Admission Diagnosis Of Heart Failure Research Articles

Unsupervised machine learning to identify subphenotypes among cardiac intensive care unit patients with heart failure.

Hospitalized patients with heart failure (HF) are a heterogeneous population, with multiple phenotypes proposed. Prior studies have not examined the biological phenotypes of critically ill patients with HF admitted to the contemporary cardiac intensive care unit (CICU). We aimed to leverage unsupervised machine learning to identify previously unknown HF phenotypes in a large and diverse cohort of patients with HF admitted to the CICU. We screened 6008 Mayo Clinic CICU patients with an admission diagnosis of HF from 2007 to 2018 and included those without missing values for common laboratory tests. Consensus k-means clustering was performed based on 10 common admission laboratory values (potassium, chloride, anion gap, blood urea nitrogen, haemoglobin, red blood cell distribution width, mean corpuscular volume, platelet count, white blood cell count and neutrophil-to-lymphocyte ratio). In-hospital mortality was evaluated using logistic regression, and 1year mortality was evaluated using Cox proportional hazard models after multivariable adjustment. Among 4877 CICU patients with HF who had complete admission laboratory data (mean age 69.4years, 38.4% females), we identified five clusters with divergent demographics, comorbidities, laboratory values, admission diagnoses and use of critical care therapies. We labelled these clusters based on the characteristic laboratory profile of each group: uncomplicated (25.7%), iron-deficient (14.5%), cardiorenal (18.4%), inflamed (22.3%) and hypoperfused (19.2%). In-hospital mortality occurred in 10.7% and differed between the phenotypes: uncomplicated, 2.7% (reference); iron-deficient, 8.1% [adjusted odds ratio (OR) 2.18 (1.38-3.48), P<0.001]; cardiorenal, 10.3% [adjusted OR 2.11 (1.37-3.32), P<0.001]; inflamed, 12.5% [adjusted OR 1.79 (1.18-2.76), P=0.007]; and hypoperfused, 21.9% [adjusted OR 4.32 (2.89-6.62), P<0.001]. These differences in mortality between phenotypes were consistent when patients were stratified based on demographics, aetiology, admission diagnoses, mortality risk scores, shock severity and systolic function. One-year mortality occurred in 31.5% and differed between the phenotypes: uncomplicated, 11.9% (reference); inflamed, 26.8% [adjusted hazard ratio (HR) 1.56 (1.27-1.92), P<0.001]; iron-deficient, 33.8% [adjusted HR 2.47 (2.00-3.04), P<0.001]; cardiorenal, 41.2% [adjusted HR 2.41 (1.97-2.95), P<0.001]; and hypoperfused, 52.3% [adjusted HR 3.43 (2.82-4.18), P<0.001]. Similar findings were observed for post-discharge 1year mortality. Unsupervised machine learning clustering can identify multiple distinct clinical HF phenotypes within the CICU population that display differing mortality profiles both in-hospital and at 1year. Mortality was lowest for the uncomplicated HF phenotype and highest for the hypoperfused phenotype. The inflamed phenotype had comparatively higher in-hospital mortality yet lower post-discharge mortality, suggesting divergent short-term and long-term prognosis.

Time to Dementia Diagnosis Among Veterans with Comorbid Insomnia and Depressive Episodes.

Older adults with heart failure are at elevated risk of Alzheimer's disease and related dementias (AD/ADRD). Research suggests that insomnia and depressive episodes contribute somewhat dissociable impacts on risk for AD/ADRD in this patient population, although the temporal ordering of effects is unknown. This study examined time to dementia diagnosis among patients with comorbid insomnia and/or depressive episodes in an epidemiological sample. Secondary data analyses were conducted using a cohort study of 203,819 Veterans with a primary admission diagnosis of heart failure in 129 VA Medical Centers. Patients with diagnoses of both insomnia and depressive episodes had the shortest time to a dementia diagnosis at both 1-year (Hazard ratio = 1.43, 95% CI [1.36, 1.51]) and 3-year follow-up time points (Hazard ratio = 1.40, 95% CI [1.34, 1.47]) versus patients with one or neither comorbidity. Individuals with both comorbidities had the shortest time to dementia onset. Screening for these comorbidities may help to identify patients at elevated risk of dementia who could benefit from enhanced monitoring or early intervention strategies for more rapid detection and management of dementia symptoms.

