Acute Decompensated Heart Failure Readmission Research Articles

Abstract 16776: Recurrent Admission of Acute Decompensated Heart Failure Among Patients With and Without PAD and Its Significance in the CKD Population: The ARIC Cohort Study

Introduction: Peripheral artery disease (PAD) and chronic kidney disease (CKD) are common comorbidities in patients with heart failure (HF). Importantly, CKD is associated with a greater risk of incident PAD and is a known risk factor for worse outcomes in HF patients. However, it is unclear whether the concomitant existence of PAD and CKD increases the risk of recurrent hospitalization for acute decompensated heart failure (ADHF). Methods: Since 2005, the Atherosclerosis Risk in Communities (ARIC) study has conducted hospital surveillance of ADHF with events verified by physician review. Demographics, comorbidities, laboratory data, and medications were abstracted from medical record by trained personnel. Hazard ratios of ADHF readmissions were analyzed using repeat-events Cox regression. Models were adjusted for age, race, sex, year and hospital of admission, coronary artery disease (CAD), COPD, and diabetes mellitus. CKD was defined by glomerular filtration rate [GFR] ≤60 mL/min/1.73m 2 . Results: From 2005-2018, there were 1049 index hospitalizations for ADHF (mean age 77 years, 66% white) with measured creatinine, who were discharged alive. Of these, 155 (15%) had a diagnosis of PAD and 66% had CKD stage 3a or worse (GFR ≤60 mL/min/1.73m 2 ). Patients with PAD had a greater prevalence of smoking, CAD, myocardial infarction, and stroke. The 1-year ADHF readmission rate tended to be higher in patients with PAD, irrespective of CKD stage, compared to those without PAD ( Figure 1 ). After adjustments, PAD was associated with greater hazards of 1-year ADHF readmissions, both in patients with CKD stage 3a or worse (HR, 1.71; 95% CI: 1.25 - 2.32) and without CKD (HR, 1.84; 95% CI: 1.07-3.15). Conclusion: Patients with ADHF and concomitant PAD have a higher prevalence of cardiovascular comorbidities and higher likelihood of 1-year ADHF readmission, irrespective of the CKD status. Focused strategies to prevent ADHF readmission in this high-risk group are warranted.

Abstract 12044: Sex-Related Differences in Long-Term Outcomes Across the Spectrum of Left Ventricular Ejection Fraction in Acute Decompensated Heart Failure Patients

Background: An important knowledge gap remains on sex-related differences in heart failure (HF) management. Recently, it has been recognized that patients, particularly women, with supra-normal left ventricular ejection fraction (snLVEF) are at high risk of adverse outcomes. Aims: We sought to evaluate the sex related differences of long-term outcomes across the spectrum of LVEF in acute decompensated HF (ADHF) patients. Methods: We analyzed 3943 ADHF patients (age 77 years; 59.8% male) who were enrolled in WET-HF multicenter registry in Japan from 2006 to 2017. The association of long-term outcomes across the spectrum of LVEF were compared between men and women. Results: In both HF with reduced EF (HFrEF; LVEF < 50%) and preserved EF (HFpEF), female patients were older and had lower body mass index, lower prevalence of ischemic etiology, and smaller LV chamber size. In HFrEF, implementation of guideline-directed medical therapy such as the combination of renin-angiotensin-system inhibitor (RASi), β-blocker and mineralocorticoid receptor antagonist (MRA) was significantly lower in women at discharge, even after adjustment for covariates (RASi + β-blocker : odds ratio [OR], 0.80, p=0.049; RASi + β-blocker + MRA: OR, 0.73, p=0.016). Female patients showed higher incidence of the primary endpoint, defined as the composite of cardiac death and ADHF readmission during 1,000 days after discharge ( p = 0.009, log-rank test). However, female sex did not remain significant after adjustment for covariates. Restricted cubic spline analysis demonstrated a U-shaped relationship with a nadir at LVEF 60% between LVEF and the hazard ratio of the primary endpoint in women, but this relationship was not observed in men ( p for interaction = 0.048, Figure A, B ). This trend was more evident after excluding patients with valvular heart disease ( p for interaction = 0.014, Figure C, D ). Conclusions: In women, not only low LVEF but also snLVEF were associated with worse long-term outcomes.

