Comorbid Heart Failure Research Articles

Long-term outcomes of 265,737 patients hospitalised with atrial fibrillation and atrial flutter from 2008 to 2015

Abstract Background Atrial fibrillation/atrial flutter (AF/AFL) hospitalisations are common, however, little is known about the long-term outcomes of these episodes. Objective To examine the incidence of mortality, all-cause and cause-specific re-hospitalisations at up to 8 years after a hospitalisation for AF/AFL. Methods Unique patients hospitalised with a primary diagnosis of AF/AFL from 2008–2015 were identified using nation-wide hospitalisation data from Australia and New Zealand. All-cause mortality was the primary outcome. Secondary endpoints included all-cause and cause-specific re-hospitalisations. Results were reported as incident rate per 100 patient-years. Results We included 265,737 patients (mean age 69.9±13.9y, female 45.2%, elective 28.7%). The median length of stay was 1 day (Interquartile range [IQR] 0–4 days) and the median CHA2DS2-VASc score was 2 (IQR 1–2). During the index hospitalisation, 9,837 (3.7%) patients underwent catheter or surgical ablation and 52,634 (19.8%) underwent cardioversion. During the median follow-up time of 3.4 years (range 0–8.0 years), 53,669 patients died (incident rate of 5.7/100 patient-years) with a survival probability gradually decreasing from 92.8% (95% CI 92.7–92.9%) at 1-year to 65.4% (95% CI 64.9–65.8%) at 8-years post-discharge (Table 1 and Figure 1). All-cause re-hospitalisations occurred in 210,118 patients (incident rate of 22.2/100 patient-years) with a rehospitalisation-free survival probability of 7.1% (95% CI 6.9—7.3%) at the end of follow-up. Unplanned re-hospitalisations occurred more frequently than planned episodes (incident rate of 17.2 vs. 16.6/100 patient-years respectively). AF/AFL accounted for 25.1% of all-cause re-hospitalisations (incident rate of 8.9/100 patient-years) and the probability of freedom from re-hospitalisations for AF/AFL was 55.4% (95% CI 55.0–55.8%) at 8-years. Incident rates of re-hospitalisations for catheter ablation (1.5/100 patient-years), stroke (1.6/100 patient-years), heart failure (2.7/100 patient-years), and acute myocardial infarction (1.0/100 patient-years) were low. In subgroup analyses, worse survival was observed in female patients, older age groups, patients with comorbid heart failure, hypertension, diabetes, and those who did not undergo ablation during the index hospitalisation. Conclusion Nearly two-thirds of patients were surviving by 8-years following an AF/AFL hospitalisation with a low rate of re-hospitalisations for stroke, heart failure, and myocardial infarction. However, re-hospitalisations for recurrent atrial arrhythmia were common. Efforts to reduce re-hospitalisations, especially unplanned encounters, are required to improve patient outcomes. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): National Heart Foundation of Australia

Association of neighbourhood-level poverty with outcomes and clinical care following atrial fibrillation diagnosis in a universal healthcare system

Abstract Background There are limited data on the association of poverty with outcomes and care patterns after an atrial fibrillation (AF) diagnosis in jurisdictions with universal healthcare. The Canadian province of Ontario provides publicly funded healthcare and prohibits private payment for medically necessary physician and in-hospital care. It also covers prescription medications for residents aged >65 years. Purpose Determine the association of neighbourhood-level poverty with outcomes and processes of care after AF diagnosis in older people within a universal healthcare system. Methods Using linked administrative databases, we conducted a population-based cohort study of community-dwelling adults aged ≥66 years who were newly diagnosed with AF in Ontario between April 1, 2007 and March 31, 2019. The primary exposure was material deprivation of patients' neighborhood of residence. This metric is derived using Canadian census data to estimate inability to access and attain basic material needs. Neighborhoods were categorized by quintile of material deprivation from Q1 (wealthiest) to Q5 (poorest). We used cause-specific hazards regression models to study the association of deprivation quintile with time to the following outcomes over one year from AF diagnosis: death, ischemic stroke, bleeding, heart failure (HF) hospitalization, cardiology services, and AF-specific treatments. Models accounted for clustering by region of residence and adjusted for age, sex, diabetes, HF, stroke/transient ischemic attack, vascular disease, hypertension, bleeding history, rural residence, renal function, and setting of AF diagnosis (hospital, emergency department [ED] or outpatient). Results We studied 350,353 patients with AF (median age 78 years, 48.9% female). People from neighborhoods in higher deprivation quintiles (poorer) were more likely to be diagnosed in hospital/ED than outpatient settings. Relative to people from the wealthiest neighbourhoods (Q1), patients in the poorest neighbourhoods (Q5) had higher prevalence of baseline hypertension, diabetes, HF, vascular disease and other comorbidities. In adjusted analyses (Figure), higher quintiles of neighborhood poverty were associated with greater rates of death, ischemic stroke, bleeding, and HF hospitalization, but lower rates of cardiology visits, cardiac testing, anticoagulation, anti-arrhythmic medications, cardioversion, or AF ablation. Conclusions In a setting of universal healthcare and prescription medication coverage, people living in poorer neighbourhoods had worse baseline health and higher rates of adverse outcomes after an AF diagnosis. Despite this, people in poorer neighbourhoods had less cardiology visits and diagnostic tests and were less likely to receive anticoagulation and rhythm control interventions. This shows that universal healthcare and medication coverage are insufficient to achieve equitable health care and outcomes for people with AF. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): This research was funded by a Canadian Institutes of Health Research Foundation grant; and is supported by ICES (formerly the Institute for Clinical Evaluative Sciences), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC).

