospitalization rates has not been well studied. Methods: Data from 232,236 fee for service Medicare patients admitted with ischemic stroke to 1581 AHA GWTG-Stroke participating hospitals between January 2009 and December 2012 were analyzed. Estimated GFR in mL/min/1.73 m2 was determined based on the MDRD study equation categorized as: no CKD (GFR ≥60); stage 3a CKD (GFR 45-59); stage 3b CKD (GFR 30-44); stage 4 CKD, (GFR 15-29); stage 5 CKD (GFR &lt;15 excluding those on dialysis). Dialysis was identified by ICD-9 codes. Multivariable Cox proportional hazards models adjusted for demographics, medical history, NIHSS, arrival hour, and hospital characteristics were used to determine the independent associations of CKD (reference group those without CKD) with mortality and readmission at 30 days and 1 year. Results: After adjustment, 30-days poststroke mortality was highest among those with CKD stage 5 (HR 1.94, 95%CI 1.72-2.18), even after excluding in-hospital mortality and patients discharged to hospice (HR 2.09, 95%CI 1.66-2.63). Unadjusted 1-year mortality and readmission rates were highest among patients on dialysis (Figure). After adjustment, 1-year post-stroke mortality remained highest among patients on dialysis (HR 2.19, 95%CI 2.08-2.31), even after excluding in-hospital mortality and discharge to hospice (HR 2.65, 95%CI 2.49-2.81). For those discharged alive, 30-day and 1-year rehospitalization rates were also highest among patients on dialysis (HR 2.10, 95%CI 1.95-2.26; HR 2.55, 95%CI 2.44-2.66, respectively) as was the 30-day and 1-year composite of mortality and rehospitalization (HR 2.04, 95%CI 1.90-2.18; HR 2.46, 95% CI 2.36-2.56, respectively). Conclusion: Among Medicare beneficiaries with acute ischemic stroke, poststroke mortality and rehospitalization varied by CKD stage and were highest among those with advanced CKD.

Relation between serum sodium levels and clinical outcomes in Turkish patients hospitalized for heart failure: a multi-center retrospective observational study.

Objective:The purpose of the study was to analyze the prevalence of hyponatremia and related 1-year outcomes of patients hospitalized for decompensated heart failure with reduced ejection fraction (HFrEF) in Turkish patients.Methods:A total of 500 hospitalized patients with HFrEF were consecutively included in a retrospective study at 19 participating hospitals. Patients were categorized according to their serum sodium levels (sNa) on admission day as normonatremic (135–145 mEq/L) and hyponatremic (<135 mEq/L). One-year all-cause mortality, re-hospitalization rates, and the impact of the changes in sNa at the time of discharge to clinical outcomes were examined.Results:Hyponatremia was observed in 29% of patients. Patients with hyponatremia had lower blood pressures, creatinine clearance, and left ventricular ejection fraction and higher serum creatinine and BUN levels on admission compared with those with normonatremia. Hyponatremia was associated with higher 1-year all-cause mortality (14% vs. 2.6%, p<0.001) and re-hospitalization rates (46.9% vs. 33.7%, p=0.005). After adjustment for covariates, hyponatremia was independently associated with 1-year all-cause mortality (adjusted HR, 4.762; 95% CI, 1.941–11.764; p=0.001). At discharge, only 50.8% of hyponatremic patients were corrected to normonatremia (≥135 mEq/L). Those with persistent hyponatremia had the highest all-cause mortality (p<0.001).Conclusion:In this study, it is demonstrated that hyponatremia is relatively common and is associated with increased 1-year all-cause mortality and re-hospitalization rates among Turkish patients hospitalized with HFrEF. Approximately 50% of the patients with initial low sNa had persistent hyponatremia at discharge, and these patients had the worst clinical outcomes.