Abstract 12544: Point-of-Care Ultrasound Estimation of Right Atrial Pressure Predicts Early Readmission in Patients With Acute Decompensated Heart Failure

Introduction: We previously developed and validated a highly accurate non-invasive, point-of-care ultrasound (POCUS) technique that uses right internal jugular vein (RIJV) compliance to predict elevated right atrial pressure (RAP). We sought to determine whether this POCUS technique would predict 30-day readmission in acute decompensated heart failure (ADHF) patients. Hypothesis: POCUS-based estimation of RAP at the time of discharge can predict 30-day readmission in patients with ADHF. Methods: In this prospective cohort study, consecutive patients admitted with ADHF were screened for eligibility. POCUS images of the RIJV at end-expiration and at maximal expansion during Valsalva were collected daily during the patient’s stay. To assess compliance, the change in cross-sectional area (CSA) of the RIJV induced by Valsalva was calculated using ImageJ and referred to as the distensibility index (DI). From ROC analysis, a DI≥66% was considered negative for elevated RAP while a DI<66% was considered positive (PPV 87%). 30 days post-discharge, readmission data were collected from patients’ EMR and a follow-up phone call. Sensitivity/specificity and predictive value analyses were conducted based on readmission data for those discharged with positive and negative tests. Results: A total of 237 admitted patients were eligible for this analysis. Patients discharged with a POCUS-estimated elevated RAP had a 30 day readmission rate 3.5 times greater than those discharged with normal POCUS-estimated RAP (26.7% vs 7.6%). POCUS-based normal RAP at discharge had a 92.4% negative predictive value (NPV) for avoiding 30-day readmission (P<.001). A subset of patients in this cohort (n=81) were admitted to a local community hospital. In this setting, POCUS estimation of RAP at discharge had a 95.7% NPV (P<.001) for avoiding 30-day readmission, and patients discharged with a POCUS-based elevated RAP had a 30-day readmission rate 9.6 times greater than those discharged with a normal POCUS test (41.2% vs 4.3%) . Conclusions: POCUS estimation of RAP strongly predicts avoidance of 30-day readmission for ADHF. Using this technique to guide discharge planning, potentially to reduce readmission for ADHF, deserves further investigation in a prospective randomized trial.

Urine osmolality predicts worsening renal function and poor prognosis in acute decompensated heart failure

Abstract Background/Purpose Worsening renal function (WRF) can sometimes occur in the patients with acute decompensated heart failure (ADHF) and increase the risk of morbidity and mortality (1). In a previous study, it was reported that fractional excretion of sodium (FENa) reflects net sodium reabsorption from nephron segments and predicts WRF during treating ADHF (2). On the other hand, recently the new drugs which approach urine concentration mechanism and affect urine osmolality (U-OSM), such as tolvaptan and sodium-glucose cotransporter-2 inhibitor, have begun to be widely used as treatment of heart failure. Thus, we focused on U-OSM, which reflects not only sodium handling but also water excretion controlled by the collecting duct, and evaluated the association between WRF and U-OSM. Moreover, previous studies have demonstrated that FENa, fractional excretion of urea nitrogen and transtubular potassium concentration gradient are markers for long-term prognosis in patients with ADHF (3–5). Therefore, we also studied whether U-OSM can predict prognosis in ADHF. Methods A total of 157 patients admitted to our hospital because of a primary diagnosis of ADHF from February 2020 through July 2021 were retrospectively reviewed. U-OSM in the spot urinary samples were examined within 72 hours after admission. U-OSM was calculated based on the following validated formula (6): U-OSM = 1.07 × {2 × [urine sodium (mEq/L)] + [urine urea nitrogen (mg/dL)]/2.8 + [urine creatinine (mg/dl)] × 2/3} + 16.2. The primary outcome was the occurrence of WRF during hospitalization. WRF was defined as increased serum creatinine ≥0.3 mg/dL from baseline (7). The secondary outcome was the occurrence of ADHF readmission and all-cause death within 180 days after discharge. Results Primary Outcome. WRF developed in 46% of all patients. In the patients that developed WRF during hospitalization, U-OSM was significantly lower than in the patients without WRF (366±106 mOsm/L versus 430±128 mOsm/L; P<0.001). Receiver operating characteristic curve analysis revealed the optimal cutoff values of U-OSM was 403 mOsm/L (AUC 0.64; 95% CI: 0.56–0.72; P<0.001) to predict the WRF (Figure 1). On multivariable logistic regression analysis, U-OSM (OR, 1.99, 95% CI: 1.27–3.12; p=0.003) and serum creatinine (OR, 1.00, 95% CI: 0.99–1.00; P=0.009) were independent predictors of WRF. Secondary Outcome. There were 34 patients (22%) readmitted and 9 patients (6%) died within 180 days after discharge. ROC curve analysis revealed the optimal cutoff values of U-OSM as 349 mOsm/L (C-statistic 0.74; 95% CI: 0.65–0.83; P<0.001) to predict ADHF readmission and all-cause death within 180 days (Figure 2A). On Kaplan-Meier analysis, the secondary outcome was significantly higher in patients with U-OSM<349 mOsm/L (u-OSM≥349, 57%, U-OSM<349, 43%; HR, 0.99; 95% CI: 0.99–1.00, P<0.001) (Figure 2B). Conclusion U-OSM on admission may be a predictor of WRF and a prognostic marker in ADHF patients. Funding Acknowledgement Type of funding sources: None.

