Admission For Acute Decompensated Heart Failure Research Articles

The Use of Drugs that Should be Avoided or Used with Caution in Patients Hospitalized for Acute Decompensated Heart Failure.

Heart failure (HF) is a pervasive global health concern, with acute decompensated heart failure (ADHF) contributing significantly to morbidity and mortality. Medications used in patients with HF may exacerbate HF or prolong the QT interval, posing additional risks. The objective is to assess the prevalence and utilization patterns of medications known to cause or exacerbate HF and prolong the QT interval among patients with ADHF. Understanding these patterns is crucial for optimizing patient care and minimizing potential risks. A retrospective chart review was conducted at Huntsville Hospital, Huntsville, USA, covering 602 patients with ADHF over a 40-month period. Inclusion criteria involved age ≥ 18 years, a history of HF, and ADHF admission. The 2016 American Heart Association Scientific Statement was used to identify drugs that may cause or exacerbate HF and those that could prolong the QT interval RESULTS: Among the 602 patients, 57.3% received medications causing or exacerbating HF, notably albuterol (34.9%) and diabetes medications (20.4%), primarily metformin, followed by urologic agents (14.3%), mostly tamsulosin, and nonsteroidal anti-inflammatory drugs (NSAIDs) (6.1%). Moreover, 82.9% were on medications prolonging the QT interval, with loop diuretics, amiodarone, ondansetron, and famotidine most prevalent. Furthermore, 42.1% of the patients received more than two concomitant medications that prolong the QT interval, which can further exacerbate the risk of torsades de pointes. This study underscores the high prevalence of HF-causing or HF-exacerbating medications and QT-prolonging drugs in patients with ADHF. Healthcare professionals must be cognizant of these patterns, advocating for safer prescribing practices to optimize patient outcomes and reduce the burden of HF-related hospitalizations.

Impact of Outpatient Beta Blocker Therapy Adjustment on Tachyarrhythmias in Patients With Heart Failure With Reduced Ejection Fraction Admitted for Acute Decompensated Heart Failure.

Background: Limited data exists to evaluate the optimal management of outpatient beta blocker therapy when patients with heart failure with reduced ejection fraction (HFrEF) are admitted for acute decompensated heart failure (ADHF). Objective: This study aimed to compare the effects of holding or decreasing the dose of outpatient beta blocker therapy vs continuation of therapy on rates of tachyarrhythmias during admission for ADHF. Methods: This single-center, retrospective cohort study divided patients with HFrEF (left ventricular ejection fraction less than or equal to 40%) admitted for ADHF into two cohorts: one that had their outpatient beta blocker continued at the same dose upon admission and one that had it held or dose decreased. The primary outcome was a composite of non-sustained or sustained ventricular tachycardia, ventricular fibrillation, or atrial fibrillation or flutter with rapid ventricular response during the hospitalization. Secondary outcomes included the individual tachyarrhythmias in the primary outcome, in-hospital mortality, and 90-day re-admission for heart failure. Results: Of the 137 patients included, 82 were in the continuation cohort and 55 in the discontinuation/reduction cohort. The median length of stay was 5.3 days (interquartile range, 3.8-7.6). No significant difference in the primary composite outcome was found between the discontinuation/reduction and continuation cohorts (29.1% vs 22.0%; relative risk [95% confidence interval], 1.33 [.74-2.37]; P = .420). No significant differences were seen between the two cohorts for any of the secondary outcomes. Conclusion: Beta blocker therapy adjustment on admission for ADHF may not affect the occurrence of tachyarrhythmias in patients with HFrEF.

Long-term impact of home-based monitoring after an admission for acute decompensated heart failure: a systematic review and meta-analysis of randomised controlled trials

