Exacerbation Of Congestive Heart Failure Research Articles

Association of device detected atrial and ventricular tachyarrhythmia with adverse events in patients with an implantable cardioverter-defibrillator.

Heart failure patients with a history of atrial fibrillation (AF) and ventricular tachycardia/ventricular fibrillation (VT/VF) are known to have worse outcomes. However, there are limited data on the temporal relationship between development of these arrhythmias and the risk of subsequent congestive heart failure (CHF) exacerbation and death. The study cohort comprised 5511 patients implanted with an implantable cardioverter-defibrillator (ICD) in landmark clinical trials (MADIT-II, MADIT-RISK, MADIT-CRT, MADIT-RIT, and RAID) who were in sinus rhythm at enrollment. Multivariate cox analysis was performed to evaluate the time-dependent association between development of in-trial device detected AF and VT/VF with subsequent CHF exacerbation and death. Multivariate analysis showed that AF occurrence and VT/VF occurrence were both associated with a similar magnitude of risk for subsequent CHF exacerbation (HR = 1.73 and 1.87 respectively, p < .001 for both). In contrast, only in-trial VT/VF was associated with a significant > two-fold increase in the risk of subsequent mortality (HR = 2.13, p < .001) whereas AF occurrence was not associated with a significant mortality increase after adjustment for in-trial VT/VF (HR = 1.36, p = .096). Our findings from a large cohort of ICD recipients enrolled in landmark clinical trials show that device detected AF and VT/VF can be used to identify patients with increased risk for CHF exacerbation and mortality. These findings suggest a need for early intervention in CHF patients who develop device-detected atrial and ventricular tachyarrhythmias.

Thoracic ultrasound may improve paramedic diagnostic and management accuracy in undifferentiated respiratory distress.

Patients with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) exacerbations present with similar history and physical examination findings. This complicates both the diagnostic process and the creation of appropriate treatment plans for patients presenting in respiratory distress, particularly in the prehospital setting. Thoracic point-of-care-ultrasound (POCUS) may increase diagnostic accuracy; however, its potential to improve patient management by emergency medical services clinicians is unknown. We aimed to determine whether a brief thoracic POCUS educational intervention would improve prehospital diagnostic accuracy and treatment plans for patients with COPD and CHF exacerbations. In this prospective pre-/post-study, paramedics completed a thoracic POCUS training program. The pre-test presented history and physical examination data for 10 patients and asked paramedics to diagnose each patient with COPD or CHF exacerbation and to select the appropriate treatment(s). The post-test asked paramedics to interpret ultrasound images in addition to selecting diagnosis and treatment(s). Pre-post differences in average cumulative diagnostic and management accuracy were analyzed using paired two-tailed t-tests. Thirty-three paramedics participated in the study. At baseline, paramedics selected the accurate patient diagnosis and treatment(s) 73% and 60% of the time, respectively. On the post-test, diagnostic accuracy improved by 17% (95% confidence interval [CI]: 11-24, p<0.001) and appropriate treatment selection improved by 23% (95% CI: 16-28, p<0.001). Paramedics correctly interpreted ultrasound images 90% of the time. Effective training of paramedics to recognize the clinical scenario of undifferentiated respiratory distress and their associated thoracic ultrasound images may lead to improved treatment plans.

Rare case of pseudo-pneumoperitoneum as a triad of extensive subcutaneous emphysema and pneumomediastinum as a complication of non-invasive respiratory support

Respiratory support through non-invasive ventilation and high-flow nasal cannula is frequently used in patients with acute respiratory failure as a way to maintain oxygenation without intubation. Although mostly well-tolerated, infrequent but increasingly recognized complications can occur, such as pneumothorax, pneumomediastinum, and subcutaneous emphysema. This likely occurs as a result of alveolar rupture from barotrauma related to ventilatory support and dissection of higher-pressure air along the pulmonary interstitium and into the anatomic cavities of the chest. We present a rare case of pseudo-pneumoperitoneum as a result of non-invasive respiratory support. This occurred as part of a triad of pneumomediastinum and extensive subcutaneous emphysema extending circumferentially around the abdomen and into the scrotum of a hypoxic patient with congestive heart failure and chronic obstructive pulmonary disease exacerbation with pneumonia requiring aggressive respiratory support.

Influenza Vaccine Effectiveness Pre-pandemic Among Adults Hospitalized With Congestive Heart Failure or Chronic Obstructive Pulmonary Disease and Older Adults.