Abstract 85: Evaluation Of Guideline-Directed Medical Therapy Prescribing In Patients Undergoing Transcatheter Edge-to-Edge Repair

Background: The benefits of guideline-directed medical therapy (GDMT) in heart failure (HF) are well established, but the optimization of GDMT prior to and following transcatheter edge-to-edge repair (TEER) remains understudied. The purpose of this study was to evaluate GDMT use pre-and post-TEER. Methods: We performed a retrospective analysis of the electronic health records from 2019 to 2021 at the University of Illinois at Chicago of patients that underwent TEER. Patients were included if they had follow-up records within 6 months and a baseline ejection fraction (EF) < 50%. Demographic information, vitals, labs, and pertinent echocardiogram information were obtained at baseline and 6 months. GDMT doses were collected at baseline, discharge, 30 days, 3, and 6 months. Results: In total, 20 patients were included: 15 were male (75%) and 19 were non-white (95%). The average age was 66.8 years old (range 32.8-86.5). Past medical history was significant for 19 with hypertension (95%) and 15 with hyperlipidemia, coronary artery disease, and smoking history, respectively (75%). Pre-procedure mean blood pressure and heart rate were 123/74 mmHg and 81 bpm. Average creatinine was 1.66 ± 0.94 mg/dL and 1.10 ± 0.97 mg/dL at baseline and 6 months, respectively. A total of 9 patients (45%) had functional mitral regurgitation, 11 (65%) had primary or degenerative mitral regurgitation. A total of 6 patients (30%) had 11 readmissions for acute decompensated HF, 2 patients died, and 1 patient’s EF improved to > 50% by 6 months. GDMT is described in Table 1. No patients were prescribed SGLT2 inhibitors. Conclusion: GDMT for patients pre-and post-TEER procedure is neither prescribed nor titrated effectively. Further investigation will focus on confounding factors affecting prescribing patterns and titrations. Our findings demonstrate a continued opportunity for quality improvement in GDMT optimization during TEER hospital admission and follow-up visits.

IV Sodium Ferric Gluconate Complex in Patients Hospitalized Due to Acute Decompensated Heart Failure and Iron Deficiency.

Background: Patients suffering from heart failure (HF) and iron deficiency (ID) have worse outcomes. Treatment with intra-venous (IV) ferric carboxymaltose has been shown to reduce HF rehospitalizations and to improve functional capacity and symptoms in patients with HF and reduced ejection fraction (HFrEF). However, IV ferric carboxymaltose is significantly more expensive than IV sodium ferric gluconate complex (SFGC) limiting its availability to most HF patients around the globe. Methods: A retrospective analysis comparing patients admitted to internal medicine or cardiology departments between January 2013 to December 2018 due to acute decompensated HF (ADHF) and treated with or without IV SFGC on top of standard medical therapy. Results: During the study period, a total of 1863 patients were hospitalized due to ADHF with either HFrEF or HF with preserved ejection fraction (HFpEF). Among them, 840 patients had laboratory evidence of iron deficiency (absolute or functional) and met the inclusion criteria. One hundred twenty-two of them (14.5%) were treated with IV SFGC during the index hospitalization. Patients treated with IV iron were more likely to have history of ischemic heart disease, atrial fibrillation, and chronic kidney disease. The rate of readmissions due to ADHF was similar between the groups at 30 days, 3 months, and 1 year. Conclusion: High risk patient hospitalized to ADHF and treated with IV SFGC showed comparable ADHF readmission rates, compared to those who did not receive iron supplementation.

Abstract 15299: Outpatient Intravenous Lasix Trial in Reducing Hospitalization for Acute Decompensated Heart Failure (OUTLAST)

Introduction: Hospitalization for acute decompensated heart failure (ADHF) remains a major source of morbidity and mortality. While previous studies have shown outpatient intravenous (IV) diuretic therapy to be safe and cost-effective, there have been no randomized controlled trials to evaluate the utilization of continued outpatient IV furosemide diuretic maintenance treatment in patients with HF following hospitalization for ADHF. Hypothesis: We hypothesized that 30-day hospital readmission from ADHF would be lower with routine, standardized outpatient IV diuretic treatment along with a comprehensive HF care approach vs standard treatment. Methods: In a single center, prospective, randomized, double-blind study, 100 patients were randomized to receive standard of care (Group 1), IV placebo infusion (Group 2), or IV furosemide infusion (Group 3) over 3 hours, biweekly for a one-month period following hospitalization for ADHF. Patients in Groups 2 and 3 also received a comprehensive HF care protocol including bi-weekly clinic visits for dose-adjusted IV-diuretics, medication adjustment, laboratory, weight, and blood pressure-monitoring, and education during infusion visits. Echocardiography, Kansas City Cardiomyopathy Questionnaire (KCCQ) and depression questionnaires were performed at baseline and 30-day follow-up. The primary outcome was 30-day re-hospitalization for ADHF. Results: Overall, a total of 94 patients were included in the study (mean age 64 years, 56% males, 69% African American, 70% HF reduced ejection fraction). There were a total of 14 (15%) readmissions for ADHF at 30 days, 6 (17.1%) in Group 1, 7 (22.6%) in Group 2, and 1 (3.7%) in Group 3 (overall p=0.11; p=0.037 comparing Group 2 and Group 3). Patients receiving IV furosemide infusion experienced significantly greater urine output and weight loss compared to those receiving placebo without any significant increase creatinine and no significant between group differences in echocardiography parameters, KCCQ or depression scores. Conclusions: The use of a standardized protocol of outpatient IV furosemide infusion for a one-month period following hospitalization for ADHF was found to be safe and efficacious in reducing 30-day re-hospitalization.