Patients with heart failure have high rehospitalisation rates and poor cardiovascular outcomes. Home-based monitoring (HBM) has emerged with promising results in different settings. However, its long-term effects on patients recently admitted for acute decompensated heart failure (ADHF) remain uncertain. We systematically searched PubMed, Embase, and Cochrane Library for randomised controlled trials (RCTs) comparing HBM with usual care (UC) that were published between database inception and June 24, 2023. We included studies with patients admitted for ADHF in the previous 6 months and with a minimum follow-up of 6 months. We excluded studies with patients hospitalised for reasons other than ADHF and studies with disproportional education interventions between arms. Statistical analyses were performed using R software version 4.3.2. We pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) for categorical and continuous outcomes, respectively. Cochrane Collaboration's tool for assessing risk of bias in RCTs (RoB 2) was used to assess study quality. Publication bias was assessed via funnel plots and Egger's test, and heterogeneity was assessed through I2 statistics and sensitivity analysis. The protocol for this systematic review and meta-analysis was registered in the International Prospective Register of Systematic Reviews (PROSPERO, CRD42023465359). We included 16 RCTs comprising 4629 patients, of whom 2393 (51.7%) were randomised to HBM and 3150 (68%) were men. Follow-up ranged from six to fifteen months. As compared with UC, HBM significantly reduced all-cause mortality (RR 0.75; 95% CI 0.61, 0.91; p=0.005), all-cause hospitalisations (RR 0.82; 95% CI 0.70, 0.97; p=0.018), cardiovascular (CV) mortality (RR 0.53; 95% CI 0.36, 0.79; p=0.002), hospitalisations for heart failure (RR 0.75; 95% CI 0.62, 0.91; p=0.004), and CV hospitalisations (RR 0.72; 95% CI 0.55, 0.95; p=0.018). There were no significant differences in length of hospital stay (MD 0.97 days; 95% CI -0.90, 2.84; p=0.308). In patients recently admitted with ADHF, HBM significantly reduces long-term all-cause mortality and hospitalisations, CV mortality and hospitalisations, and hospitalisations for heart failure, as compared with UC. This supports the implementation of HBM as a standard practice to optimise patient outcomes following admissions for ADHF. However, future studies are warranted to evaluate the efficacy and safety of implementing HBM in the real-world setting. None.

Comparison of Characteristics and Outcomes in Patients With Acute Decompensated Heart Failure Admitted Under General Medicine and Cardiology Units

Acute decompensated heart failure (ADHF) is a leading cause of cardiovascular disease hospitalisations associated with significant morbidity and mortality. In hospitals, HF patients are typically managed by cardiology or physician teams, with differences in patient demographics and clinical outcomes. This study utilises contemporary HF registry data to compare patient characteristics and outcomes in those with ADHF admitted into General Medicine and Cardiology units. The Victorian Cardiac Outcomes Registry was utilised to identify patients hospitalised with ADHF 30-day period in each of four consecutive years. We compared patient characteristics, pharmacological management and outpatient follow-up of patients admitted to General Medicine and Cardiology units. Primary outcome measures included in-hospital mortality, 30-day readmission, and 30-day mortality. Between 2014 and 2017, a total of 1,253 patients with ADHF admissions were registered, with 53% admitted in General Medicine units and 47% in Cardiology units. General Medicine patients were more likely to be older (82 vs 71 years; p<0.001), female (51% vs 34%; p<0.001), and have higher prevalence of comorbidities and preserved left ventricular function (p<0.001). There were no differences in primary outcome measures between General Medicine and Cardiology in terms of: in-hospital mortality (5.0% vs 3.9%; p=0.35), 30-day readmission (23.4% vs 23.6%; p=0.93), and 30-day mortality (10.0% vs 8.0%; p=0.21). Hospitalised patients with HF continue to have high mortality and rehospitalisation rates. The choice of treatment by General Medicine or Cardiology units, based on the particular medical profile and individual needs of the patients, provides equivalent outcomes.

The impact of COVID-19 pandemic on air particulate matter exposure and heart attacks: a 5-year retrospective cohort study in Taiwan (2017-2021).

Heart attacks including acute ST-segment elevation myocardial infarction (STEMI) and acute decompensated heart failure (ADHF) caused from the particulate matter (PM) and air pollutant exposures are positively associated with regional air pollution severity and individual exposure. The exceptional coronavirus disease epidemic of 2019 (COVID-19) may enhance the air conditions in areas under COVID-19 pandemic. We sought to study the impact of COVID-19 pandemic on air particulate matter (PM) exposure and heart attacks in Taiwan. This retrospective cohort study was conducted in one teaching hospital in Taichung, Taiwan. We examined emergency patients diagnosed with acute STEMI and ADHF from January 1, 2017, to March 31, 2020, (i.e., before the COVID-19 pandemic) and from April 1, 2020, to December 31, 2021, (after the COVID-19 pandemic). The effects of particulate matter with a diameter of less than 2.5 micrometers (PM2.5) and PM10 as well as temperature and humidity on environmental air pollutants were recorded. The analysis was performed with a unidirectional case-crossover research design and a conditional logistic regression model. Both PM2.5 and PM10 levels had a positive association with the risk of acute STEMI before the COVID-19 pandemic (PM2.5 adjusted odds ratio (OR): 1.016, 95% confidence interval (CI): 1.003-1.032 and PM10 adjusted OR: 1.009, 95% CI: 1.001-1.018) and ADHF (PM2.5 adjusted OR: 1.046, 95% CI: 1.034-1.067 and PM10 adjusted OR: 1.023, 95% CI: 1.027-1.047). Moreover, the results demonstrated that PM2.5 and PM10 were not associated with the risk of acute STEMI or ADHF after the COVID-19 pandemic. Reduction in PM2.5 and PM10 levels after the COVID-19 pandemic were noted. Hospital admissions for acute STEMI (7.4 and 5.8/per month) and ADHF (9.7 and 8.2/per month) also decreased (21.6 and 15.5%) after the COVID-19 pandemic. In Taiwan, paradoxical reductions in PM2.5 and PM10 levels during the COVID-19 pandemic may decrease the number of hospital admissions for acute STEMI and ADHF. As the COVID-19 pandemic eases, the condition of air pollution may gradually become worse again. The governments should formulate better policies to improve the health of the public and the quality of the air.