Development and validation of the Tool for Pharmacists to Predict 30-day hospital readmission in patients with Heart Failure (ToPP-HF).

Pharmacists are well positioned to provide transitions of care (TOC) services to patients with heart failure (HF); however, hospitalizations for patients with HF likely exceed the capacity of a TOC pharmacist. We developed and validated a tool to help pharmacists efficiently identify high-risk patients with HF and maximize their potential impact by intervening on patients at the highest risk for 30-day all-cause readmission. We conducted a retrospective cohort study including adults with HF admitted to a health system between October 1, 2016, and October 31, 2019. We randomly divided the cohort into development (n = 2,114) and validation (n = 1,089) subcohorts. Nine models were applied to select the most important predictors of 30-day readmission. The final tool, called the Tool for Pharmacists to Predict 30-day hospital readmission in patients with Heart Failure (ToPP-HF) relied upon multivariable logistic regression. We assessed discriminative ability using the C statistic and calibration using the Hosmer-Lemeshow goodness-of-fit test. The risk of 30-day all-cause readmission was 15.7% (n = 331) and 18.8% (n = 205) in the development and validation subcohorts, respectively. The ToPP-HF tool included 13 variables: number of hospital admissions in previous 6 months; admission diagnosis of HF; number of scheduled medications; chronic obstructive pulmonary disease diagnosis; number of comorbidities; estimated glomerular filtration rate; hospital length of stay; left ventricular ejection fraction; critical care requirement; renin-angiotensin-aldosterone system inhibitor use; antiarrhythmic use; hypokalemia; and serum sodium. Discriminatory performance (C statistic of 0.69; 95% confidence interval [CI], 0.65-0.73) and calibration (Hosmer-Lemeshow P = 0.28) were good. The ToPP-HF performs well and can help pharmacists identify high-risk patients with HF most likely to benefit from TOC services.

Age and shock severity predict mortality in cardiac intensive care unit patients with and without heart failure.

AimsAge is an important risk factor for mortality among patients with cardiogenic shock and heart failure (HF). We sought to assess the extent to which age modified the performance of the Society for Cardiovascular Angiography and Interventions (SCAI) shock stage for in‐hospital and 1 year mortality in cardiac intensive care unit (CICU) patients with and without HF.Methods and resultsWe retrospectively reviewed unique admissions to the Mayo Clinic CICU during 2007–2015 and stratified patients by age and SCAI shock stage. The association between age and in‐hospital mortality was analysed using multivariable logistic regression, and 1 year mortality was analysed using Cox proportional hazards analysis, both in the entire cohort and among patients with an admission diagnosis of HF or acute coronary syndrome (ACS). The final study population included 10 004 unique patients with a mean age of 67 ± 15 years, including 46.1% with HF and 43.1% with ACS. Older patients more frequently had HF and had more extensive co‐morbidities, higher illness severity, more organ failure, and differential use of critical care therapies. The percentage of patients with SCAI shock stages A, B, C, D, and E were 46%, 30%, 16%, 7%, and 1%, respectively. Patients with HF were older, had greater severity of illness and higher SCAI shock stage, and had higher rates of death at all time points. In‐hospital mortality occurred in 908 (9%) patients, including 549 (12%) patients with HF (61% of all hospital deaths). Age was independently associated with hospital mortality (adjusted odds ratio per 10 years 1.3, 95% confidence interval 1.2–1.4, P < 0.001) and 1 year mortality (adjusted hazard ratio per 10 years 1.2, 95% confidence interval 1.2–1.3, P < 0.001) in the overall cohort. The associations of age with both hospital mortality (adjusted odds ratio 1.6 vs. 1.3 per 10 years older) and 1 year mortality (adjusted hazard ratio 1.5 vs. 1.3 per 10 years older) were higher for patients with ACS compared with patients with HF. Older age was associated with higher adjusted hospital mortality and 1 year mortality in each SCAI shock stage (all P < 0.05). Additive increases in both hospital mortality and 1 year mortality were observed with increasing age and SCAI shock stage.ConclusionsAge is an independent risk factor for mortality that modifies the relationship between the SCAI shock stage and mortality risk in CICU patients, providing robust risk stratification for in‐hospital and 1 year mortality. Although patients with HF had a higher risk of dying, age was more strongly associated with mortality among patients with ACS.