Risk prediction of major adverse cardiac events by high sensitivity troponin is modified by comorbidities

Abstract Background High-sensitivity cardiac troponin (hs-cTn) is a well-established biomarker for the evaluation of Emergency Department (ED) patients with possible acute coronary syndrome. These patients often have comorbid conditions that may impact hs-cTn values. However, prior studies and current guidelines addressing the relationship between comorbidities and hs-cTn are limited. Purpose To determine whether an interaction exists between comorbidities and baseline hsTnT values on the risk of 30-day major adverse cardiac events (MACE) in a multicenter United States (US) cohort. Methods Adult ED patients with suspected acute coronary syndrome were prospectively enrolled in a multicenter cohort study in the US. Baseline blood samples were collected and hs-cTnT concentrations were measured at a central laboratory. Comorbid conditions, such as obesity, hypertension, hyperlipidemia, diabetes, coronary artery disease, congestive heart failure, renal disease, peripheral vascular disease, prior stroke, and history of coronary interventions, were collected at time of enrollment. The primary outcome was adjudicated MACE, defined as occurrence of myocardial infarction, cardiovascular or uncertain death, or coronary revascularization within 30 days. Hs-cTnT values were dichotomized using manufacturer's limit of quantification (LOQ) at 6 ng/dL and the upper reference limit (URL) of 19 ng/dL. The utility the LOQ and URL cut-offs in predicting MACE was evaluated using logistic regression. Effect modification of comorbid conditions was independently evaluated by including an interaction term between comorbidity and hs-cTnT. Results Among 1460 participants with a baseline hs-cTn measurement, 46.3% (676/1460) were female and 37.1% (542/1460) were Black with a mean age of 57.6±12.9 years. The prevalence of MACE was 14.4% (210/1460). Participants with a baseline hs-cTnT below LOQ were 0.08 (95% CI: 0.04–0.16) times less likely to have MACE compared to those exceeding LOQ. Those with a baseline hs-cTnT exceeding URL were 9.5 (95% CI: 7.0–12.9) times more likely to have MACE. The presence of prior stroke significantly modified the association between baseline hs-cTnT below LOQ and risk of MACE (p=0.006). Among those with prior stroke (n=158), there was no significant association between baseline hs-cTnT below LOQ and risk of MACE (p=0.451). For the association between hs-cTnT above URL and MACE, significant negative interaction was detected by hypertension (p<0.001), hyperlipidemia (p=0.002), coronary artery disease (p=0.002), percutaneous coronary intervention (p=0.001), and congestive heart failure (p=0.038) comorbidity. Conclusion In a diverse, multicenter, US cohort the association between baseline hs-cTnT and the risk of MACE was weakened by the presence of several comorbid conditions. This suggests that the safety of previously validated hs-cTnT diagnostic strategies may be diminished when applied to populations with a high prevalence of comorbid conditions. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Roche Diagnostics

Prevalence of and factors associated with undiagnosed stage 3 chronic kidney disease in patient with a history of heart failure: a report from REVEAL-CKD