Abstract 15017: Early Post-discharge Follow-up Delay After Hospitalization for Heart Failure With Preserved Ejection Fraction Reduces Readmission for Heart Failure in the Following Year

Introduction: Early physician follow-up after hospital discharge for acute decompensated heart failure (ADHF) is recommended by the AHA to prevent early hospital readmission. This recommendation has not been specifically evaluated for heart failure with preserved ejection fraction (HFpEF). Hypothesis: Earlier follow-up should lead to decrease in readmissions for ADHF in the HFpEF population even when adjusting for confounding factors. Methods: Consecutive ADHF hospitalisation that occurred inclusively between 2015 and 2018 were reviewed. Main inclusion criterion was left ventricular ejection fraction ≥45%. The major exclusion criteria were: severe valvulopathy, hypertrophic cardiomyopathy, acute coronary syndrome 3 months before hospitalisation, chronic kidney failure (eGFR <30 ml/min), severe chronic respiratory disease and death before discharge. Follow-up delay after discharge was dichotomized (early vs late/no follow up) by using the median delay. Main outcome was hospital readmission in the year following discharge. Multivariate logistic regression was performed for main outcome according to follow-up delay and adjusted for age, sex, medication at discharge and major comorbid conditions. Results: A total of 163 heart failure readmission (37% of patients) occurred in 438 patients in the year following the first hospitalisation. Median readmission delay was of 62 days. Median dedicated follow-up delay was 30 days and was arranged in 68% of cases. After adjusting for confounding variables, early follow-up was significantly associated with fewer readmission (adjusted odds ratio 0.57, 95% CI; 0.34-0.97). Conclusions: Early dedicated follow-up after discharge for HFpEF was associated with fewer readmission over the year following discharge even when adjusting for major confounding variables.

Effects of a multidisciplinary heart failure program in short term readmissions of heart failure patients, preliminary results

Abstract Background Unexpected readmissions are frequent among heart failure patients, due to their natural history that implies multiple readmissions, with high costs and clinical relevance. Purpose We aimed to assess the impact of a Multidisciplinary Heart Failure Program (MHFP) on the readmission-free period after an episode of acute decompensated heart failure (ADHF). Methods We carried out an analytical and observational study including all patients admitted to our Universitary Hospital, which covers 220,000 individuals, with an episode of heart failure when there was not a Multidisciplinary Heart Failure Program (January 2013 to December 2013). Once the MHFP was established, we compared non-MHFP patients with every patient admitted during February 2019 and February 2020 in terms of clinical data, imaging technique findings and short-term readmissions. Results The rate of readmission during this period was a 24.8% in non-MHFP and 17.2% in MHFP (p=0.15). However, we could find differences in median time to readmission due to ADHF, that was 1.74 months (CI 95%, 0.12–3.35) in non-MHFP, compared to 5.125 months (CI 95%, 4.15–6.09) in MHFP (p=0.002) (see Graph 1). There were also no significant differences in terms of basic characteristics between the MHFP and the non-MHFP patients (age, gender, left ventricular ejection fraction, left bundle branch block, hypertension). It is remarkable that establishing a MHFP has lengthened the readmission-free period. The rate of decompensation in the first and sixth month was respectively in the non–MHFP 9% and 21%; and in the MHFP 2% and 10%. Conclusion According to our results, the implantation of this Multidisciplinary Heart Failure Program has shown a reduction in the time to ADHF readmission compared with a cohort of similar pts some years before, which is clinically relevant. Graph 1 Funding Acknowledgement Type of funding source: None

Recurrent Admissions for Acute Decompensated Heart Failure Among Patients With and Without Peripheral Artery Disease: The ARIC Study.

BackgroundPeripheral artery disease (PAD) is both a common comorbidity and a contributing factor to heart failure. Whether PAD is associated with hospitalization for recurrent decompensation among patients with established heart failure is uncertain.Methods and ResultsSince 2005, the ARIC (Atherosclerosis Risk in Communities) study has conducted active surveillance of hospitalized acute decompensated heart failure (ADHF), with events verified by physician review. From 2005 to 2016, 1481 patients were hospitalized with ADHF and discharged alive (mean age, 78 years; 69% White). Of these, 207 (14%) had diagnosis of PAD. Those with PAD were more often men (55% versus 44%) and smokers (17% versus 8%), with a greater prevalence of coronary artery disease (72% versus 52%). Patients with PAD had an increased risk of at least 1 ADHF readmission, both within 30 days (11% versus 7%) and 1 year (39% versus 28%) of discharge from the index hospitalization. After adjustments, PAD was associated with twice the hazard of ADHF readmission within 30 days (HR, 2.02; 95% CI, 1.14–3.60) and a 60% higher hazard of ADHF readmission within 1 year (HR, 1.60; 95% CI, 1.25–2.05). The 1‐year hazard of ADHF readmission associated with PAD was stronger with heart failure with reduced ejection fraction (HR, 2.01; 95% CI, 1.29–3.13) than preserved ejection fraction (HR, 1.04; 95% CI, 0.69–1.56); P for interaction=0.05.ConclusionsPatients with ADHF and concomitant PAD have a higher likelihood of ADHF readmission. Strategies to prevent ADHF readmissions in this high‐risk group are warranted.