Abstract 182: Causes and Prevention of Hospital Readmissions Secondary to Heart Failure in Southern Appalachia

Objective: Recognize opportunities to mitigate readmissions following hospitalization for heart failure. Background: Heart failure (HF) is the leading cause of hospital readmissions, defined as hospital admissions that occur within 30 days of previous hospital discharge. The Hospital Readmission Reduction Program within the Affordable Care Act penalizes hospitals for readmission rates that surpass the national average for targeted diagnoses including HF. Southern Appalachia has higher HF readmission rates when compared to the national average, even among similar patients with matched comorbidities. These hospitals subsequently incur heavy financial penalties. Methods: Institutional review board (IRB) approved retrospective chart review study analyzing medical facilities in Southern Appalachia to determine factors contributing to higher readmission rates secondary to HF from 2014 to 2017. Results: Data from 3,555 patients’ charts were reviewed who had an index admission diagnosis of HF and were discharged between 2014 to 2017; 818 of these patients were readmitted within 30 days. Length of stay (LOS) of more than 5 days was significantly associated with an increased readmission rate (p = 0.0347), and current tobacco use was also significantly associated with an increased readmission rate (p = 0.0214). Use of angiotensin converting enzyme inhibitors (ACE-I) upon discharge was associated with a decrease in likelihood of readmission (p = 0.0014). Other medications prescribed at discharge (beta blockers, aldosterone antagonists, diuretics, antiplatelet, and statin) were not associated with affecting the readmission rate. Comorbidities including diabetes mellitus (DM), chronic renal failure (CRF), and psychiatric diagnoses were all associated with significantly increasing the readmission rate (p = 0.0468, p = 0.0061, and p = 0.0085, respectively). The discharge time of the day, day of the week, and month of the year were not associated with affecting the readmission rate. The type of payor for the medical care, the discharge location, and whether patients received a palliative medicine consult while hospitalized also did not affect the readmission rate. Conclusion: Strategies to mitigate readmission rates secondary to HF include limiting LOS to less than 5 days, providing smoking cessation education, and prescribing an ACE-I at the time of discharge. Methods to minimize development of DM and CRF through controlling contributing risk factors and ensuring appropriate management of psychiatric disorders are additional platforms for decreasing readmission rates for HF. Counter to previous assumptions, the discharge time of the day, day of the week, and month of the year did not affect the rate of readmissions, nor did the type of payor, the discharge location, or whether patients received palliative medicine consults.

Impact of a Patient Navigator Program on Hospital-Based and Outpatient Utilization Over 180Days in a Safety-Net Health System.

With emerging global payment structures, medical systems need to understand longer-term impacts of care transition strategies. To determine the effect of a care transition program using patient navigators (PNs) on health service utilization among high-risk safety-net patients over a 180-day period. Randomized controlled trial conducted October 2011 through April 2013. Patients admitted to the general medicine service with ≥1 readmission risk factor: (1) age≥60; (2) in-network inpatient admission within prior 6months; (3) index length of stay ≥ 3days; or (4) admission diagnosis of heart failure or (5) chronic obstructive pulmonary disease. The analytic sample included 739 intervention patients, 1182 controls. Through hospital visits and 30days of post-discharge telephone outreach, PNs provided coaching and assistance with medications, appointments, transportation, communication with primary care, and self-care. Primary outcomes: (1) hospital-based utilization, a composite of ED visits and hospital admissions; (2) hospital admissions; (3) ED visits; and (4) outpatient visits. We evaluated outcomes following an index discharge, stratified by patient age (≥ 60 and < 60years), using a 180-day time frame divided into six 30-day periods. The PN program produced starkly different outcomes by patient age. Among older PN patients, hospital-based utilization was consistently lower than controls, producing an 18.7% cumulative decrease at 180days (p=0.038); outpatient visits increased in the critical first 30-day period (p=0.006). Among younger PN patients, hospital-based utilization was 31.7% (p=0.038) higher at 180days, largely reflecting sharply higher utilization in the initial 30days (p=0.002), with non-significant changes thereafter; outpatient visits experienced no significant changes. A PN program serving high-risk safety-net patients differentially impacted patients based on age, and among younger patients, outcomes varied over time. Our findings highlight the importance for future research to evaluate care transition programs among different subpopulations and over longer time periods.