Abstract Background Chronic kidney disease (CKD) is a serious debilitating condition affecting 10% of the world's population, yet it remains largely under recognised even among patients with pre-existing comorbidities. Approximately 5% of patients with CKD have a history of heart failure (HF), however factors associated with undiagnosed CKD in patients with multimorbidity remain unclear. Purpose REVEAL-CKD is a multinational initiative to assess undiagnosed CKD. This analysis aims to assess prevalence and factors associated with undiagnosed stage 3 CKD in patients with heart failure. Methods From the US, we utilised TriNetX, a federated research network providing statistics on electronic health records. Adult patients, with two consecutive estimated glomerular filtration rate (eGFR) measurements ≥30 and <60 mL/min/1.732 at least 90 days apart were identified between 2015–2020. HF status was ascertained by ICD codes prior to the index date (date of the second eGFR measurement). Patients with no ICD code for CKD at any time before or up to 6 months after the index date were considered to have undiagnosed CKD. Results The study cohort included 31,263 patients with eGFR values indicating stage 3 CKD and pre-existing HF with mean age of 72 years (standard deviation: 11 years). The overall prevalence of undiagnosed CKD was 48.5% (n=15,159, 95% Confidence Interval: 47.9–49.0). Prevalence of undiagnosed CKD increased with age, was greater than 50% in female patients and was between 38% and 46% in patients with other pre-existing comorbidities (Table 1). Compared to patients with diagnosed CKD, the undiagnosed group had more females (41% versus 60%) and a had higher proportion of patients in the older age group (≥75 years: 43% versus 52%). Fewer undiagnosed CKD patients had pre-existing comorbidities than those with diagnosed CKD. Conclusion This study suggests that a large proportion of either older or female patients with baseline HF comorbidity have undiagnosed CKD. These results suggest that an opportunity exists for more proactive CKD diagnosis and monitoring of patients with comorbidities Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): AstraZeneca

Morbidity and mortality in elderly patients with heart failure managed with a comprehensive care model vs. usual care: The UMIPIC program

BackgroundElderly patients with heart failure (HF) have a high degree of comorbidity which leads to fragmented care, with frequent hospitalizations and high mortality. This study evaluated the benefit of a comprehensive continuous care model (UMIPIC program) in elderly HF patients. Methods and resultsWe prospectively analyzed data from the RICA registry on 2862 patients with HF treated in internal medicine departments. They were divided into two groups: one monitored in the UMIPIC program (UMIPIC group, n: 809) and another which received conventional care (RICA group, n: 2.053). We evaluated HF readmissions during 12 months of follow-up and total mortality after episodes of HF hospitalization. UMIPIC patients were older with higher rates of comorbidity and preserved ejection fraction than the RICA group. However, the UMIPIC group had a lower rate of HF readmissions (17% vs. 26%, p < .001) and mortality (16% vs. 27%, respectively; p < .001). In addition, we selected 370 propensity score-matched patients from each group and the differences in HF readmissions (15% UMIPIC vs. 30% RICA; hazard ratio [HR] = 0.44; 95% confidence interval [CI] 0.32−0.60; p < .001) and mortality (17% UMIPIC vs. 28% RICA; hazard ratio = 0.58; 95% CI 0.42–0.79; p = .001) were maintained. ConclusionsThe implementation of the UMIPIC program, based on comprehensive continuous care of elderly patients with HF and high comorbidity, markedly reduce HF readmissions and total mortality.

TSH Variations in Chronic Heart Failure Outpatients: Clinical Correlates and Outcomes.

Hypothyroidism is a frequently observed comorbidity in patients with chronic heart failure (CHF), possibly giving rise to unfavorable outcomes. The aim of the study was to evaluate the impact of TSH changes over time on cardiac function and prognosis of outpatients with CHF. Patients underwent clinical, electrocardiographic, and echocardiographic evaluations at baseline and after 12 months. Moreover, blood chemistry tests were performed to evaluate renal function, cardiac biomarkers, fT3, fT4, and TSH levels. Based on TSH serum levels, patients were retrospectively classified into four categories: Group 1, patients with improved thyroid function at one-year follow up vs. baseline; Group 2, patients with stable and mildly high TSH values (3.74 - 10 mUI/L); Group 3, patients with worsening thyroid function; Euthyroid patients Group, TSH levels within the normal range of reference at baseline as well as at 12 months follow-up. We considered as end-points: one-year changes of laboratory and echocardiographic parameters; hospitalizations due to worsening of HF (acute decompensated heart failure - ADHF); death for all causes. Among 257 patients, 174 (67.7%) were euthyroid at baseline and after 12 months. Group 1 patients (n. 22, 8.6%) showed a significant improvement in systolic and diastolic function, filling pressures, NT-proBNP and Galectin-3. Group 2 patients (n. 34, 13.2%) did not exhibit significant modifications in studied parameters. Group 3 patients (n. 27, 10.5%) showed worsening of diastolic function and NT-proBNP and a greater risk of ADHF (HR: 2.12; 95%CI: 1.20-3.74; p: 0.009) and death (HR: 4.05; 95%CI: 2.01-8.15; p<0.001). In patients with CHF, changes in thyroid function over time influenced echocardiographic parameters and biomarkers reflecting modifications of cardiac function and prognosis, thus suggesting the clinical relevance of thyroid deficiency screening and correction.