Impact of Aggressive Transitional Care Strategies on Reducing Adverse Outcomes in Veterans Hospitalized for Acute Decompensated Heart Failure

Introduction Patients hospitalized with acute decompensated heart failure (ADHF) have high readmission rates and mortality. The aim of this study was to evaluate the impact of a post-discharge Heart Failure Access Clinic (HFAC) visit on 30-day ADHF readmission and mortality rates. METHODS Admissions to the Madison VA for ADHF between April 2018 and May 2019 were assessed retrospectively. Exclusions were as follows: death during index admission, referral to hospice, post-discharge care at an outside VA, LVAD/transplant, and ineligibility for HFAC. For veterans with multiple admissions during this time period, only the first hospitalization was analyzed. Demographic, laboratory, and clinical data were collected. Readmissions for ADHF at 30 days and all-cause mortality at 15 months were analyzed. Categorical outcomes were compared using chi squared test/Fisher's test, continuous variables via one-way ANOVA and Kruskal Wallis tests for non-normal data. RESULTS Of the 142 patients offered HFAC, 119 patients were seen (84%). Demographics are shown in Table 1. Patients who were offered HFAC and not seen were more likely to be active smokers, have higher systolic BP, and have shorter hospital stays. On average, patients were seen in HFAC 8.7+/-5.1 days after discharge. Reasons for not being seen in HFAC: readmission (n=7), patient preference (no show =5, cancel =5, decline =3), and scheduling error (n=3). No patients died prior to the scheduled HFAC appointment. Patients seen in HFAC had lower 30-day readmission rates (15.8% vs 39.1%; p=0.01). Despite comparable predicted death rates (MAGGIC risk calculator), all-cause mortality was substantially lower in patients seen in HFAC versus those who were not seen (Figure 1). CONCLUSIONS Veterans who were offered HFAC but not seen had a significant increase in 30-day readmission rate and all-cause mortality. The difference in readmission rate was attributable to pre-HFAC hospitalizations within 1 week of discharge, suggesting the need for earlier HFAC appointments. Further study needs to be undertaken to determine whether the HFAC visit is responsible for the reduction in all-cause mortality.

Abstract 346: A Trial of Pre-discharge Point of Care Ultrasound for Acute Decompensated Heart Failure

Background: Acute decompensated heart failure (ADHF) is a primary reason for hospital admission and readmission in the elderly. Prior studies have demonstrated that sonographic pulmonary B-lines and large inferior vena cava (IVC) diameter with reduced collapsibility may accurately predict ADHF readmission. Ultrasound is a readily available bedside tool that can be used to assess a patient’s volume status, which can be difficult to assess under certain clinical conditions. The purpose of this project is to determine if a pre-discharge focused lung and IVC ultrasound exam can be used to predict readmission in a veteran patient population. Methods: This is a single-center study conducted at the Miami Veterans Affair Medical Center (VAMC). Only patients with a primary diagnosis of ADHF admitted to a hospitalist team through the emergency room will be considered. Exclusion criteria include: pre-existing structural lung disease; primary right-sided heart failure; severe tricuspid regurgitation; or hospice status. A single operator will evaluate all included patients for B-lines and IVC dimension within 24 hours of admission and discharge. Ultrasound results, without management recommendations, will be given to hospitalists to use at their discretion to support clinical decision-making. Patients will be categorized based on positive or negative ultrasound findings. The primary outcome of interest is 30-day readmission rate. Secondary outcomes include 90-day readmission, all-cause mortality, length of stay, and changes in weight or renal function. Chi-square and Mann-Whitney testing will be used to analyze categorical and continuous variables, respectively. Kaplan-Meier survival curves will be generated for both patient cohorts. Results/Anticipated Results: Through quarter 3 of fiscal year 2019, the Miami VAMC had 215 unique admissions for ADHF. The average 30-day readmission rate per quarter was 18.44% (total 40 of 215). Study enrollment is ongoing. We anticipate that many patients may demonstrate discrepancy of volume status between their clinical and ultrasound exams, and that patients found to have B-lines and/or large IVCs with poor collapsibility will have worse outcomes. Conclusion: Decreasing readmissions for acute decompensated heart failure is a priority for both patients and physicians. Persistent volume overload has been associated with increased risk for readmission. Ultrasound may be a useful augmentation to the physical exam to determine a patient’s volume status to further guide inpatient treatment, predict prognosis, and determine readiness for discharge.