18 One Page User Friendly Proforma Delivers Dramatic Improvements in Heart Failure Management in a Busy District General Hospital

<h3>Background</h3> Heart failure affects almost one million people in the UK with survival rates comparable to or worse than many cancers. Recent publications of the NICOR National Heart Failure Audit have focused attention on the need for improvement. This challenge is particularly acute in busy district general hospitals in London such as Whipps Cross University Hospital. <h3>Objective</h3> We aimed to investigate if the implementation of a simple one-page user friendly Whipps Cross Heart Failure Improvement Proforma- the ‘WHIP form’ in all medical wards could help improve the management of patients admitted with heart failure against standard quality measures. <h3>Methods</h3> The ‘WHIP form’ was introduced and implemented in all medical wards supported with a one-day educational seminar and a new dedicated heart failure email service. <h3>Results</h3> Between June to September 2015, 106 patients with a primary admission diagnosis of heart failure were enrolled and managed using the ‘WHIP form’. Inpatient mortality remained stable at 11.3% with an average hospital stay of 13.5 days. The 30-day readmission rate halved from 14% to 7%. Patients with documented left ventricular systolic dysfunction on Echocardiogram had significant improvements in the prescription of prognostic medication on discharge: ACEi/ARBs prescription increased from 78% from 88% [10% improvement]. B-Blockers prescription increased from 68% to 95% [27% improvement]. <h3>Conclusion</h3> The initiation of an “easy to use” one page heart failure management proforma led to a dramatic reduction in 30-day readmission rates and significant increase in the prescription of prognostically important ACE inhibitors and B-blockers. If the reductions in 30-day readmissions are sustained, we estimate that our cost neutral intervention could translate to yearly savings of nearly £80K for Whipps Cross University Hospital alone.

NT-proBNP and Its Correlation with In-Hospital Mortality in the Very Elderly without an Admission Diagnosis of Heart Failure.

BackgroundThe diagnosis of heart failure (HF) is often difficult and underestimated in very elderly comorbid patients, especially when an echocardiographic evaluation is not available or feasible. Aim: to evaluate NT-proBNP values and their correlation with in-hospital mortality in a population of very elderly hospitalized for medical conditions other than HF.MethodsWe performed a prospective observational study on 403 very elderly admitted to an Internal Medicine and Geriatrics Department. Exclusion criterion was an admission diagnosis of HF. Patients with at least one symptom or sign compatible with HF were tested for NT-proBNP. NT-proBNP values < 300 pg/ml were considered as an age-independent exclusion criterion for HF (high negative predictive value), while NT-proBNP values ≥ 1800 pg/ml were considered as a diagnostic criterion. Main comorbidities and laboratory parameters were considered to adjust regression analyses between NT-proBNP and in-hospital mortality.ResultsNT-proBNP values ≥ 1800 pg/ml were present in 61.0% of patients and 32.8% of patients laid between 300 ≤ NT-proBNP < 1800 pg/ml values. NT-proBNP values were associated with the main indices of disease severity/organ failure considered such as reduced eGFR, reduced albumin and elevated CRP. NT-proBNP values ≥ 1800 pg/ml and ln(NT-proBNP) values were significantly associated with in-hospital mortality independently from the main comorbidities and lab parameters considered. The patients, who were already taking ACE inhibitors/Angiotensin Receptor Blockers before admission, showed lower in-hospital mortality.ConclusionsTesting for NT-proBNP should be strongly recommended in the hospitalized very elderly, because of the very high prevalence of underlying HF and its impact on in-hospital mortality, to identify an underlying cardiac involvement that requires appropriate treatment.