Response to cardiac resynchronisation therapy in men and women: a secondary analysis of the SMART-AV randomised controlled trial

ObjectivesThere is a controversy about whether both sexes’ response to cardiac resynchronisation therapy (CRT) is similar. We aimed to assess a causal effect of sex on CRT response.DesignSecondary analysis of...

Characterization of American teduglutide consumers from 2015 to 2020: A large database study.

Teduglutide, a glucagon-like peptide-2 analog, is a novel therapy for intestinal failure that reduces need for parenteral support, especially in patients without a functional terminal ileum or colon. It can also predispose patients to accelerated progression of gastrointestinal (GI) malignancy and fluid overload. We demographically and clinically characterized American patients prescribed teduglutide. The Explorys database is an aggregate of deidentified patient data from dozens of US healthcare systems. We used SNOMED classification to identify patients prescribed teduglutide from 2015 to 2019. Through the browse cohort feature we determined the demographics, postsurgical anatomy, comorbidities, and indication for teduglutide use among these patients. Of approximately 72 million patients, 170 were prescribed teduglutide. A large majority were female (70.6%). Most common etiologies of short-bowel syndrome were intestinal obstruction (52.9%) and Crohn's disease (41.2%). Common postsurgical anatomy included total colectomy (41.2%) and ileostomy. Common incident symptoms included abdominal pain (41.2%) and nausea (23.5%). Thirty (17.6%) patients were prescribed teduglutide despite comorbid heart failure, and 5.9% despite prior GI malignancy. A total of 11.8% of patients had a history of benign GI neoplasms before starting teduglutide. A total of 5.9% of patients had posttreatment formation of colon polyps. In a large American database, the teduglutide prescription is rare. Only a minority have postsurgical anatomy associated with the most robust response to teduglutide. Serious adverse events appear rare, but a substantial number of patients are at risk for adverse effects because of the presence of comorbid heart failure or GI neoplasm.

MPN-028: Heart Failure: A Cause of Polypharmacy, Drug-Drug, and Food-Drug Interactions in Essential Thrombocythemia

Introduction: Essential thrombocythemia (ET) is a rare BCR-ABL1-negative myeloproliferative neoplasm characterized by excessive production of platelets. Cardiovascular comorbidities, including chronic heart failure (HF), pose significant challenges in the management of ET. Polypharmacy, defined as the prescription of 5 or more drugs daily, and the risk of drug-drug (DDI) and food-drug (FDI) interactions have not been assessed so far in ET patients diagnosed with HF. Objective: To investigate the risk of polypharmacy, DDI, and FDI in ET patients with or without HF. Methods: The electronic medical records of the Internal Medicine Clinic of an emergency university hospital in Romania were searched from inception to February 2021. Electronic medical records were available since August 2014. We included all ET patients who had signed the written informed consent for participation in medical research and for whom information regarding the prescribed medications was available. The study was approved by the ethics council of the hospital. DDI and FDI were evaluated using an online drug interaction checker. Results: The study group included 15 ET patients of whom 4 suffered from HF (26.67%). Patients with ET+HF were older (77.75±7.93 versus 58.64±11.50 years, P=0.009) and were prescribed more drugs (9.25±3.40 versus 5.73±2.37 drugs/day, P=0.040) versus ET patients without HF. Patients diagnosed with ET and HF were also exposed to more potential DDI (10.25±9.50 versus 2.27±2.28, P=0.016) and FDI (3.50±3.00 versus 1.27±0.90, P=0.037). ET patients diagnosed with HF had a significantly higher number of potential major (3.25±2.63 versus 0.64±0.92, P=0.010) and moderate (5.75±5.68 versus 1.18±1.40, P=0.021) DDI, but the potential minor DDI were similar between the two groups. ET+HF patients were more likely to be at risk for major FDI (1.00±0.82 versus 0.18±0.40, P=0.020), but the risk of moderate and minor FDI was similar between ET patients with and without HF. Conclusions: HF can be considered a significant cause of polypharmacy, as well as potential DDI and FDI, in patients with ET. Further research is needed to clarify the impact of these findings on the current therapeutic management of ET, especially in patients with HF and other cardiovascular comorbidities.