Data are limited on influenza vaccine effectiveness (VE) in the prevention of influenza-related hospitalizations in older adults and those with underlying high-risk comorbidities. We conducted a prospective, test-negative, case-control study at 2 US hospitals from October 2018-March 2020 among adults aged ≥50 years hospitalized with acute respiratory illnesses (ARIs) and adults ≥18 years admitted with congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD) exacerbations. Adults were eligible if they resided in 1 of 8 counties in metropolitan Atlanta, Georgia. Nasopharyngeal and oropharyngeal swabs were tested using BioFire FilmArray (bioMérieux, Inc.) respiratory panel, and standard-of-care molecular results were included when available. Influenza vaccination history was determined from the Georgia vaccine registry and medical records. We used multivariable logistic regression to control for potential confounders and to determine 95% confidence intervals (CIs). Among 3090 eligible adults, 1562 (50.6%) were enrolled. Of the 1515 with influenza vaccination history available, 701 (46.2%) had received vaccination during that season. Influenza was identified in 37 (5.3%) vaccinated versus 78 (9.6%) unvaccinated participants. After adjustment for age, race/ethnicity, immunosuppression, month, and season, pooled VE for any influenza-related hospitalization in the eligible study population was 63.1% (95% CI, 43.8-75.8%). Adjusted VE against influenza-related hospitalization for ARI in adults ≥50 years was 55.9% (29.9-72.3%) and adjusted VE against influenza-related CHF/COPD exacerbation in adults ≥18 years was 80.3% (36.3-93.9%). Influenza vaccination was effective in preventing influenza-related hospitalizations in adults aged ≥50 years and those with CHF/COPD exacerbations during the 2018-2020 seasons.

Abstract 17187: The Relationship Between N-Terminal Pro-Brain Natriuretic Peptide Levels and Poor Outcomes in Covid-19 Patients

Introduction: N-terminal pro-brain natriuretic peptide (NT-proBNP) is a biomarker reflecting increased cardiac stress. It is a key variable in assessing patients with various pathologies. However, assessment of NT-proBNP as a variable in the prognostication of poor outcomes in COVID-19 patients is lacking. In addition, COVID-19 has brought its own variables and sequelae along with overlapping pathologies in a variety of systems. Hypothesis: With the systemic impact that COVID-19 can have, NT-proBNP represents a variable that will aid in identifying patients at higher risk of poor outcomes. We aim to assess the utility of NT-proBNP to help predict the incidence of major adverse cardiovascular events (MACE) and mortality in patients hospitalized with COVID-19. Methods: Using a multi-center observational database, we analyzed 1,692 hospitalized COVID-19 PCR-positive patients at Methodist Health System from March to July 2020. We examined NT-proBNP levels, in-hospital death or hospice referral rates, and incidence of MACE in the cohort. MACE was defined as congestive heart failure (CHF) exacerbation, pericardial effusion, cardiac tamponade, myocarditis, pericarditis, myocardial infarction (MI), stroke, pulmonary embolism/deep vein thrombosis, or shock. The incidence of mortality and MACE were compared between patients with and without elevated NT-proBNP levels. Elevated NT-proBNP levels were those &gt;900 pg/mL. A chi-square ( X 2 ) and odds ratio (OR) test were used to analyze observed variables. Results: Of the 1,692 hospitalized patients, 576 patients (34.0%) arrived with elevated NT-proBNP levels. Patients with elevated NT-proBNP had a higher incidence of mortality (OR=3.2559, 95% CI=2.522-5.203, p&lt;0.0001) and MACE (OR=6.564, 95% CI=5.255-8.199, p&lt;0.0001) compared to patients with NT-proBNP levels &lt;900 pg/mL. Additionally, the elevated NT-proBNP patients had a higher incidence of CHF exacerbation, MI, and shock compared to patients with NT-proBNP levels &lt;900 pg/mL. Conclusions: NT-proBNP levels can be a vital tool in recognizing COVID-19 patients who are at higher risk of poor outcomes. The use of NT-proBNP can further aid in prognostication in patients presenting to the hospital with COVID-19.