Prognostic impact of in-hospital hyperglycemia in hospitalized patients with acute heart failure: Results of the IN-HF (Italian Network on Heart Failure) Outcome registry

ObjectivesAlthough diabetes mellitus is frequently associated with heart failure (HF), the association between elevated admission glucose levels and adverse outcomes has not been well established in hospitalized patients with acute HF. MethodsWe prospectively evaluated in-hospital mortality, post-discharge 1-year mortality and 1-year re-hospitalization rates in the Italian Network on Heart Failure (IN-HF) Outcome registry cohort of 1776 patients hospitalized with acute HF and stratified by their admission glucose levels (i.e., known diabetes, newly diagnosed hyperglycemia, no diabetes). ResultsCompared with those without diabetes (n=586), patients with either known diabetes (n=749) (unadjusted-odds ratio [OR] 1.64, 95%CI 0.99–2.70) or newly diagnosed hyperglycemia (n=441) (unadjusted-OR 2.34, 95%CI 1.39–3.94) had higher in-hospital mortality, but comparable post-discharge 1-year mortality rates. After adjustment for age, sex, systolic blood pressure, estimated glomerular filtration rate, left ventricular ejection fraction, HF etiology and HF worsening/de novo presentation, the results remained unchanged in patients with known diabetes (adjusted-OR 1.86, 95%CI 1.01–3.42), while achieved borderline significance in those with newly diagnosed hyperglycemia (adjusted-OR 1.81, 95%CI 0.95–3.45). One-year re-hospitalization rates were lower in patients with newly diagnosed hyperglycemia (adjusted-hazard ratio 0.74, 95%CI 0.56–0.96) than in other groups. ConclusionsElevated admission blood glucose levels are associated with poorer in-hospital survival outcomes in patients with acute HF, especially in those with previously known diabetes. This finding further highlights the importance of tight glycemic control during hospital stay and address the need of dedicated intervention studies to identify customized clinical protocols to improve in-hospital survival of these high-risk patients.

Abstract 12647: Race and Gender Differences in Post-Myocardial Infarction Angina Frequency and Rehospitalization Risk

Background: Race and gender disparities in in-hospital treatment and outcomes of acute myocardial infarction (MI) patients have been described, yet little is known about race and gender differences in post-MI angina frequency and rehospitalization risk. Methods: Among 11,595 MI patients treated with PCI during the index hospitalization who survived the first year post-discharge in the TRANSLATE-ACS study (2010–2012), we examined 6-week and 1-year angina frequency stratified by race and gender. We used multivariable logistic regression to assess factors associated with 1-year unplanned rehospitalization and assessed for interactions between angina status, race, and gender. Results: Among 11,595 patients, there were 7,726 (66.6%) white males, 2,816 (24.3%) white females, 616 (5.3%) black males, and 437 (3.8%) black females. Comorbidities, including hypertension, diabetes, and heart failure, were most prevalent among black females, followed by black males, white females, and white males. Compared with white patients, black patients were significantly less likely to be angina-free at 6 weeks (female: 48.7% vs. 59.8%; male: 55.0% vs. 65.3%, both p&lt;0.0001) and 12 months (female: 50.6% vs. 61.1%; male: 53.7% vs. 68.9%, both p&lt;0.0001). As shown in the Figure, rates of 1-year unplanned rehospitalization were highest among black females (34.6%), followed by white females (31.3%), black males (30.0%), and white males (25.5%, p&lt;0.0001). In the multivariable model, 6-week angina was the factor most strongly associated with 12-month unplanned rehospitalization (HR 1.40; 95% CI 1.28, 1.54; p&lt;0.0001); this relationship was not modified by race or gender (both p interaction &gt;0.05). Conclusions: Race and gender differences in post-MI angina frequency exist. Efforts to reduce post-MI rehospitalizations should target improvements in angina treatment.