The Relationship Between Valproate and Lamotrigine/Levetiracetam Use and Prognosis in Patients With Epilepsy and Heart Failure: A Danish Register-Based Study

To compare the hazard for all-cause mortality and mortality due to heart failure (HF) between valproate (VPA) and levetiracetam (LEV)/lamotrigine (LTG) users in patients aged ≥ 65 with comorbidities of epilepsy and HF. This was a cohort study using Danish registers during the period from January 1996 to July 2018. The study population included new users of LTG, LEV or VPA. A Cox regression model was used to compute crude and adjusted hazard ratios for the outcome, using an intention-to-treat approach. Average treatment effects (eg, 1-year absolute risks), risk differences and the ratio of risks were computed using the G-formula based on a Cox regression model for the outcomes at the end of the follow-up period. We included 1345 subjects in the study population. VPA users (n = 696), when compared to LTG/LEV users (n = 649), had an increased hazard of mortality due to HF (hazard ratio [HR] 2.39; 95% CI 1.02-5.60) and to all-cause mortality (HR 1.37; 95% CI 1.01-1.85) in both crude and adjusted analyses. The 1-year absolute risks for all-cause mortality were 29% (95% CI 25%-33%) and 22% (95% CI 18%-26%) for VPA and LTG/LEV users. For mortality due to HF, 1-year absolute risks were 5% (95% CI 3%-7%) and 2% (95% CI 1%-4%) for VPA and LTG/LEV users. The average risk ratio, with LTG/LEV as the reference group, was 1.31 (95% CI 1.02-1.71) for all-cause mortality and 2.35 (95% CI 1.11-5.76) for HF mortality. In older people with HF and epilepsy, treatment with VPA was associated with a higher risk of all-cause and HF mortality compared to treatment with LTG and LEV.

Beneficios de un modelo asistencial integral en pacientes ancianos con insuficiencia cardíaca y elevada comorbilidad: programa UMIPIC

BackgroundElderly patients with heart failure (HF) have a high degree of comorbidity which leads to fragmented care, with frequent hospitalizations and high mortality. This study evaluated the benefit of a comprehensive continuous care model (UMIPIC program) in elderly HF patients. Methods and resultsWe prospectively analyzed data from the RICA registry on 2,862 patients with HF treated in internal medicine departments. They were divided into two groups: one monitored in the UMIPIC program (UMIPIC group, n: 809) and another which received conventional care (RICA group, n: 2.053). We evaluated HF readmissions during 12 months of follow-up and total mortality after episodes of HF hospitalization. UMIPIC patients were older with higher rates of comorbidity and preserved ejection fraction than the RICA group. However, the UMIPIC group had a lower rate of HF readmissions (17% vs. 26%, p<.001) and mortality (16% vs. 27%, respectively; p<.001). In addition, we selected 370 propensity score-matched patients from each group and the differences in HF readmissions (15% UMIPIC vs. 30% RICA; hazard ratio [HR]=0.44; 95% confidence interval [CI] 0.32-0.60; p<.001) and mortality (17% UMIPIC vs. 28% RICA; hazard ratio=0.58; 95% CI 0.42-0.79; p=.001) were maintained. ConclusionsThe implementation of the UMIPIC program, based on comprehensive continuous care of elderly patients with HF and high comorbidity, markedly reduce HF readmissions and total mortality.

Prevalence and temporal trends of anemia in patients with heart failure.

Anemia is an important comorbidity in heart failure (HF), and it is associated with increased adverse disease experience and mortality. Previous reports have focused mainly on HF presenting in healthcare settings. We, therefore, set out to establish the nationwide prevalence and temporal trends of anemia in community-based patients with HF in the US. To establish the nationwide prevalence and temporal trends of anemia in community-based patients with HF in the US. The NHANES dataset, conducted by the CDC National Center for Health Statistics was used to collect nationally representative data on the health and nutritional status of the non-institutionalized US population. We utilized the National Health and Nutrition Examination data collected over five survey cycles (2007-16). Included were participants aged 20-80 years with self-reported diagnosis of HF. Anemia was defined using 2 sex specific cut offs of 13 and 12 g/dl (cutoff 1), and 12 and 11 g/dl (cutoff 2), for men and women, respectively. The Chi square test was used to compare prevalence across different categories and survey cycles. Data analysis was done using STATA 16 with P-values < 0.05 considered statistically significant. The median hemoglobin in all HF patients was 13.5 g/dl (IQR 12.4-14.5). The prevalence of anemia among community-based patients with HF in the US was 21.34% (cutoff 1) and 9.03% (cutoff 2) and has been stable from 2007 to 2016. The burden of anemia was disproportionately higher in NH Blacks (34.48%, 95% CI 27.12-42.67) and those with BMI < 25 Kg/m2 (17.4%, 95% CI 10.9-26.64). The prevalence of anemia in patients with HF in the US is at least 9% and has remained stable over the past decade. This high persistent burden with limited proven interventions should spur further efforts aimed at identifying impactful ways of addressing anemia in patients with HF.