Peripheral Venous Pressure to Predict Congestive Heart Failure Readmission

Introduction Acute decompensated heart failure (ADHF) readmission rates are high and act as a burden to both the patient and the healthcare system. Non-invasive measures of hemodynamic status are limited in accuracy, leading to patients being discharged with residual congestion and a higher likelihood of subsequent readmission for ADHF. Peripheral venous pressure (PVP) measurement involves transducing a peripheral intravenous (PIV) catheter and may serve as a minimally invasive method of determining hemodynamic status in patients with ADHF. PVP measurements have been shown to correlate with CVP measurements in heart failure patients, but the clinical relevance of this has not yet been established. We sought to examine if PVP measurements may predict heart failure readmission. Methods A prospective feasibility study was conducted from July to December 2018. Patients admitted with ADHF were enrolled on day-of-discharge. Using a standard pressure transducer leveled to the phlebostatic access, measurement of PVP was performed at the bedside using a previously-inserted PIV. The electronic medical record was reviewed for subsequent readmissions. The primary end-point was readmission at 30 days post-discharge. Results 29 patients were enrolled. The mean age of participants was 65.6 +/- 10.8 years. 66% of patients were male and 55% of patients were black. 72% of patients had a reduced ejection fraction (EF) and 28% had a preserved EF. At the time of discharge, the mean PVP was 11.6 +/- 4.9 mmHg. 5 patients (17%) were readmitted within 30 days. Mean PVP for those readmitted was 12.0 +/- 2.1 mmHg vs 11.5 +/- 5.3 mmHg for those without readmission (difference of the means 0.5 mmHg, p= 0.86). PVP was not significantly impacted by whether a 22-gauge or 20-gauge PIV was used (difference of means 2.3 mmHg, p= 0.51). Waveform analysis on a subset of patients showed lower PVP in those with a sinusoidal waveform as opposed to a flatline or static waveform (12.8 vs. 17.4 mmHg, p=0.32). Conclusion In this small feasibility study, few patients were readmitted for heart failure in 30 days. PVP was similar among the 5 patients readmitted with ADHF. PVP measurement was readily obtainable and PVP was not significantly impacted by PIV gauge. Further study of this clinical application to PVP measurement is warranted.

Bedside Ultrasound Assessment of Jugular Venous Compliance as a Potential Point-of-Care Method to Predict Acute Decompensated Heart Failure 30-Day Readmission.

BackgroundHeart failure is one of the most costly diagnosis‐related groups, largely because of hospital readmissions. Objective assessment of volume status to ensure optimization before hospital discharge could significantly reduce readmissions. We previously demonstrated an ultrasound method of quantifying percentage of cross‐sectional area (CSA) change of the right internal jugular vein with Valsalva that reliably estimates central venous pressure.Methods and ResultsPatients admitted with acute decompensated heart failure (ADHF) underwent ultrasound measurements of the right internal jugular vein at end‐expiration and during the strain phase of Valsalva to determine a percentage of CSA change. An initial subgroup of patients with right heart catheterization and accompanying ultrasound measurements of the right internal jugular vein identified a percentage of CSA change predictive of right atrial pressure (RAP) ≥12 mm Hg. Images of admitted ADHF patients were obtained at admission and discharge for final analysis. Simultaneous right heart catheterization and right internal jugular vein ultrasound measurements demonstrated that a <66% CSA change predicted RAP ≥12 mm Hg (positive predictive value: 87%; P<0.05, receiver operating characteristic curve). Elevated admission RAP by percentage of CSA change normalized by discharge (P<0.05), indicating that this test is significantly responsive to therapeutic interventions. Using the cutoff value of 66% CSA change, normal RAP at discharge had 91% predictive value for patients avoiding 30‐day readmission (P<0.05).ConclusionsThis bedside ultrasound technique strongly correlates to invasive RAP measurement in ADHF patients, identifies restoration of euvolemia, and is predictive of 30‐day ADHF readmission. This tool could help guide inpatient ADHF treatment and may lead to reduced readmissions.

Readmission for Acute Decompensated Heart Failure among Patients Successfully Treated with Transcatheter Aortic Valve Replacement: A PARTNER-1 Substudy