Long-term impact of remote monitoring after hospitalisations for acute decompensated heart failure: a systematic review and meta-analysis of randomised controlled trials

Abstract Background Remote monitoring (RM) has demonstrated to improve outcomes of patients with heart failure (HF) in different settings. However, the long-term efficacy of RM after discharge of patients hospitalised for acute decompensated heart failure (ADHF) remains uncertain. Purpose We aimed to perform a systematic review and meta-analysis comparing RM with usual care (UC) in patients recently hospitalised for ADHF. Methods We systematically searched PubMed, EMBASE, and Cochrane Library in February 2023 in accordance with PRISMA guidelines for randomised controlled trials (RCTs) comparing RM with UC initiated within 6 weeks of discharge after an admission for ADHF, with a minimum follow-up of 6 months. Statistical analyses were performed using R Software 4.1.0., and heterogeneity was assessed using I² statistics. We extracted the data following the intention-to-treat principle. Results We included six RCTs comprising 2,817 patients, of whom 1,436 (51.0%) were randomised to RM. Follow-up ranged from 6 to 15 months. In the pooled analysis, RM was associated with a significant reduction in cardiovascular mortality (OR 0.59; 95% CI 0.36–0.97; p=0.036; I²=0%; Fig. 1A) and cardiovascular hospitalisations (OR 0.71; 95% CI 0.57–0.88; p=0.002; I²=0%; Fig. 1B), with a low heterogeneity between studies. Nonetheless, there was no significant difference between RM and UC with regards to hospitalisations for HF (OR 0.88; 95% CI 0.67–1.15; p=0.340; I²=66%; Fig. 2A) or all-cause hospitalisations (OR 0.89; 95% CI 0.73–1.08; p=0.241; I²=67%; Fig. 2B), albeit with a high heterogeneity between studies. Conclusion In this meta-analysis, post-discharge RM was associated with a reduction in cardiovascular mortality and cardiovascular hospitalisations rates as compared with UC in patients admitted for ADHF.Figure 1Figure 2

Abstract 13566: Voice as a Biomarker to Detect Acute Decompensated Heart Failure: Pilot Study for the Analysis of Voice Using Deep Learning Models

Acute decompensated heart failure (ADHF) is a systemic congestion state requiring timely management. Admission for ADHF is closely related to the readmission and post-discharge mortality in patients, which makes it imperative to detect ADHF in its early stage. Body fluid overload due to ADHF can change voice characteristics by causing edema of lung, larynx, and vocal cord. Voice is a noninvasive and accessible biomarker which can be monitored even in telemedicine practices, but there are few studies in the area. We hypothesized that there would be certain differences of voice characteristics in patients with ADHF when admitted to the hospital and at discharge. This was a prospective study conducted in a tertiary hospital in Korea. Patients with ADHF needed admission were eligible for enrollment, and those with respiratory infection, sepsis, lung/vocal cord disease, acute coronary syndrome, or serum creatinine&gt;3mg/dL were excluded. A total of 112 patients were enrolled between July 1, 2020 and December 31, 2022. Voice was recorded two times: at admission for ADHF, and at discharge. Patients were asked to phonate five Korean vowels (‘a/e/i/o/u’) for 3 seconds each, and then to repeat the sentence ‘daehan minkook manse’ five times. Voice was classified by Convolutional Neural Networks (CNNs). Mel-Spectrogram was conducted to convert the audio from waveform to the spectrogram, and then, transfer learning was done to further classify the voice characteristics. Deep learning models including DenseNet, InceptionNet, and ResNet were conducted to classify voice samples and identify potential characteristics associated with ADHF. We trained the models to classify whether certain voice belongs to ADHF state or recovered state. We treated it as a binary classification task, and the best performing model achieved a classification accuracy of 79% with DenseNet. Interestingly, the classification accuracy conducted with CNNs was highest for ‘u’ achieving 72%, compared to other vowels. To the best of our knowledge, this is the first study to try to detect ADHF with voice using deep learning models, especially with CNNs. We achieved a best classification accuracy of 79%. Our results proposed the possibility of voice as a useful biomarker to detect ADHF in its early stage.