Pain intensity and pain medication prescription patterns in Veterans with heart failure and back pain

BackgroundPain and heart failure are highly comorbid. ObjectivesThe purpose of this study was to examine differences in pain intensity and pain medication prescriptions among Veterans with comorbid heart failure and pain and those with pain alone. MethodsThe Musculoskeletal Disorder (MSD) cohort includes 5,237,763 Veteran diagnosed with a musculoskeletal disorder between 2000 and 2013. Veterans with comorbid heart failure and back pain (heart failure+, n = 3,950, Mage = 70.5 ± 12) were compared to those with back pain alone (heart failure-, n = 165,290, Mage = 52.1 ± 17.5). ResultsIn multivariate adjusted models, heart failure+ was associated with a higher likelihood of moderate/severe pain (OR = 1.12; 95% CI 1.04–1.21), a higher likelihood of opioids (OR = 1.63; CI = 1.52–1.75) and/or gabapentin prescriptions (OR = 1.18; CI = 1.02–1.36), but a lower likelihood of NSAID prescriptions (OR = 0.57; CI = 0.50–0.66). ConclusionsComorbid cardiovascular and pain conditions present a challenge in clinical management that warrants further study.

TaiChi and Qigong for Depressive Symptoms in Patients with Chronic Heart Failure: A Systematic Review with Meta-Analysis.

Background Depression is a debilitating comorbidity of heart failure (HF) that needs assessment and management. Along with mind-body exercise to deal with HF with depression, the use of TaiChi and/or Qigong practices (TQPs) has increased. Therefore, this systematic review assesses the effects of TQPs on depression among patients with HF. Methods Randomized controlled trials (RCTs) that examined the effect of TQPs on depression in patients with HF were searched by five databases (PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, CINAHL, and China National Knowledge Infrastructure (CNKI)). With standardized mean difference (SMD) and 95% confidence intervals (95% CI), random-effects meta-analyses of the effect of TQPs on depressive symptoms were performed. Results Of eight included RCTs, seven (481 patients) provided data for the meta-analysis. The pooling revealed that TQPs contribute to depression remission in HF (SMD −0.66; 95% CI −0.98 to −0.33, P < 0.0001; I2 = 64%). Its antidepressive effect was not influenced by intervention duration or exercise setting, but rather by ejection fraction subtype, depressive severity, and depression instruments. The beneficial effects were preserved when the study with the largest effect was removed. Conclusion This study suggests that TQPs might be a good strategy for alleviating depressive symptoms in patients with HF. And rigorous-design RCTs, which focus on the identified research gaps, are needed to further establish the therapeutic effects of TQPs for depression in HF.

Prevalence and quality of antihypertensive therapy among hypertension patients enrolled in the Ghana National Health Insurance Scheme

Hypertension is a leading cause of morbidity in Ghana. However, there is insufficient data on the prevalence and quality of antihypertensive therapy. To describe the prevalence of use and quality of antihypertensive therapy. A cross-sectional study design was used to analyze the 2015 Ghana National Health Insurance Scheme (NHIS) electronic claims data. Hypertension diagnosis was defined using ICD-10 codes. The primary outcomes assessed were the prevalence of use and quality of antihypertensive therapy. Quality of antihypertensive therapy was defined as the use of antihypertensive agents recommended for treating hypertension patients with comorbid heart failure, myocardial Infarction/Coronary Artery Disease, diabetes, chronic kidney disease or stroke. We used multivariable logistic regression models to identify predictors of antihypertensive use and quality of therapy. Antihypertensive medication use was very high (86%) among the 161 873 hypertension patients covered under the Ghana NHIS. Only a third (32%) of hypertension patients received guideline-concordant therapy. Angiotensin receptor blockers were consumed at the highest dosages of 120 (Interquartile Range [IQR]: 60, 180) daily defined doses over a year. Males (odds ratio [OR]=0.60; 95% Confidence Interval [CI]:0.58, 0.61) and those with comorbid stroke (OR=0.91, 95% CI:0.84, 0.99), diabetes (OR=0.72; 95% CI:0.69, 0.74) and stroke (OR=0.74, 95%CI:0.68, 0.80) were less likely to use antihypertensives, all other predictors were associated with higher use. Antihypertensive medication use was very high among hypertension patients covered under the Ghana NHIS. However, there was indication of suboptimal quality of the antihypertensive therapy provided.

Patients’ and carers’ perspective of the impact of heart failure on quality of life: a qualitative study

ABSTRACT Heart failure (HF) is a syndrome associated with high mortality and morbidity. HF patients tend to be at a high risk of poor clinical and psychosocial outcomes. This study aimed to capture patients’ and carers perspectives of HF, the impact on their health reported QoL, and the factors associated with their poor health outcomes. To explore HF patients’ and carers’ views on their QoL since diagnosis. This study used a cross-sectional, qualitative design with semi-structured interviews conducted with participating patients and carers. Thirteen adults (> 18 years) with HF and 21 carers were interviewed over the telephone, following a semi-structured interview schedule. Interviews were transcribed verbatim and analysed using inductive thematic analysis. Three main themes were identified, with an overarching theme . Themes included impact on patients’ lifestyle including diet, smoking and inability to part-take in social activities, adjusting to HF diagnosis and co-morbidity management, and psychological/mental health issues such as anxiety and depression. Patients with HF are at high-risk of various issues which can negatively impact their QoL. Additionally, Carers play a vital role in the management of HF patients. Effective patient centred care and better communication between patients, carers and healthcare professionals is vital in HF management.