THE COST OF HOSPITALIZATION AND LENGTH OF STAY FOR CHRONIC HEART FAILURE CASES IN CANADA

s S273 Canadian Cardiovascular Society (CCS) Oral CARE DELIVERY FOR HEART FAILURE PATIENTS Monday, October 26, 2015 517 THE COST OF HOSPITALIZATION AND LENGTH OF STAY FOR CHRONIC HEART FAILURE CASES IN CANADA N Zaour, M Barbeau, N Liu, R Borrelli, A Fischer Mississauga, Ontario BACKGROUND: Heart failure affects more than 600,000 patients in Canada and is associated with high rates of hospitalization and mortality. There is a lack of recent research on the real world Canadian hospitalization costs of chronic heart failure (CHF), which is critical in evaluating the economic burden of CHF. The objective of this study is to evaluate the costs and length of stay (LOS) of CHF inpatient hospitalizations that either resulted in death or survival prior to discharge. METHODS: 2009-2013 hospital abstracts from the Canadian Institute for Health Information (CIHI)’s Discharge Abstract Database (DAD) and National Ambulatory Care Reporting System (NACRS) were analyzed using a cross-sectional design. Patient hospitalization abstracts were eligible if patients had a principal diagnosis of chronic (congestive) heart failure (International Classification of Diseasese10 I50.0), were 18 years of age, did not leave the hospital against medical advice or prior to being seen, and had a valid health card number. Non-parametric statistical tests were used. RESULTS: 156,847 hospitalization abstracts were included, 140,900 and 15,947 survival and death cases respectively. Overall, 86% of cases were 65 years and 49% female. The mean cost of a CHF inpatient hospitalization was $10,123. Patients who survived hospitalization incurred a mean cost of $9,222, while patients who died during hospitalization incurred a mean cost of $18,087. The costs associated with hospitalization survival were statistically different (p 75 years compared to those who were young (20-64 years old). A history of cancer, stroke, myocardial infarction, renal failure, and dementia were independent predictors of mortality after index HF hospitalization (Table 1). CONCLUSION: Overall mortality and HF re-hospitalization rates have failed to improve from 2007 to 2012. HF admissions continue to be associated with high rates of re-hospitalizations and death. The strongest factors associated with 1-year mortality and re-hospitalization were increasing age and medical comorbidities, such as CVA, renal failure, and cancer.

Outcomes of heart failure with preserved ejection fraction in a Southeast Asian cohort.

Heart failure with preserved ejection fraction (HF-PEF) has been shown to be of better or equivalent prognosis than heart failure with reduced ejection fraction (HF-REF). We aimed to characterize and study the outcome of HF-PEF in a multiethnic South East Asian context. This is a single-centre retrospective analysis of 312 patients admitted with decompensated heart failure over 1 year from January to December 2009. We evaluated clinical characteristics of patients according to left ventricular ejection fraction at least 50 or less than 50%. Outcomes as defined by 1-year mortality and 90-day re-hospitalization rates for heart failure were compared between the two groups in an in-patient setting. The median age was 68 years and median length of hospitalization was 4 days. Around 21.8% had HF-PEF. Patients with preserved ejection fraction were more often older, female, hypertensive, with atrial fibrillation, had no coronary artery disease and had never smoked before. They were less often prescribed antiplatelets, angiotensin-converting enzyme inhibitor/angiotensin-II receptor blocker, aldosterone-receptor antagonists, digoxin and loop diuretics. After 1 year, mortality was 5.9% in patients with HF-PEF and 11.3% in those with HF-REF, but the difference was nonsignificant (P = 0.195). There was also no difference in 90-day rehospitalization rates between the groups (16.2 vs. 17.6%, respectively, P = 0.780). Poor prognostic factors for the cohort of heart failure patients included increased age, diabetes and renal impairment, but not left ventricular ejection fraction. HF-PEF is associated with distinct risk factors from HF-REF, but has a similar morbidity and mortality to HF-REF.

Transapical and Transaortic Transcatheter Aortic Valve Replacement in the United States

When transcatheter aortic valve replacement (TAVR) cannot be carried out through transfemoral access, alternative access TAVR is indicated. The purpose of this study was to explore inhospital and 1-year outcomes of patients undergoing alternative access TAVR through the transapical (TA) or transaortic (TAo) techniques in the United States. Clinical records of 4,953 patients undergoing TA (n = 4,085) or TAo (n = 868) TAVR from 2011 to 2014 in The Society of Thoracic Surgeons (STS)/American College of Cardiology Transcatheter Valve Therapy Registry were linked to Centers for Medicare and Medicaid Services hospital claims. Inhospital and 1-year clinical outcomes were stratified by operative risk; and the risk-adjusted association between access route and mortality, stroke, and heart failure repeat hospitalization was explored. Mean age for all patients was 82.8 ± 6.8 years. The median STS predicted risk of mortality was significantly higher among patients undergoing TAo (8.8 versus 7.4, p < 0.001). When compared with TA, TAo was associated with an increased risk of unadjusted 30-day mortality (10.3% versus 8.8%) and 1-year mortality (30.3% versus 25.6%, p = 0.006). There were no significant differences between TAo and TA for inhospital stroke rate (2.2%), major vascular complications (0.3%), and 1-year heart failure rehospitalizations (15.7%). Examination of high-risk and inoperable subgroups showed that 1-year mortality was significantly higher for TAo patients classified as inoperable (p = 0.012). Patients undergoing TAo TAVR are older, more likely female, and have significantly higher STS predicted risk of mortality scores than patients operated on by TA access. There were no risk-adjusted differences between TA and TAo access in mortality, stroke, or readmission rates as long as 1 year after TAVR.

