Acute Decompensated Heart Failure Registry Research Articles

Characteristics of Patients Hospitalized With Acute Decompensated Heart Failure Who Are Referred for Hospice Care

Hospice is a potential option for patients with end-stage heart failure whose symptoms and clinical status have progressed despite maximal medical therapy. However, little is known about hospice referral practices when patients are admitted because of acute decompensated heart failure. Data from the Acute Decompensated Heart Failure Registry (ADHERE) were analyzed from October 1, 2001, to December 31, 2005, accounting for 182 898 patient episodes with known disposition from 307 hospitals. Demographic data, clinical characteristics, and medical management were compared in the group discharged to hospice vs patients discharged to home or to intermediate-care facilities. Hospitals, stratified by frequency of discharge of patients to hospice, were evaluated for adherence to performance measures. Temporal trends according to discharge category were analyzed using analysis of variance, and predictors of hospice referral were determined by multivariate analysis. The hospice cohort composed 1.6% (n = 3010) of the total sample. Patients referred to hospice were generally older, more likely to have been admitted because of antecedent heart failure in the preceding 6 months, more likely to receive intravenous inotropic therapy, less likely to receive angiotensin-converting enzyme inhibitors, and less likely to undergo a procedure (eg, dialysis or cardiac catheterization) during the hospitalization. The median rate of hospice referral increased from 0.8% in 2001 to 1.3% in 2005 (P < .008). Hospitals in the upper quartile of hospice referrals had comparable or higher rates of adherence to quality indicators for heart failure than did hospitals in the lowest quartile. Variables obtained at admission that were associated with hospice referral included older age (per 10-year increment; odds ratio [OR], 1.63; 95% confidence interval [CI], 1.57-1.68), lower serum sodium concentration (per 5-mEq/L [to convert to millimoles per liter, multiply by 1.0] increment; OR, 0.81; 95% CI, 0.78-0.83), lower systolic blood pressure (per 10-mm Hg increment; OR, 0.86; 95% CI, 0.85-0.88), higher serum urea nitrogen concentration (per 10-mg/dL to convert to millimoles per liter, multiply by 0.375] increment; OR, 1.20; 95% CI, 1.18-1.21), and absence of lipid-lowering drug therapy (use of drug OR, 0.69; 95% CI, 0.63-0.75). A small percentage of patients admitted to acute care hospitals with decompensated heart failure are referred to hospice at rates increasing with time. Hospitals that refer patients to hospice are more likely to be in compliance with heart failure performance measures. Further investigation is required to determine if the hospice option is appropriately selected and if it should be offered to a broader cohort of patients.

Misleading Negative Chest Radiographs: Should We ADHERE to the Conclusions?

In this issue, Collins et al present data from the Acute Decompensated Heart Failure Registry (ADHERE) and suggest that the initial emergency department (ED) chest radiograph may be insensitive to predict a hospital discharge diagnosis of acutely decompensated heart failure. The assertion that the chest radiograph is not that sensitive (for many disorders) is not new; however, the idea that 1 in 5 congestive heart failure patients has a false-negative chest radiograph in the ED seems inconsistent with clinical practice. If the chest radiograph does not show signs of heart failure, are we really missing clinically important cases? The face validity of these conclusions seems incongruent with our practice. Either the results are correct and we have been wrong in a number of cases for many years, or the data and assumptions used by Collins et al to infer these conclusions are invalid. I will make an argument for why the latter is likely true.

History of Depression as a Predictor of Adverse Outcomes in Patients Hospitalized for Decompensated Heart Failure

To evaluate the prevalence and impact of depression on the risk of in-hospital death or need for cardiopulmonary resuscitation (CPR) in patients admitted for decompensated heart failure. Observational single-center study. Coronary care unit and cardiac intermediate-care unit of a tertiary referral center. One hundred seventy-one patients hospitalized with decompensated heart failure who were included in the Acute Decompensated Heart Failure Registry (ADHERE). The 34 patients with a history of depression had a higher likelihood of experiencing the combined end point of in-hospital death or CPR compared with the 137 patients without a history of depression (17.7% vs 6.6%, p<0.05). A history of depression (odds ratio 3.3, 95% confidence interval 1.01-10.6, p<0.05) was still predictive of in-hospital death or CPR in a multivariate analysis after adjusting for predictors of the combined end point. This study suggests that a history of depression is associated with an increased risk of in-hospital mortality or CPR in patients hospitalized for decompensated heart failure. Our results require confirmation in larger trials.

Implications of New ICD, BiV and ICD/BiV Guideline Implementation on Device Utilization among Patients with Heart Failure

Background: The current population impact of new implantable cardioverter defibrillator (ICD) Madit criteria and ACC/AHA biventricular (BiV) device implantation guidelines published in 2002 in patients with heart failure has not been fully evaluated. Objectives: The purpose of this study was to determine the current practice and potential eligibility of device implantation in patients (pts) admitted to a large tertiary care center with a primary diagnosis of heart failure. Methods: The data was collected from November of 2001 to April of 2003 as part of a national acute decompensated heart failure registry (Adhere). A complete patient profile was obtained in 261 pts including QRS width, ejection fraction (EF), NHYA functional class and underlying CHF etiology. Pts were separated into 3 groups according to device implantation during their index admission or eligibility for device implantation : ICD only (Madit I and II ICD criteria), BiV pacemaker only (ACC/AHA BiV guidelines, and BiV/ICD (both criteria). Results: The study included 169 male pts, mean age 59.8 +/− SD13.2 yrs and 92 females pts with a mean age of 59.9+/−12.5 yrs. ICD criteria were met by 43 pts (16%); of those 4 received an ICD and 4 a BiV/ICD. BiV criteria were met by 31 pts(31%), of those 4 received a BiV/ICD and 1 an ICD only. BiVICD criteria were met by 26 pts (10%); of those 1 received an ICD and 4 recieved a BiV/ICD. The devide group had a mean length of stay of 9.24+/−SD6.81 days and mean EF (19.92% +/−SD8.36). The non-device group had a mean length of stay of 7.29+/− SD6.32 days and mean EF(25.37+/−SD11.6). Three pts died during their hospital admission. Conclusion: This study reveals an apparent underutilization of device implantation according to published guidelines. Out of 261 pts, 105(40.2%) satisfied criteria for device impantation but only 18(17.1%) recieved one. Although the indication for device implantation is influenced by multiple factor, there appears to be a bias toward device implantation in the sicker or less responsive to medical therapy patients as suggested by the longer lenght of stay and lower EF in this group. The social and economic impact of device utilization on the healthcare system is left to be determined as new guidelines become more widely accepted.