THU405 A Delicate Balance

Abstract Disclosure: N. Mohan: None. M.S. Shah: None. Introduction: Primary hyperparathyroidism is a disorder of excessive parathyroid hormone production causing increased calcium levels, usually due to a parathyroid adenoma. Commonly these cases are asymptomatic and detected incidentally on routine labs. They can be managed conservatively with sufficient fluid intake and avoiding dehydration. Congestive heart failure patients on diuretics with primary hyperparathyroidism require a delicate balance of their volume status to prevent exacerbation of either condition. We present a case of a woman with repeated hospitalizations due to poor volume status control. Clinical Case: An 82-year-old female with congestive heart failure (CHF), primary hyperparathyroidism (diagnosed 17 years ago), sick sinus syndrome with a pacemaker, and persistent atrial fibrillation presented to the emergency room with worsening b/l lower limb swelling for a few months. The remaining review of systems was largely negative. At home, she was on Losartan, Furosemide, and Carvedilol. Vitals were stable and physical exam revealed b/l lower extremity pitting edema. Chest x-ray showed cardiomegaly with mild pulmonary vascular congestion. Pertinent labs were NT pro-BNP 2190, Calcium 11.3 mg/dL, PTH 143 pg/mL, and Vit D, 25-hydroxy 48.6 ng/mL. The patient was started on IV diuretics and her home medications for CHF exacerbation. ECHO showed EF 39%, grade III diastolic dysfunction, severe pulmonary hypertension, mitral and tricuspid regurgitation. She was managed conservatively for her hypercalcemia and advised to maintain hydration at home. Spironolactone and Dapagliflozin were added to her regimen, and Furosemide was increased at discharge. The patient was re-admitted three weeks later with fatigue and decreased fluid intake. Vitals were stable and physical exam revealed dehydration. Pertinent labs were Calcium 13.4 mg/dL, Potassium 5.7 mmol/L, Creatinine 1.7 mg/dL (baseline 1.0), PTH 204 pg/mL, and Vit D 54.1 ng/mL. Repeat ECHO showed EF 15%. She was started on gentle 0.9% NS IV fluid to correct the hypercalcemia while preventing volume overload. Hypercalcemia and acute kidney injury improved with hydration. She was put on Cinacalcet 30 mg and home medications were modified for better volume control at discharge. Conclusion: This case highlights the complications of balancing the volume status with primary hyperparathyroidism and CHF. This patient’s primary hyperparathyroidism was well-controlled for more than fifteen years on adequate hydration. However, worsening CHF resulted in a higher requirement for diuretics, thereby worsening her hypercalcemia. Even though parathyroidectomy is an established treatment modality, she was not a suitable candidate due to age and comorbidities. Hence, to prevent such complications, parathyroidectomy must be considered early in patients with heart disease and even in asymptomatic hyperparathyroidism. Presentation: Thursday, June 15, 2023

Multiparametric ultrasound for upper extremity dialysis access evaluation.

The evolution of ultrasound (US) techniques has greatly improved the evaluation of many parameters in dialysis vascular access, which is typically achieved through an arteriovenous fistula (AVF) or graft (AVG). These techniques include grayscale B-mode, color Doppler, power Doppler, spectral Doppler, non-Doppler US flow imaging techniques, contrast-enhanced US, and elastography. In conjunction with a patient's medical history and physical examination, US provides crucial information about the native vascular bed prior to the surgical creation of an arteriovenous anastomosis. It also tracks the maturation progress of the newly created AVF or AVG and aids in diagnosing potential complications of the vascular access. These complications include thrombosis, steal syndrome, aneurysms, pseudoaneurysms, hematomas, infection, ischemic neuropathy, exacerbation of preexisting congestive heart failure, and stenosis.

Malnutrition Is Associated With Poor Outcomes In Patients Admitted With Congestive Heart Failure Exacerbation

Malnutrition Is Associated With Poor Outcomes In Patients Admitted With Congestive Heart Failure Exacerbation