ABSTRACTBackground: Readmission for acute decompensated heart failure (ADHF) following transcatheter aortic valve replacement (TAVR) is common and linked with mortality. However, time course of ADHF readmissions, their risk factors, and their association with long-term outcomes are not well understood. Our objectives were to identify the temporal pattern of readmission for ADHF following TAVR, which patients are at high risk, and the association of readmission for ADHF and subsequent mortality.Methods: We evaluated 2467 patients successfully treated and discharged in the PARTNER-1 trial, and followed for 5 years. Baseline and discharge clinical, pharmacologic, procedure, and echocardiographic characteristics were considered. The likelihood and temporal pattern of ADHF readmission after accounting for the competing risk of death were assessed using nested competing-risk methodology for repeating time-related events. Risk factors were identified by unsupervised bootstrap-aggregation machine learning.Results: Admission for ADHF following TAVR was associated with an increased risk of subsequent readmission. Accounting for baseline, procedure, and discharge characteristics, we identified greater severity of post-procedure mitral and aortic regurgitation, both lower- and higher-gradient aortic stenosis, oxygen-dependent COPD, baseline calcium channel blocker and long-acting nitrate use, and longer index hospitalization length of stay as risk factors for readmission for ADHF.Conclusion: Early readmission for ADHF following TAVR was associated with clinical, pharmacologic, and echocardiographic characteristics. The resulting models may be used to identify patients at high risk for early readmission following TAVR and to suggest future prospective trials, particularly to treat combined mitral regurgitation associated with aortic stenosis.

Recurrent Acute Decompensated Heart Failure Admissions for Patients With Reduced Versus Preserved Ejection Fraction (from the Atherosclerosis Risk in Communities Study)

Hospitals are required to report all-cause 30-day readmissions for patients discharged with heart failure. Same-cause readmissions have received less attention but may differ for heart failure with reduced ejection fraction (HFrEF) versus heart failure with preserved ejection fraction (HFpEF). The ARIC study began abstracting medical records for cohort members hospitalized with acute decompensated heart failure (ADHF) in 2005. ADHF was validated by physician review, with HFrEF defined by ejection fraction <50%. Recurrent admissions for ADHF were analyzed within 30 days, 90 days, 6 months, and 1 year of the index hospitalization using repeat-measures Cox regression models. All recurrent ADHF admissions per patient were counted rather than the more typical analysis of only the first occurring readmission. From 2005 to 2014, 1,133 cohort members survived at least 1 hospitalization for ADHF and had ejection fraction recorded. Half were classified as HFpEF. Patients with HFpEF were more often women and had more co-morbidities. The overall ADHF readmission rate was greatest within 30 days of discharge but was higher for patients with HFrEF (115 vs 88 readmissions per 100 person-years). After adjustments for demographics, year of admission, and co-morbidities, there was a trend for higher ADHF readmissions with HFrEF, relative to HFpEF, at 30 days (hazard ratio [HR] 1.41, 95% confidence interval [CI] 0.92 to 2.18), 90 days (HR 1.39, 95% CI 1.05 to 1.85), 6 months (HR 1.47, 95% CI, 1.18 to 1.84), and 1 year (HR 1.42, 95% CI 1.18 to 1.70) of follow-up. In conclusion, patients with HFrEF have a greater burden of short- and long-term readmissions for recurrent ADHF.

The effect of intravenous isosorbide dinitrate in acute decompensated heart failure in hospital.

Background According to new recommendations for the management of acute decompensated heart failure (ADHF) in 2015, intravenous vasodilator therapy might be given as an early therapy when systolic blood pressure is normal to high (≥110mmHg). Only 29% of patients with ADHF are treated with vasodilators without medical contraindication. Objective To evaluate the effect of the systematic use of ISDN on ADHF without contraindication especially on rehospitalization rate. Settings The 600-bed hospital (Centre Hospitalier de l'Ouest Vosgien, Neufchâteau, France). Methods This is a retrospective study with data analysed from medical records. Patients with ADHF episodes and hospitalization in the cardiology department or intensive care unit (ICU) between November 2013 and December 2015 were included resulting in 199 hospitalizations in the analysis (37 were treated by ISDN, and 162 were not). Main outcome measure Effects of ISDN on 180-day hospital readmission for ADHF or acute myocardial infarction (AMI), in-hospital mortality, length of stay, number of ICU admissions, and ICU length of stay. Results Patients who received ISDN required more ICU admissions than the other patients (54.1 vs 33.3%, p=0.02). Nevertheless 180-day hospital readmission was lower for patients who were receiving ISDN (8.1 vs 22.8%, p=0.04). ISDN did not influence other clinical outcomes tested. Conclusion ISDN may minimize or prevent the consequences of altered haemodynamics. Lower rehospitalization rate with ISDN was seen in this study.

Brain-Type Natriuretic Peptide and Amino-Terminal Pro-Brain-Type Natriuretic Peptide Discharge Thresholds for Acute Decompensated Heart Failure: A Systematic Review.