Urinary Angiotensinogen Level Predicts AKI in Acute Decompensated Heart Failure: A Prospective, Two-Stage Study.

A major challenge in prevention and early treatment of acute cardiorenal syndrome (CRS) is the lack of high-performance predictors. To test the hypothesis that urinary angiotensinogen (uAGT) is an early predictor for acute CRS and 1-year prognosis in patients with acute decompensated heart failure (ADHF), we performed a prospective, two-stage, multicenter cohort study in patients with ADHF. In stage I (test set), 317 patients were recruited from four centers. In stage II (validation set), 119 patients were enrolled from two other centers. Daily uAGT levels were analyzed consecutively. AKI was defined according to Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guidelines. In stage I, 104 (32.8%) patients developed AKI during hospitalization. Daily uAGT peaked on the first hospital day in patients who subsequently developed AKI. After multivariable adjustment, the highest quartile of uAGT on admission was associated with a 50-fold increased risk of AKI compared with the lowest quartile. For predicting AKI, uAGT (area under the receiver-operating characteristic curve [AUC]=0.84) outperformed urinary neutrophil gelatinase-associated lipocalin (AUC=0.78), the urinary albumin/creatinine ratio (AUC=0.71), and the clinical model (AUC=0.77). Survivors in stage I were followed prospectively for 1 year after hospital discharge. The uAGT level independently predicted the risk of 1-year mortality (adjusted odds ratio, 4.5; 95% confidence interval, 2.1 to 9.5) and rehospitalization (adjusted odds ratio, 3.6; 95% confidence interval, 1.6 to 5.7). The ability of uAGT in predicting AKI was validated in stage II (AUC=0.79). In conclusion, uAGT is a strong predictor for acute CRS and 1-year prognosis in ADHF.

Abstract 18802: Sex Differences in the Risk of 1-year Re-hospitalization in Young Women and Men following Acute Myocardial Infarction

Background: It is currently unknown whether young women (≤55 yrs) have a greater risk of all cause-re-hospitalization following AMI than similarly aged men. This is an important subgroup to study considering younger women’s higher post-AMI mortality compared with age-matched men. We determined if there are sex differences in the 1-year re-hospitalization rate, including factors associated with this outcome. Methods: Young AMI patients (N=1414, 28% women) were identified from the 24-center prospective, observational TRIUMPH study. Patient data was abstracted from medical records and health status was collected through interviews at the time of the AMI [Short Form 12 (SF-12), and the Seattle Angina Questionnaire (SAQ)]. Physicians adjudicated each re-hospitalization the year after discharge. We compared sexes using t-test/x2 and Cox proportional hazards analysis, sequentially adjusting for important covariates. Results: The crude 1-yr re-hospitalization rate was higher in women vs. men (32% vs. 23%, P&lt;0.001), and women also had more hypertension (64% vs. 53%), diabetes (34% vs. 22%), lung disease (9% vs. 3%), and depression (14% vs. 6%; P&lt;0.0001 for all). At presentation, women had worse general health scores (SF-12 physical summary=41±12 vs. 44±11, mental summary= 45±13vs.49±11, P&lt;0.0001 for all), more angina (SAQ angina frequency=83±22 vs. 87±19), poorer physical function (SAQ physical limitation=82±24 vs. 89±19) and worse quality of life (57±23 vs. 62±23; P&lt;0.001 for all). In the fully adjusted model, female sex was no longer significantly associated with 1-year re-hospitalization post AMI (HR=1.20, 95%CI = 0.93, 1.56). Conclusion: Young women have a higher crude rate of 1-year re-hospitalization post AMI compared with men, however this effect was attenuated following adjustment. In addition to conventional risk factors, health status/psychosocial issues may be contributing factors in the risk of re-hospitalization among these young patients.