Abstract 12398: Prognostic Impact of Early Ablation in Patients With Decompensated Heart Failure Accompanied by Atrial Fibrillation

Introduction: Atrial fibrillation (AF) and heart failure (HF) frequently coexist, which leads to worse clinical outcomes. Catheter ablation (CA) of AF in younger patients with HF with reduced EF (HFrEF) has become an established treatment option. However, clinical impact of early CA of AF in patients hospitalized for acute decompensated heart failure (ADHF) is uncertain. Hypothesis: This study aims to investigate the prognostic impact of early CA of AF in patients who were hospitalized for ADHF. Methods: Consecutive 234 patients with ADHF requiring in-hospital care accompanying with AF were retrospectively analyzed 2 years after discharge. Patients who underwent CA within 3 months after HF admission (CA group; n=51) and those who did not (optimal medical therapy [OMT] group; n=183) were compared with regards to clinical outcomes. Results: The median age of the studied population was 83 year-old; 72±12 in the CA group and 84±9 in the OMT group. Persistent AF was observed in 92.2% in the CA group and 63.9% in the OMT group. During 2 years after admission, recurrence of AF was observed in 19.6% in the CA group and 82.0% in the OMT group. In the crude study, all-cause mortality and HF mortality were significantly lower in the CA group than in the OMT group (all-cause: hazard ratio (HR) [95%CI]: 0.07 [0.01-0.53], p=0.00074; HF: HR 0.19 [0.07-0.48], p=0.000078; respectively) (Figure A and Figure B). Since the OMT group had severer characteristics including age, sex or NYHA class, a propensity-matched analysis was performed (n=33, each group). All-cause mortality tended to be lower in the CA group (HR 0.19 [0.02-1.67], p=0.13) (Figure C), however, it did not reach to a statistical significance. On the other hand, HF readmission rate was still significantly lower in the CA group even after the propensity-matched analysis (HR 0.17 [0.04-0.59], p=0.0054) (Figure D). Conclusions: CA of AF early after ADHF admission was associated with a better long-term prognosis in patients with HF and AF.

Acute Decompensated Heart Failure with Preserved Ejection Fraction: Do the Asian Phenotypes Fit?

Background: There is sparsity in regional data surrounding heart failure with preserved ejection fraction (HFpEF)-related acute decompensated heart failure (ADHF) admissions in southeast Asia. This study aims to describe the characteristics, clinical parameters and outcomes related to HFpEF-linked ADHF admissions. Methods: A retrospective, observational study was conducted in a major cardiac tertiary centre in Malaysia over a 10-year period (2009–2018). A total of 4,198 patients were identified, of which 632 had HFpEF. Results: HFpEF patients were significantly older (mean 67.6 years) and female (52.2%). A high proportion of HFpEF patients had hypertension (73.4%), diabetes (58.1%), coronary artery disease (57.9%) and ischaemic cardiomyopathy (50.8%), although this remains significantly lower versus non-HFpEF patients. Atrial fibrillation (AF) was more common among HFpEF patients (34.7%). HFpEF patients in the study population appeared relatively stable, compared to non-HFpEF patients, supported by better blood results (suggestive of less congestion) on admission, shorter duration of inpatient stay, lower use of emergency cardiac procedures, lower in-hospital mortality rates and lower rates of HF readmission and all-cause mortality. However, when compared to other registries, specifically the ASIAN-HF cohort, HF readmission and all-cause mortality within the first year were higher in the present study cohort (37.9%, versus 12.1–23.6%). Conclusion: The present study highlights key characteristics of HFpEF patients in Malaysia and challenges the notion of the five major phenotypes of HF proposed by previous studies. Therefore, granularity in data collection and analysis is key, especially in a heterogenous condition like HFpEF, and efforts should be improved to obtain more information on local HFpEF patients.

Racial and Socioeconomic Differences in Heart Failure Hospitalizations and Telemedicine Follow-up During the COVID-19 Pandemic: Retrospective Cohort Study.