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial.

Evidence-based interventions to reduce hospital readmissions may not generalize to resource-constrained safety-net hospitals. To determine if an intervention by patient navigators (PNs), hospital-based Community Health Workers, reduces readmissions among high risk, low socioeconomic status patients. Randomized controlled trial. General medicine inpatients having at least one of the following readmission risk factors: (1) age ≥60 years, (2) any in-network inpatient admission within the past 6 months, (3) length of stay ≥3 days, (4) admission diagnosis of heart failure, or (5) chronic obstructive pulmonary disease. The analytic sample included 585 intervention patients and 925 controls. PNs provided coaching and assistance in navigating the transition from hospital to home through hospital visits and weekly telephone outreach, supporting patients for 30 days post-discharge with discharge preparation, medication management, scheduling of follow-up appointments, communication with primary care, and symptom management. The primary outcome was in-network 30-day hospital readmissions. Secondary outcomes included rates of outpatient follow-up. We evaluated outcomes for the entire cohort and stratified by patient age >60 years (425 intervention/584 controls) and ≤60 years (160 intervention/341 controls). Overall, 30-day readmission rates did not differ between intervention and control patients. However, the two age groups demonstrated marked differences. Intervention patients >60 years showed a statistically significant adjusted absolute 4.1% decrease [95% CI: -8.0%, -0.2%] in readmission with an increase in 30-day outpatient follow-up. Intervention patients ≤60 years showed a statistically significant adjusted absolute 11.8% increase [95% CI: 4.4%, 19.0%] in readmission with no change in 30-day outpatient follow-up. A patient navigator intervention among high risk, safety-net patients decreased readmission among older patients while increasing readmissions among younger patients. Care transition strategies should be evaluated among diverse populations, and younger high risk patients may require novel strategies.

Racial and Ethnic Differences in 30-Day Readmission and 1-Year Mortality among Patients Hospitalized for Heart Failure

Objective: Contemporary outcomes data among heart failure (HF) patients younger than age 65 are limited, especially among Hispanics. This study evaluated the association between race/ethnicity, 30-day readmission, and 1-year mortality among a diverse cohort of hospitalized HF patients overall and by age group. Methods: This was a 1-year prospective study of consecutively hospitalized patients with an admission diagnosis of HF who participated in a NHLBI clinical outcomes study (N=407; 52% white, 25% Hispanic, 20% black, 3% Asian; 38% female; mean age 65 ± 15 years). Demographics, comorbidities, medications, and outcomes (30-day readmssion; death at 1-year) were systematically obtained by clinical information system. Multivariate logistic regression was used to evaluate associations between race/ethnicity and outcomes, adjusted for covariates. Results: The 30-day readmission rate was 10% (n=41). By 1-year, 23% (n=94) of patients died. Hispanics had significantly higher odds of readmission versus whites/Asians (adjusted OR=3.1; 95% CI=1.4-6.9) and blacks (adjusted OR=3.6; 95%CI=1.2-10.3). These race/ethnic differences were observed among patients ≥ 65, but not <65 years old. In contrast, Hispanics had a lower 1-year death rate versus whites/Asians (16% versus 27%; p=0.03), not significant after covariate adjustment (adjusted OR=0.6; 95% CI=0.3-1.1), observed among patients ≥ 65 (OR=0.3; 95% CI=0.1-0.7), but not <65 years (OR=1.2; 95% CI=0.5-2.8). Conclusion: Among patients hospitalized for HF, older, but not younger, Hispanics had a higher 30-day readmission rate versus others. In contrast, 1-year death rate was lower among older, but not younger, Hispanics versus whites/Asians.