Prognostic Effect of Carbohydrate Antigen 125-guided Therapy in Patients Recently Discharged for Acute Heart Failure (CHANCE-HF). Study Design

Introduction and objectivesMorbidity and mortality after admission for acute heart failure remain prohibitively high. In that setting, plasma levels of antigen carbohydrate 125 have shown to correlate with the severity of fluid overload and the risk of mortality and readmission. Preliminary data suggests a potential role of antigen carbohydrate 125 to guide therapy. The objective of this study is to evaluate the prognostic effect of an antigen carbohydrate 125-guided management strategy vs standard therapy in patients recently discharged for acute heart failure. MethodsThis is a multicenter, randomized, single-blind, efficacy trial study of patients recently discharged from acute heart failure (< 180 days), New York Heart Association functional class II-IV and antigen carbohydrate 125 > 35 U/ml. A randomization scheme was used to allocate participants (in a 1:1 ratio) to receive therapy guided by antigen carbohydrate 125 (aiming to keep normal values) or standard treatment. Mainly, antigen carbohydrate 125-guided therapy is focused on the frequency of monitoring and titration of decongestive therapies and statins. As of December 10, 2013, there were 383 patients enrolled. The primary outcome was the composite of 1-year all-cause mortality or rehospitalization for acute heart failure. Analysis was planned to be intention-to-treat. ConclusionsDiscovering novel therapeutic strategies or finding better ways of optimizing established treatments have become a health care priority in heart failure. This study will add important knowledge about the potential of antigen carbohydrate 125 as a management tool for monitoring and titration of therapies where optimal utilization has not been well defined, such as diuretics and statins.Trial registration: ClinicalTrials.gov number: NCT02008110.

Efecto pronóstico de una estrategia terapéutica guiada por los valores del antígeno carbohidrato 125 (CHANCE-HF). Diseño del estudio

Introduction and objectivesMorbidity and mortality after admission for acute heart failure remain prohibitively high. In that setting, plasma levels of antigen carbohydrate 125 have shown to correlate with the severity of fluid overload and the risk of mortality and readmission. Preliminary data suggests a potential role of antigen carbohydrate 125 to guide therapy. The objective of this study is to evaluate the prognostic effect of an antigen carbohydrate 125-guided management strategy vs standard therapy in patients recently discharged for acute heart failure. MethodsThis is a multicenter, randomized, single-blind, efficacy trial study of patients recently discharged from acute heart failure (< 180 days), New York Heart Association functional class II-IV and antigen carbohydrate 125 > 35U/ml. A randomization scheme was used to allocate participants (in a 1:1 ratio) to receive therapy guided by antigen carbohydrate 125 (aiming to keep normal values) or standard treatment. Mainly, antigen carbohydrate 125-guided therapy is focused on the frequency of monitoring and titration of decongestive therapies and statins. As of December 10, 2013, there were 383 patients enrolled. The primary outcome was the composite of 1-year all-cause mortality or rehospitalization for acute heart failure. Analysis was planned to be intention-to-treat. ConclusionsDiscovering novel therapeutic strategies or finding better ways of optimizing established treatments have become a health care priority in heart failure. This study will add important knowledge about the potential of antigen carbohydrate 125 as a management tool for monitoring and titration of therapies where optimal utilization has not been well defined, such as diuretics and statins.Trial registration: ClinicalTrials.gov number: NCT02008110.Full English text available from: www.revespcardiol.org/en

Heart rate variability measured early in patients with evolving acute coronary syndrome and 1-year outcomes of rehospitalization and mortality.