Low rates of heart failure (HF) hospitalizations were observed during the 2020 peak of the COVID-19 pandemic. Additionally, posthospitalization follow-up transitioned to a predominantly telemedicine model. It is unknown whether the shift to telemedicine impacted disparities in posthospitalization follow-up or HF readmissions. The aim of this paper is to determine whether the shift to telemedicine impacted racial and ethnic as well as socioeconomic disparities in acute decompensated heart failure (ADHF) follow-up and HF readmissions. We additionally sought to investigate the impact of the COVID-19 pandemic on the severity of ADHF hospitalizations. This was a retrospective cohort study of HF admissions across 8 participating hospitals during the initial peak of the COVID-19 pandemic (March 15 to June 1, 2020), compared to the same time frame in 2019. Patients were stratified by race, ethnicity, and median neighborhood income. Hospital and intensive care unit (ICU) admission rates, inpatient mortality, 7-day follow-up, and 30-day readmissions were assessed. From March 15, 2019, to June 1, 2020, there were 1162 hospitalizations for ADHF included in the study. There were significantly fewer admissions for ADHF in 2020, compared with 2019 (442 vs 720; P<.001). Patients in 2020 had higher rates of ICU admission, compared with 2019 (15.8% vs 11.1%; P=.02). This trend was seen across all subgroups and was significant for patients from the highest income quartile (17.89% vs 10.99%; P=.02). While there was a trend toward higher inpatient mortality in 2020 versus 2019 (4.3% vs 2.8%; P=.17), no difference was seen among different racial and socioeconomic groups. Telemedicine comprised 81.6% of 7-day follow-up in 2020, with improvement in 7-day follow-up rates (40.5% vs 29.6%; P<.001). Inequities in 7-day follow-up for patients from non-Hispanic Black racial backgrounds compared to those from non-Hispanic White backgrounds decreased during the pandemic. Additionally, those with telemedicine follow-up were less likely to be readmitted in 30 days when compared to no follow-up (13.8% vs 22.4%; P=.03). There were no major differences in HF ICU admissions or inpatient mortality for different racial and socioeconomic groups during the COVID-19 pandemic. Inequalities in 7-day follow-up were reduced with the advent of telemedicine and decreased 30-day readmission rates for those who had telemedicine follow-up.

Dynamic right ventricular structural and functional changes in acute decompensated heart failure, new insights from serum sST2 and speckle-tracking echocardiography imaging

Abstract Background Right ventricular (RV) mechanics are affected by volume/pressure overload in acute decompensated heart failure (ADHF) which can be detected using biomarkers and echocardiography. ST2 (suppression of tumorigenicity 2) is a biomarker of myocardial fibrosis and remodeling, that has been studied in patients with ADHF. Although baseline serum soluble ST2 (sST2) values at ADHF admission have been proved to predict outcomes, serial measurements are even of greater value. Purpose To evaluate the right ventricular dynamic structural and functional changes in ADHF patients during hospitalization, using serum sST2 and speckle-tracking echocardiography imaging. Methods We prospectively enrolled 61 ADHF patients with LV ejection fraction less than 50% and serum NT-proBNP more than 900 pg/ml. All patients received intravenous diuretics and did not require inotropic support during hospital stay. Blood samples were collected to measure serum sST2 levels on hospital admission and discharge. All patients underwent serial conventional and speckle tracking echocardiography on admission, at 48 hours and on hospital discharge. RV speckle tracking echocardiography analysis was done using 2D Cardiac Performance Analysis version 4.6. Results Serum sST2 had significant strong positive correlation with serum NT-proBNP on admission (r=0.84, P&amp;lt;0.0001) and showed significant reduction from 2.47 (1.27–4.05) ng/ml on admission to 1.86 (1.06–3.24) ng/dl at hospital discharge (P&amp;lt;0.0001) denoting successful decongestion. There was significant decrease in inferior vena cava diameter (P&amp;lt;0.0001) and estimated pulmonary artery systolic pressure (EPASP) (P=0.002) throughout hospital stay, however this was not associated with significant change in RV dimensions (P&amp;gt;0.05) or contractility assessed by trans-annular plane systolic excursion (TAPSE) (P=0.09) and S-wave velocity at lateral tricuspid annulus (P=0.9). There was significant improvement in RV free wall strain (RVFWS) (P=0.005) assessed by speckle tracking echocardiography which was mainly noticed after the first 48 hours till discharge, but RV 4-chamber strain (RV4CS) did not change significantly (P=0.06). Conclusions RVFWS assessed by speckle tracking echocardiography can detect improvement in RV systolic function not detected by other conventional echocardiographic parameters in ADHF patients. Improvement in RVFWS together with decline in serum sST2 levels can be used as marker of improved cardiac mechanics and successful decongestion. Funding Acknowledgement Type of funding sources: None.

Effect of environment and season on acute decompensated heart failure: Data from low-to middle-income country

ObjectivesThe environmental effect in heart failure (HF) patients is well established. However, the data is limited from low-to middle-income countries like India. This study determined the impact of environment on acute decompensated HF (ADHF) admissions and mortality in India. MethodsRetrospectively, the data of all HF patients admitted between April 2017 and March 2019 was accessed through electronic hospital records. Simultaneously, the environmental-related data was collected from the central pollution control board. ResultsThe study included 4561 patients of ADHF. The peak of monthly ADHF events (admission and mortality) was observed during the chilly month (January) while the lowest rates were observed in summer months (May–June). The most significant factor correlating inversely with the monthly ADHF admission (r = −0.78, p = 0.003) and mortality (r = −0.65, p = 0.004) was the maximum air temperature, and it was found to be the independent predictor for both ADHF mortality [t = −2.78, β = −0.84; 95%CI(-6.0 to −0.6), p = 0.021] and admission [t = −4.83, β = −0.91; 95%CI(-19.8 to −6.9), p = 0.001]. The above correlation was better seen in the elderly subset and male gender. Humidity and the air pollution attributes did not have a significant correlation with ADHF admission or mortality. ConclusionIn conclusion, even in low-to middle-income country like India, a periodic effect of season was demonstrated for ADHF mortality and admission, with a peak in ADHF events noted during winter months especially in the regions having extremes of seasons. Air pollution could not affect the ADHF outcome for which further studies are needed.