Management of heart failure complicating acute coronary syndromes in Montenegro and Serbia

It is essential that context-appropriate health research and health interventions take place in countries with economy in transition. The aims of this study were to describe the clinical characteristics, management, and in-hospital outcomes of acute coronary syndrome (ACS) patients with heart failure (HF) in Montenegro and Serbia. The data of this study are a framework of the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC; [NCT01218776][1]), a multi-national and multicentre registry of patients hospitalized with ACS in the European countries that emerged from the Socialist era. The present analysis focused on participants admitted to 15 hospitals in Montenegro and Serbia with a diagnosis of ACS during the period between October 2012 and August 2013. Among 1115 patients, 94 (8.4%) had an admission diagnosis of HF (Killip Class II or III). Heart failure patients were significantly older ( P < 0.001). Heart failure was more frequently associated with hypertension. When compared with patients presenting without HF (Killip Class I), those with HF had lower rates of reperfusion therapy either by percutaneous coronary intervention (47.9 vs. 60.7%, P = 0.015) or by fibrinolysis (2.1 vs. 11.8%, P = 0.004). In multivariate logistic regression analysis, older age, prior coronary artery bypass graft, and ST-segment elevation myocardial infarction were the relevant predictor of HF at admission. Heart failure on admission was associated with a marked increase in mortality rates during hospitalization (13.8 vs. 3.7%, P < 0.001). After adjustment for differences in clinical characteristics, HF was still associated with higher mortality (odds ratio 2.88, 95% confidence interval 1.22–6.79, P = 0.016). Heart failure is observed in nearly 9% of patients with ACS in Serbia and Montenegro and is also associated with a significant increase in in-hospital mortality. More aggressive treatment of these patients is warranted to improve prognosis. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01218776&atom=%2Fehjsupp%2F16%2Fsuppl_A%2FA61.atom

Impact of Methicillin Resistant Staphylococcus aureus Contact Isolation Units on Medical Care

BackgroundPatient isolation using contact precautions has gained widespread use to halt MRSA transmission, however supportive data is scarce and concerns regarding patient safety and satisfaction have been raised. At our institution, MRSA patients are isolated on a dedicated ward (cohort isolation), rather than in separate rooms. Our objectives were (1) to determine the proportion of bedside medical visits to patients on an isolation ward, (2) to quantify complications in those patients and (3) to determine if those complications are related to isolation and if they can be prevented.MethodsThis retrospective case-control study was performed on the two sites of a tertiary teaching hospital in Sherbrooke, QC, Canada. We matched MRSA patients with an admission diagnosis of heart failure or chronic obstructive pulmonary disease to similar non-isolated controls. The proportion of bedside visits was ascertained through the number of progress notes with subjective elements or with a physical examination. Complications were sought through an extensive file review, and events were analysed according to Baker’s CAES causality and preventability scales.ResultsOverall, 111 patient pairs were analysed (35 with heart failure and 76 with COPD). Isolated patients received less bedside visits (subjective notes/1,000 patient-days: 849.6 vs. 983.3, p = 0,001). Attending physicians (454.5 vs. 451.4, p = 0,02) and residents (347.0 vs. 416.9, p = 0.01) are responsible for this discrepancy, while medical students appear to visit isolated and non-isolated patients equally (116.5 vs. 114.9, p = 0.90). Isolated patients showed a tendency towards longer stay and more preventable complications, although no difference in the total number of complications was observed.ConclusionIsolated patients have less documented care that suggests less bedside visits from the medical staff, which could hamper the therapeutical relationship. Further studies are needed to explain this finding.

Characteristics and in-hospital outcomes of patients with acute coronary syndromes and heart failure in the United Arab Emirates

BackgroundHeart failure (HF) is a serious complication of acute coronary syndromes (ACS), and is associated with high in-hospital mortality and poor long-term survival. The aims of this study were to describe the clinical characteristics, management and in-hospital outcomes of coronary syndrome (ACS) patients with HF in the United Arab Emirates.FindingsThe study was selected from the Gulf Registry of Acute Coronary Events (Gulf RACE), a prospective multi-national, multicenter registry of patients hospitalized with ACS in six Middle East countries. The present analysis was focused on participants admitted to various hospitals in the UAE with a diagnosis of ACS in 2007 and were analyzed in terms of HF (Killip class II/III and IV) on admission. Of 1691 patients (mean age: 52.6 ± 11.7 years; 210 Females, 1481 Males) with ACS, 356 (21%) had an admission diagnosis of HF (Killip class II/III and IV). HF patients were less frequently males (19.2% vs. 34.3%; P < 0.001). HF was more frequently associated with hypertension (64.3% vs. 43.9%; P < 0.001), hyperlipidemia (49.4% vs. 31.8%; P < 0.001) and diabetes mellitus (DM) (51.1% vs. 36.2%; P < 0.001). HF was significantly associated with in-hospital mortality (OR = 11.821; 95% CI: 5.385-25.948; P < 0.001). In multivariate logistic regression, age, hyperlipidemia, heart rate and DM were associated with higher in-hospital HF.ConclusionsHF is observed in about 1 in 5 patients with ACS in the UAE and is associated with a significant increase in in-hospital mortality and other adverse outcomes.