Acute decompensated heart failure (ADHF) requiring hospitalization is associated with high postdischarge mortality and readmission rates. To examine the association between achieving predischarge natriuretic peptide (NP) thresholds and mortality and readmission rates in adults hospitalized for ADHF. Multiple databases from 1947 to October 2016 (English-language studies only). Trials and observational studies that compared mortality and readmission outcomes between patients with ADHF achieving a specific predischarge NP goal and those not achieving the goal. Two investigators independently extracted study characteristics and assessed study risk of bias. One author graded the overall strength of evidence, with review by a second author. One randomized trial, 3 quasi-experimental studies, and 40 observational studies were identified. The most commonly used thresholds were a brain-type NP (BNP) level of 250 pg/mL or less or an amino-terminal pro-brain-type NP (NT-proBNP) decrease of at least 30%. Achievement of absolute BNP thresholds reduced postdischarge all-cause mortality (7 of 8 studies) and the composite outcome of mortality and readmission (12 of 14 studies). Achievement of percentage-change BNP thresholds reduced the composite outcome (5 of 6 studies), and achievement of percentage-change NT-proBNP thresholds reduced all-cause and cardiovascular mortality (2 of 4 studies) and the composite outcome (9 of 9 studies). All findings were low-strength. The randomized trial, assessed as having high risk of bias, suggested that a predischarge decrease in NT-proBNP level was associated with lower risk for the composite outcome. Two quasi-experimental studies and 5 observational studies had low risk of bias. Low-risk-of-bias studies had outcome estimates similar in magnitude and direction to estimates from high-risk-of-bias studies. Most studies failed to adjust for critical confounders and had inadequate definition or assessment of exposures and outcomes. Low-strength evidence suggests an association between achieving NP predischarge thresholds and reduced ADHF mortality and readmission. None.

Abstract P302: Lack of Obesity Paradox in 30 Day and Annual Cumulative Acute Decompensated Heart Failure Readmissions

Background: Recent study demonstrated paradoxical relationship between body mass Index (BMI) and all cause mortality in patients with acute decompensated heart Failure (ADHF), where higher BMI was associated with decreased mortality. We sought to test whether this relationship exists between BMI and ADHF readmissions Methods: Consecutive patients presented to the emergency department from March 2014 to July 2015 with the diagnosis of ADHF were analyzed in a retrospective cohort study. Cohort was grouped in to prespecified BMI categories; normal weight (BMI &lt;26 Kg/m2 ), Over weight (BMI 25-30 Kg/m2 ) and Obese (BMI &gt;30 Kg/m2 and above). Primary endpoints were incidence of 30 day ADHF readmission and time to first ADHF readmission from the index hospitalization. Patients with end stage COPD on home O2, cirrhosis and end stage renal failure on dialysis were excluded. Unplanned hospitalizations due to other cause than ADHF were excluded. ADHF hospitalizations were adjudicated by an independent blinded clinician Results: Cohort (N=188) consisted 51(27.1%) normal weight, 61 (32.4%) over weight and 76 (40.4%) obese patients. Females were 63% (N=119), patients with heart failure with preserved ejection fraction were 47% (N=90), Obese [BMI 31(28-38) Kg/m2; Median (IQR)] patients were younger (median age; 77 years vs 83 years; P=0.002), whereas other covariates were similar between groups. In median follow up of 1.2 years, total 30 day ADHF readmissions were 32 and total ADHF admissions were 214. Incidence of both 30 day and total ADHF readmissions were similar in all 3 BMI categories; ANOVA P=0.18 (30 day ADHF readmissions) and P= 0.62 (total ADHF readmissions). Obesity was neither associated with risk for 30 day readmission; OR=0.64 (CI: 0.20 - 2.0; P= 0.45) nor with the time to first ADHF readmission from the index hospitalization; log rank P=0.5 (Figure 1) Conclusions: Higher BMI is not protective against ADHF readmissions in patients with ADHF. Further studies are needed in larger data sets to validate our findings.

Outcomes of Patients With Acute Decompensated Heart Failure Managed by Cardiologists Versus Noncardiologists

Physician practice patterns in the management of hospitalized acute decompensated heart failure (ADHF) patients may vary by specialty; comparative practice patterns in ADHF management and clinical outcomes as a function of provider type have not been well reported. We studied a total of 496 patients discharged with the principal diagnosis of ADHF to analyze practice patterns among 3 provider types (cardiologists, hospitalists, and nonhospitalists). We examined outcomes of death and rehospitalization for HF and adherence to the Joint Commission HF performance core measures. Cardiologists had the highest adherence in all 4 HF core measures compared with hospitalists and nonhospitalists. At 6months, 6.0% of the patients cared by cardiologists died compared with 10.9% and 11.4% cared by hospitalist and nonhospitalists (p= 0.12). Patients cared for by cardiologists had a significantly lower 6-month ADHF readmission rate (16.2%) compared with hospitalists (40.1%) and nonhospitalists (34.9%, p <0.001). In multivariate analysis, both hospitalist and nonhospitalist provider types were an independent predictor for 6-month ADHF-related readmission (hospitalists vs cardiologists, hazard ratioadjusted 3.01; 95% confidence interval 1.84 to 4.89, p <0.001; and nonhospitalists vs cardiologists, hazard ratioadjusted 2.07; 95% confidence interval 1.24 to 3.46, p= 0.005). In conclusion, cardiologist-delivered ADHF care is associated with greater adherence to HF core measures and with significantly lower rates of adverse outcome compared with noncardiologists.