Evaluation Of Reduced 30-Day Readmission Rates And Pharmacotherapy Management In Patients Attending Rapid Follow Up Appointments After Hospitalization For Acute Decompensated Heart Failure

<h3>Introduction</h3> : Early readmission after hospitalization for acute decompensated heart failure (ADHF) remains a major public health problem. Management of recurrent heart failure admissions creates a significant burden on the healthcare system and mortality rates rise with increasing heart failure admissions. Early follow up after heart failure hospitalization (HFH) is associated with reduced readmission. <h3>Hypothesis</h3> We hypothesized that pharmacotherapy management in the early follow up period may be associated with lower rates of readmission. <h3>Methods</h3> : We conducted a retrospective analysis of patients scheduled for post discharge rapid follow up (RFU) after HFH at The Mount Sinai Hospital (MSH) between August 1^st, 2020 and January 31^th, 2021. A chart review was performed of patients who were discharged from MSH that were seen or not seen at RFU clinic. We reviewed discharge medications as well as changes made to guideline directed medical therapy and loop diuretic therapy prior to or during RFU clinic. We surveyed hospital readmissions and evaluated the association between 30-day readmission and RFU visits as well as medication adjustments. <h3>Results</h3> During this 6 month period, 207 patients with ADHF admissions were offered RFU appointments prior to discharge. 115 (55.6%) attended a RFU visit at which time 74 (64.3%) of these patients had medication adjustments. The most commonly adjusted medication classes were diuretics (35.1%), beta blockers (14.9%), ACEI/ARBs (14.9%), and ARNIs (12.8%). The most common newly initiated medication classes were ARNIs (35%), SGLT-2Is (25%), and MRAs (20%). Overall, 48 (23.2%) patients were readmitted within 30 days, which occurred in 18 (15.7%) of those seen at RFU and 30 (32.6%) of those that did not attend RFU. Among those seen at RFU, 30-day readmission occurred in 10 (13.5%) of those with medication adjustments and in 8 (19.5%) of those that were seen but did not have medications adjustments. <h3>Conclusion</h3> : Patients with early follow up appointments after hospitalization for acute decompensated heart failure hospitalizations had a lower rate of 30-day readmission. Pharmacotherapy adjustments were made for a majority of these patients, which included the initiation of GDMT.

Relationship of early intensive- or coronary care unit admission and post-discharge performance of activities of daily living in patients with acute decompensated heart failure

Abstract Background The management of acute decompensated heart failure (ADHF) often requires intensive care. However, the effects of early intensive care unit (ICU)/coronary care unit (CCU) admission on activities of daily living (ADL) in ADHF patients have not been precisely evaluated. Thus, we assessed whether early ICU entry can improve post-discharge ADL performance in these patients. Methods and results ADHF patients (New York Heart Association I–III) admitted on emergency between April 1, 2014, and December 31, 2018, were selected from the Diagnosis Procedure Combination database and divided into ICU/CCU (ICU) and general ward (GW) groups according to the hospitalization type on admission day 1. The propensity score was calculated to create matched cohorts where treatment assignment (ICU/CCU admission) is independent of measured baseline confounding factors including ADL at admission. The primary outcome was post-ADL defined according to the Barthel index (BI) at discharge. Secondary outcomes included length of stay (LOS) and total hospitalization cost (expense). Overall, 12,231 patients were eligible, and propensity score matching created 2,985 pairs. After matching, post-ADL was significantly higher in the ICU group (GW 71.5±35.3 vs. ICU 78.2±31.2, P&amp;lt;0.001, difference in mean 6.7 (95% CI 5.1–8.4) points). After matching, LOS was significantly shorter and expenses were significantly higher in the ICU group. Subanalyses showed that patients with low ADL at admission (BI&amp;lt;60) mainly benefited from early ICU/CCU entry. Conclusions Early ICU/CCU entry was beneficially associated with post-ADL in patients with emergency ADHF admission. ADL at admission might serve as a useful criterion for ICU admission. Funding Acknowledgement Type of funding sources: None.