Postdischarge Adverse Events for 1-Day Hospital Admissions in Older Adults Admitted From the Emergency Department

We assess hospital readmission and death within 60 days in older adults admitted from the emergency department (ED) and discharged by an inpatient service within 24 hours. This was a retrospective review of ED patients aged 64 years or older, admitted from 2 hospitals (2004 to 2006), who were discharged home within 24 hours. Excluded were in-hospital deaths, observation admissions, transfers to other facilities, patients who left against medical advice, and hospice patients. Outcomes were 72-hour and 30-day readmissions and postdischarge deaths that occurred within 60 days of ED admission. Logistic regression was used to assess for predictors of readmission. A chart review of deaths after discharge was performed to assess for potential contributors to adverse outcomes. A total of 1,470 admissions met inclusion criteria as 1-day admissions. Of those, 22 (1.5%) patients returned for hospital readmission within 72 hours and 156 (10.6%) within 30 days of discharge. In the multivariable analysis, previous admissions (odds ratio [OR] 1.3; 95% confidence interval [CI] 1.1 to 1.4) and an admission diagnosis of heart failure (OR 2.2; 95% CI 1.0 to 5.0) were associated with 30-day readmission. In 841 individual patients with greater than or equal to one 1-day admission, there were 15 deaths (1.8%) within 60 days. Of those, 11 (73%) patients had abnormal ED ECG results, 6 (40%) were ruled out for acute myocardial infarction while hospitalized, and 3 (20%) had definitive follow-up arranged at discharge. One-day admissions in hospitalized older adults through the ED do not represent a group at low risk for postdischarge adverse outcomes.

Determinants and prognostic impact of heart failure complicating acute coronary syndromes: observations from the Global Registry of Acute Coronary Events (GRACE).

Few data are available on the impact of heart failure (HF) across all types of acute coronary syndromes (ACS). The Global Registry of Acute Coronary Events (GRACE) is a prospective study of patients hospitalized with ACS. Data from 16 166 patients were analyzed: 13 707 patients without prior HF or cardiogenic shock at presentation were identified. Of these, 1778 (13%) had an admission diagnosis of HF (Killip class II or III). HF on admission was associated with a marked increase in mortality rates during hospitalization (12.0% versus 2.9% [with versus without HF], P<0.0001) and at 6 months after discharge (8.5% versus 2.8%, P<0.0001). Of note, HF increased mortality rates in patients with unstable angina (defined as ACS with normal biochemical markers of necrosis; mortality rates: 6.7% with versus 1.6% without HF at admission, P<0.0001). By logistic regression analysis, admission HF was an independent predictor of hospital death (odds ratio, 2.2; P<0.0001). Admission HF was associated with longer hospital stay and higher readmission rates. Patients with HF had lower rates of catheterization and percutaneous cardiac intervention, and fewer received beta-blockers and statins. Hospital development of HF (versus HF on presentation) was associated with an even higher in-hospital mortality rate (17.8% versus 12.0%, P<0.0001). In patients with HF, in-hospital revascularization was associated with lower 6-month death rates (14.0% versus 23.7%, P<0.0001; adjusted hazard ratio, 0.5; 95% CI, 0.37 to 0.68, P<0.0001). In this observational registry, heart failure was associated with reduced hospital and 6-month survival across all ACS subsets, including patients with normal markers of necrosis. More aggressive treatment of these patients may be warranted to improve prognosis.