Abstract MP32: The Level Of Adherence To The Dietary Approaches To Stop Hypertension Diet Is Associated With The Severity Of Insulin Resistance Among Community-Dwelling Heart Failure Patients: A National Health And Nutrition Examination Survey Analysis

Introduction: Heart failure (HF) patients are at risk of new-onset diabetes. In non-HF populations, adherence to the Dietary Approaches to Stop Hypertension (DASH) diet has shown to be associated with the delayed onset of insulin resistance; however, such effect remains unknown in HF patients without history of diabetes. Methods: Using data from 1999-2016 National Health and Nutrition Examination Survey cycles, we included 348 HF participants (20+ years) without history of diabetes or diabetes medication use and with data on at least one 24-hour dietary recall. Participants were classified by DASH dietary index score quartiles: quartile 1 indicated lowest DASH index scores and lowest DASH adherence, whereas quartile 4 indicated highest DASH index scores and highest DASH adherence. The severity of insulin resistance was examined using the Homeostatic Model Assessment of Insulin Resistance and was further classified by tertiles, where the upper tertile showed the most severe insulin resistance. Associations between the severity of insulin resistance and DASH dietary adherence and its linear trends were examined using logistic regression models. Results: Participants had a mean age of 65±1 (SE) years, 44.2% were female, and 10.5% were non-Hispanic black. The age-, gender-, and race/ethnicity-adjusted odds ratio for the most severe insulin resistance group in participants with highest DASH adherence was 0.32 (95% CI, 0.11-0.99), compared to participants with lowest DASH adherence. A significant trend of more severe insulin resistance was observed as participants showed less adherence to the DASH diet (p=0.02). Conclusion: Adherence to a DASH dietary pattern was associated with improved insulin resistance among community-dwelling HF patients in the U.S. Heart healthy dietary patterns may protect HF patients against new-onset diabetes. Future research is needed to test dietary interventions aimed at the prevention of HF complications and comorbidities.

Characteristics of patients hospitalized through the emergency department with an oncology drug-related side effect.

6557 Background: Recent advances in oncology treatment present an expanding spectrum of cancer-treatment-related emergencies.Many aspects of healthcare utilization, specifically emergency department (ED) visits, are not well studied in this population. The purpose of this study is to determine (1) what proportion of cancer patients visit the ED with an oncology drug-related side effect and are admitted and (2) what factors impact the probability of inpatient admission among these patients. Methods: This study evaluated ED visits by adult patients undergoing active drug treatment for cancer insured by a large commercial and Medicare health plan in the United States between January 1, 2018, and September 30, 2019. Among cancer-related ED visits, logistic regression was used to determine the marginal effect of demographic and clinical characteristics of patients on acute inpatient admission. Results: There were 39,921 total ED visits among patients undergoing drug treatment for cancer; of these, 76% presented with an oncology drug-related side-effect. 36% of all ED visits resulted in admission, 5% resulted in an observation stay. After adjusting, age was not a significant predictor of inpatient admission. Being male (p &lt; 0.01) and living in urban (p &lt; 0.01) or suburban (p &lt; 0.01) zip codes significantly increased the likelihood of admission. Patients with colorectal (p = 0.019), gastrointestinal (p &lt; 0.01), blood (p &lt; 0.01), lung (p &lt; 0.01), metastatic (p &lt; 0.01) cancers, or Hodgkin’s lymphoma (p &lt; 0.01) had significantly increased risk of admission. Patients with prostate (p &lt; 0.01) cancer had a significantly reduced risk of admission. The primary complaint upon presentation to the ED was the most important predictor of inpatient admission; sepsis, pneumonia, medical complications, white cell disorders, metastatic cancer, and fractures were all associated with a significantly higher (all p &lt; 0.001) risk of admission. Patients with comorbid heart failure (p &lt; 0.001), those taking ulcer medications (p &lt; 0.01), or inflammatory bowel disease (p = 0.03) had a significantly increased risk of admission. Results were consistent regardless of payer (Medicare or commercial health plan). Conclusions: This study identified cancer patients for whom acute inpatient admission from an ED presentation is more likely. Future studies identifying cancer patients who may be at risk of making an ED presentation based on demographic, clinical and disease-related characteristics are needed and may help inform targeted follow up of patients to mitigate potentially avoidable ED presentation and subsequent inpatient admission.