Acute decompensated heart failure (ADHF) during COVID-19 pandemic-insights from South India

AimThis retrospective study compares admissions and outcomes due to acute decompensated heart failure (ADHF) during the COVID-19 pandemic from 25 March to 25 July 2020 with the historical patient control who were admitted during the same period in 2019. Methods and resultsData of the participating hospitals was collected and analysed from the ICC NHFR (Indian College of Cardiology National Heart Failure Registry) for 2019 and 2020. Total number of ADHF admissions, demographics, aetiology, co-morbid conditions and in-hospital mortality was compared and analysed. A significant decrease in the number of hospital admissions due to ADHF from 2019 to 2020 (1056 vs. 526 respectively) was noted. Incidence of admissions with <40% ejection fraction (EF) reduced in 2020 (72.4% and 80.2% in2020 and 2019)and >40% (EF) increased (27.6% and 19.8% in 2019 and 2020 respectively, p = 0.0005). Ischemic heart disease (IHD) was the most common aetiology (78.59% in 2019 and 80.98% in 2020, p = 0.268). The in-hospital mortality was numerically higher in 2020 (10%) than in 2019 (8%), but not statistically significant (p = 0.161). ConclusionThis study from the registry shows that the incidence of ADHF admissions during COVID-19 lockdown significantly reduced compared to the previous year. Demographic patterns remained similar but patients presenting with de-novo HF increased; IHD was the most common cause. The in-hospital mortality was numerically higher during the lockdown. The impact of lockdown perhaps led to fewer hospitalisations and this is to be factored in future strategies to address health care delivery during such crises.

Acute on chronic heart failure-Which variations on B-type natriuretic peptide levels?

ObjectiveNatriuretic peptides are useful diagnostic and prognostic markers in patients presenting to the emergency department (ED) with acute shortness of breath. However, B‐type natriuretic peptide (BNP) level represents a single snapshot in time, while changes relative to a patient's baseline may be useful in risk stratification. We aimed to define the variation of BNP levels between chronic stable and acute decompensated heart failure (ADHF) that is associated with significant clinical outcomes.MethodsWe performed a retrospective cohort chart review study of chronic heart failure (HF) patients followed in an outpatient clinic from 2010 to 2013. Inclusion criteria were available hospital and clinic BNP levels and at least 1 year of follow‐up care. ADHF was defined as a hospital admission for acute HF. Dry BNP was defined as its concentration after >3 months of optimal treatment and no variations in New York Heart Association class. Dry BNP was compared to the BNP at a subsequent ED visit that was associated with hospitalization because of ADHF.ResultsOverall, 253 patients were included. Their median (interquartile range [IQR]) dry BNP was 191(83–450) pg/mL. There were 67 ADHF admissions, occurring 15 ± 15 months after patient's dry BNP was established. At subsequent ED admission, the median (IQR) BNP was 1505 (72–2620) pg/mL. Patients requiring inpatient admission had a BNP ∼250% higher than their stable BNP (404 vs 164 pg/mL, p < 0.001).ConclusionsIn this group of chronic stable HF patients, a doubling of BNP was observed in patients who required hospitalization for acute decompensated HF. BNP doubling may represent a useful parameter to reflect clinically relevant acute decompensated HF.

Association between early intensive care or coronary care unit admission and post-discharge performance of activities of daily living in patients with acute decompensated heart failure.

The management of acute decompensated heart failure often requires intensive care. However, the effects of early intensive care unit/coronary care unit admission on activities of daily living (ADL) in acute decompensated heart failure patients have not been precisely evaluated. Thus, we retrospectively assessed the association between early intensive care unit admission and post-discharge ADL performance in these patients. Acute decompensated heart failure patients (New York Heart Association I–III) admitted on emergency between April 1, 2014, and December 31, 2018, were selected from the Diagnosis Procedure Combination database and divided into intensive care unit/coronary care unit (ICU) and general ward (GW) groups according to the hospitalization type on admission day 1. The propensity score was calculated to create matched cohorts where admission style (intensive care unit/coronary care unit admission) was independent of measured baseline confounding factors, including ADL at admission. The primary outcome was ADL performance level at discharge (post-ADL) defined according to the Barthel index. Secondary outcomes included length of stay and total hospitalization cost (expense). Overall, 12231 patients were eligible, and propensity score matching created 2985 pairs. After matching, post-ADL was significantly higher in the ICU group than in the GW group [mean (standard deviation), GW vs. ICU: 71.5 (35.3) vs. 78.2 (31.2) points, P<0.001; mean difference: 6.7 (95% confidence interval, 5.1–8.4) points]. After matching, length of stay was significantly shorter and expenses were significantly higher in the ICU group than in the GW group. Stratified analysis showed that the patients with low ADL at admission (Barthel index score <60) were the most benefited from early intensive care unit/coronary care unit admission. Thus, early intensive care unit/coronary care unit admission was associated with improved post-ADL in patients with emergency acute decompensated heart failure admission.