ObjectiveThis study sought to examine the prognostic value of heart rate variability (HRV) measurement initiated immediately after emergency department presentation for patients with acute coronary syndrome (ACS).BackgroundAltered HRV has been associated with adverse outcomes in heart disease, but the value of HRV measured during the earliest phases of ACS related to risk of 1-year rehospitalization and death has not been established.MethodsTwenty-four-hour Holter recordings of 279 patients with ACS were initiated within 45 minutes of emergency department arrival; recordings with ≥18 hours of sinus rhythm were selected for HRV analysis (number [N] =193). Time domain, frequency domain, and nonlinear HRV were examined. Survival analysis was performed.ResultsDuring the 1-year follow-up, 94 patients were event-free, 82 were readmitted, and 17 died. HRV was altered in relation to outcomes. Predictors of rehospitalization included increased normalized high frequency power, decreased normalized low frequency power, and decreased low/high frequency ratio. Normalized high frequency >42 ms2 predicted rehospitalization while controlling for clinical variables (hazard ratio [HR] =2.3; 95% confidence interval [CI] =1.4–3.8, P=0.001). Variables significantly associated with death included natural logs of total power and ultra low frequency power. A model with ultra low frequency power <8 ms2 (HR =3.8; 95% CI =1.5–10.1; P=0.007) and troponin >0.3 ng/mL (HR =4.0; 95% CI =1.3–12.1; P=0.016) revealed that each contributed independently in predicting mortality. Nonlinear HRV variables were significant predictors of both outcomes.ConclusionHRV measured close to the ACS onset may assist in risk stratification. HRV cut-points may provide additional, incremental prognostic information to established assessment guidelines, and may be worthy of additional study.

Clinical outcomes associated with proton pump inhibitor use among clopidogrel-treated patients within CYP2C19 genotype groups following acute myocardial infarction.

We examined clinical outcomes with proton pump inhibitors (PPI) use within CYP2C19 genotype groups during clopidogrel treatment following acute myocardial infarction (AMI). 2062 patients were genotyped for CYP2C19*2 and *17 variants in TRIUMPH. 12 month clinical outcomes were analyzed among patients discharged on clopidogrel within CYP2C19*2 carrier, CYP2C19*17 carrier, and CYP2C19*1 homozygote genotype groups. PPI use was not associated with a difference in mortality. Among clopidogrel-treated Caucasians following AMI, PPI use was associated with a significantly higher rate of cardiac rehospitalization (HR 1.62, 95% CI 1.19-2.19; p = 0.002) compared with no PPI use. PPI users who were carriers of the CYP2C19*17 variant experienced significantly higher rates of cardiac rehospitalization (HR 2.05, 95% CI 1.26-3.33; p = 0.003), carriers of the CYP2C19*2 variant had a trend toward increased 1-year cardiac rehospitalization (HR 1.69, 95% CI 0.95-2.99; P=0.07) while no significant differences were observed among CYP2C19*1 homozygotes. These results indicate that the risks associated with PPI use among clopidogrel-treated Caucasian post-MI patients are impacted by CYP2C19 genotype, and suggest knowledge of genotype may be useful for personalizing PPI use among patients following AMI to reduce rehospitalization.

Gender Differences in the Management and Outcome of Atrial Fibrillation Complicating Acute Heart Failure

BackgroundLittle is known about sex differences in the prevalence, treatment, and outcome of atrial fibrillation complicating acute heart failure. Methods and ResultsAmong 957 patients (429 women, 528 men), included in the BIO-HF registry, 45.2% (n = 194) of the women and 45.1% (n = 238) of the men were admitted with atrial fibrillation. The primary end point was a composite of 1-year all-cause mortality and hospitalization for heart failure. Adjusted 1-year mortality and hospitalization rates were similar between sexes (women 38.5%, men 36.0%; OR for female gender: 1.1, 95% CI 0.65–1.86; P = .71. A significant interaction between female sex and age (P = .002) was observed; with worse prognosis for women <75 years (OR 7.17, 95% CI 1.79–28.66; P = .005) compared with men <75 years. No sex differences in in-hospital treatment, restoration of sinus rhythm (16.5% in women vs 14.2% in men; P = .58), or in-hospital mortality (5.7% in women vs 6.7% in men; P = .69) were observed. ConclusionsAmong patients hospitalized with acute heart failure, no sex differences in the prevalence and management of atrial fibrillation were observed. In-hospital mortality and the composite of 1-year mortality and rehospitalization were not different between sexes, but a significant sex-age interaction was observed, with worse outcome in women <75 years versus men <75 years of age.