Machine Learning for Predicting Heart Failure Progression in Hypertrophic Cardiomyopathy.

Background: Development of advanced heart failure (HF) symptoms is the most common adverse pathway in hypertrophic cardiomyopathy (HCM) patients. Currently, there is a limited ability to identify HCM patients at risk of HF.Objectives: In this study, we present a machine learning (ML)-based model to identify individual HCM patients who are at high risk of developing advanced HF symptoms.Methods: From a consecutive cohort of HCM patients evaluated at the Tufts HCM Institute from 2001 to 2018, we extracted a set of 64 potential risk factors measured at baseline. Only patients with New York Heart Association (NYHA) functional class I/II and LV ejection fraction (LVEF) by echocardiography >35% were included. The study cohort (n = 1,427 patients) was split into three disjoint subsets: development (50%), model selection (10%), and independent validation (40%). The least absolute shrinkage and selection operator was used to select the most influential clinical variables. An ensemble of ML classifiers, including logistic regression, was used to identify patients with high risk of developing a HF outcome. Study outcomes were defined as progression to NYHA class III/IV, drop in LVEF below 35%, septal reduction procedure, and/or heart transplantation.Results: During a mean follow-up of 4.7 ± 3.7 years, advanced HF occurred in 283 (20% out of 1,427) patients. The model features included patients' sex, NYHA class (I or II), HCM type (i.e., obstructive or not), LV wall thickness, LVEF, presence of HF symptoms (e.g., dyspnea, presyncope), comorbidities (atrial fibrillation, hypertension, mitral regurgitation, and systolic anterior motion), and type of cardiac medications. The developed risk stratification model showed strong differentiation power to identify patients at advanced HF risk in the testing dataset (c-statistics = 0.81; 95% confidence interval [CI]: 0.76, 0.86). The model allowed correct identification of high-risk patients with accuracy 74% (CI: 0.70, 0.78), sensitivity 80% (CI: 0.77, 0.83), and specificity 72% (CI: 0.68, 0.76). The model performance was comparable among different sex and age groups.Conclusions: A 5-year risk prediction of progressive HF in HCM patients can be accurately estimated using ML analysis of patients' clinical and imaging parameters. A set of 17 clinical and imaging variables were identified as the most important predictors of progressive HF in HCM.

Kidney Function and Outcomes in Patients Hospitalized With Heart Failure

BackgroundFew contemporary data exist evaluating care patterns and outcomes in heart failure (HF) across the spectrum of kidney function. ObjectivesThis study sought to characterize differences in quality of care and outcomes in patients hospitalized for HF by degree of kidney dysfunction. MethodsGuideline-directed medical therapies were evaluated among patients hospitalized with HF at 418 sites in the GWTG-HF (Get With The Guidelines–Heart Failure) registry from 2014 to 2019 by discharge CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration)-derived estimated glomerular filtration rate (eGFR). We additionally evaluated the risk-adjusted association of admission eGFR with in-hospital mortality. ResultsAmong 365,494 hospitalizations (age 72 ± 15 years, left ventricular ejection fraction [EF]: 43 ± 17%), median discharge eGFR was 51 ml/min/1.73 m2 (interquartile range: 34 to 72 ml/min/1.73 m2), 234,332 (64%) had eGFR <60 ml/min/1.73 m2, and 18,869 (5%) were on dialysis. eGFR distribution remained stable from 2014 to 2019. Among 157,439 patients with HF with reduced EF (≤40%), discharge guideline-directed medical therapies, including beta-blockers, were lowest in discharge eGFR <30 mL/min/1.73 m2 or dialysis (p < 0.001). “Triple therapy” with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor–neprilysin inhibitor + beta-blocker + mineralocorticoid receptor antagonist was used in 38%, 33%, 25%, 15%, 5%, and 3% for eGFR ≥90, 60 to 89, 45 to 59, 30 to 44, <30 ml/min/1.73 m2, and dialysis, respectively; p < 0.001. Mortality was higher in a graded fashion at lower admission eGFR groups (1.1%, 1.5%, 2.0%, 3.0%, 5.0%, and 4.2%, respectively; p < 0.001). Steep covariate-adjusted associations between admission eGFR and mortality were observed across EF subgroups, but was slightly stronger for HF with reduced EF compared with HF with mid-range or preserved EF (pinteraction = 0.045). ConclusionsDespite facing elevated risks of mortality, patients with comorbid HF with reduced EF and kidney disease are not optimally treated with evidence-based medical therapies, even at levels of eGFR where such therapies would not be contraindicated by kidney dysfunction. Further efforts are required to mitigate risk in comorbid HF and kidney disease.