Disparities in acute decompensated heart failure.

The aim of this review is to discuss racial and sex disparities in the management and outcomes of patients with acute decompensated heart failure (ADHF). Race and sex have a significant impact on in-hospital admissions and overall outcomes in patients with decompensated heart failure and cardiogenic shock. Black patients not only have a higher incidence of heart failure than other racial groups, but also higher admissions for ADHF and worse overall survival, while women receive less interventions for cardiogenic shock complicating acute myocardial infarction. Moreover, White patients are more likely than Black patients to be cared for by a cardiologist than a noncardiologist in the ICU, which has been linked to overall improved survival. In addition, recent data outline inherent racial and sex bias in the evaluation process for advanced heart failure therapies indicating that Black race negatively impacts referral for transplant, women are judged more harshly on their appearance, and that Black women are perceived to have less social support than others. This implicit bias in the evaluation process may impact appropriate timing of referral for advanced heart failure therapies. Though significant racial and sex disparities exist in the management and treatment of patients with decompensated heart failure, these disparities are minimized when therapies are properly utilized and patients are treated according to guidelines.

Natriuretic Equation to Predict Loop Diuretic Response in Patients With Heart Failure

BackgroundMost acute decompensated heart failure admissions are driven by congestion. However, residual congestion is common and often driven by the lack of reliable tools to titrate diuretic therapy. The authors previously developed a natriuretic response prediction equation (NRPE), which predicts sodium output using a spot urine sample collected 2 h after loop diuretic administration. ObjectivesThe purpose of this study was to validate the NRPE and describe proof-of-concept that the NRPE can be used to guide diuretic therapy. MethodsTwo cohorts were assembled: 1) the Diagnosing and Targeting Mechanisms of Diuretic Resistance (MDR) cohort was used to validate the NRPE to predict 6-h sodium output after a loop diuretic, which was defined as poor (<50 mmol), suboptimal (<100 mmol), or excellent (>150 mmol); and 2) the Yale Diuretic Pathway (YDP) cohort, which used the NRPE to guide loop diuretic titration via a nurse-driven automated protocol. ResultsEvaluating 638 loop diuretic administrations, the NRPE showed excellent discrimination with areas under the curve ≥0.90 to predict poor, suboptimal, and excellent natriuretic response, and outperformed clinically obtained net fluid loss (p < 0.05 for all cutpoints). In the YDP cohort (n = 161) using the NRPE to direct therapy mean daily urine output (1.8 ± 0.9 l vs. 3.0 ± 0.8 l), net fluid output (−1.1 ± 0.9 l vs. −2.1 ± 0.9 l), and weight loss (−0.3 ± 0.3 kg vs. −2.5 ± 0.3 kg) improved substantially following initiation of the YDP (p < 0.001 for all pre-post comparisons). ConclusionsNatriuretic response can be rapidly and accurately predicted by the NRPE, and this information can be used to guide diuretic therapy during acute decompensated heart failure. Additional study of diuresis guided by the NRPE is warranted.

Predictability of Inpatient Mortality of Different Comorbidities in Both Types of Acute Decompensated Heart Failure: Analysis of National Inpatient Sample

BackgroundSeveral prediction models have been proposed to assess the short outcomes and in-hospital mortality among patients with heart failure (HF). Several variables were used in common among those models. We sought to focus on other, yet important risk factors that can predict outcomes. We also sought to stratify patients based on ejection fraction, matching both groups with different risk factors.MethodsWe conducted a retrospective cohort study utilizing the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) 2016 database.ResultsThere were totally 116,189 admissions for acute decompensated heart failure (ADHF). Of these, 50.9% were for heart failure with reduced ejection fraction (HFrEF) group (n = 59,195), and 49.1% were for heart failure with preserved ejection faction (HFpEF) group (n = 56,994). Overall, in-hospital mortality was 2.5% of admissions for ADHF (n = 2,869). When stratified by HF types, admissions for HFrEF had higher mortality rate (2.7%, n = 1,594) in comparison to admissions for HFpEF (2.2%, n = 1,275) (P < 0.001). Significantly associated variables in univariate analyses were age, race, hypertension, diabetes mellitus, chronic kidney disease (CKD), atrial fibrillation/flutter, obesity, and chronic ischemic heart disease (IHD), while gender and chronic obstructive pulmonary disease (COPD) did not achieve statistical significance (P > 0.1).ConclusionsTo our knowledge, this is the first study to stratify HF patients based on ejection fraction and utilizing different predictors and in-hospital mortality. These and other data support the need for future research to utilize these predictors to create more accurate models in the future.