Breaking the Readmission Cycle

Breaking the Readmission Cycle Brian Hatten I want to share the story of my difficult patient Ms. L. She has twenty-seven current medical issues. Thirty-five active prescriptions. Limited mobility requiring the use of a motorized scooter. Non-medical care gaps. And over twenty hospital admissions since 2020. I met Ms. L approximately five years ago as her hospital attending and have continued to care for her during her frequent hospitalizations. I could recite this 77-year-old female's litany of medical problems. But sufficed to say, her history is complex, with her admitting diagnoses running the gambit from cellulitis to gastrointestinal bleeding to altered mental status. But, her diagnosis and frequent exacerbations of congestive heart failure (CHF) are particularly frustrating for us both and will be my focus today. CHF makes her susceptible to fluid overload leading to feelings of shortness of breath, which progresses to respiratory distress. Like other individuals with CHF, she uses diuretics to prevent herself from becoming fluid overloaded. And, like many individuals who take diuretics, she hates them. She (un)affectionately calls her water pills "the bomb" because the effect is sudden, profound, and explosive when they begin working. The combination of the diuretic effect and her limited mobility causes significant emotional stress for Ms. L, a woman who values presenting herself outwardly as in control, well-dressed, and put together. Her dislike of the medical effect of her diuretics has led to her either taking them less often or outright discontinuing them. So, while discontinuation avoids those frustrating effects, it leads to fluid accumulation, subsequent respiratory distress, and readmission to the hospital. Her medical records mention she has memory issues. It is unclear how much her mild cognitive impairment affects her frequent readmissions. We have had many conversations where I would never suspect something was amiss. But sometimes, she can be forgetful and does not recall our recent discussions. That being said, she knows the names and uses of her medications. She can report to me her home weights when she checks them and knows what her "dry" weight should be. Yet, she does not act when her scales begin reading heavier or when she develops leg swelling. Instead, she presents to the emergency department in extremis. When directly questioned about why she lets her situation deteriorate to such a state that she requires hospitalization, she demurs. She comments that she can often be stubborn, that the diuretic effect of "the bomb" is burdensome, but always reminds me she is honest in admitting she wasn't taking her water pills. During several admissions, I worried for her survival after she had self-discontinued her medications and showed up at the emergency department in respiratory failure. For any patient with recurrent admissions, I discuss their overall goals of care to ensure we are working together toward achievable medical ends. But this conversation was essential to have with Ms. L. The possibility existed that she would present to the hospital too late in her disease process, and we would not be able to correct her respiratory failure. I wanted to ensure that the hospital staff and I respected her wishes regarding her care. Despite raising my concerns, she would [End Page 22] decline to discuss her wishes. Even worse, attempting to have her complete advance care planning documents like advance directives or a Physician Orders for Life-Sustaining Treatment (POLST) form was a futile endeavor. Ms. L was always vague and non-committal. She simply did not want to engage in those types of conversations. When asked why she declined to discuss these issues, Ms. L would reply that she was doing okay, the discussion was unnecessary, and she had family members to make those decisions for her. Caring for her during her hospital stays was a source of professional frustration for me. Her recurrent admissions made me feel like I was failing her. During each hospital stay, we would go over her medications. We repeatedly discussed how she should check her weights daily and monitor for lower extremity edema. We created multiple action plans for when to call her physicians so we could head off another hospital visit. We completed all the...

COVID-19 and Heart Failure with Preserved and Reduced Ejection Fraction Clinical Outcomes among Hospitalized Patients in the United States

Heart failure exacerbations impart significant morbidity and mortality, however, large- scale studies assessing outcomes in the setting of concurrent coronavirus disease-19 (COVID-19) are limited. We utilized National Inpatient Sample (NIS) database to compare clinical outcomes in patients admitted with acute congestive heart failure exacerbation (CHF) with and without COVID-19 infection. A total of 2,101,980 patients (Acute CHF without COVID-19 (n = 2,026,765 (96.4%) and acute CHF with COVID-19 (n = 75,215, 3.6%)) were identified. Multivariate logistic regression analysis was utilized to compared outcomes and were adjusted for age, sex, race, income level, insurance status, discharge quarter, Elixhauser co-morbidities, hospital location, teaching status and bed size. Patients with acute CHF and COVID-19 had higher in-hospital mortality compared to patients with acute CHF alone (25.78% vs. 5.47%, adjust OR (aOR) 6.3 (95% CI 6.05-6.62, p < 0.001)) and higher rates of vasopressor use (4.87% vs. 2.54%, aOR 2.06 (95% CI 1.86-2.27, p < 0.001), mechanical ventilation (31.26% vs. 17.14%, aOR 2.3 (95% CI 2.25-2.44, p < 0.001)), sudden cardiac arrest (5.73% vs. 2.88%, aOR 1.95 (95% CI 1.79-2.12, p < 0.001)), and acute kidney injury requiring hemodialysis (5.56% vs. 2.94%, aOR 1.92 (95% CI 1.77-2.09, p < 0.001)). Moreover, patients with heart failure with reduced ejection fraction had higher rates of in-hospital mortality (26.87% vs. 24.5%, adjusted OR 1.26 (95% CI 1.16-1.36, p < 0.001)) with increased incidence of vasopressor use, sudden cardiac arrest, and cardiogenic shock as compared to patients with heart failure with preserved ejection fraction. Furthermore, elderly patients and patients with African-American and Hispanic descents had higher in-hospital mortality. Acute CHF with COVID-19 is associated with higher in-hospital mortality, vasopressor use, mechanical ventilation, and end organ dysfunction such as kidney failure and cardiac arrest.

Implementation of a virtual and in-person hybrid hospital-at-home model in two geographically separate regions utilizing a single command center: a descriptive cohort study

BackgroundAs providers look to scale high-acuity care in the patient home setting, hospital-at-home is becoming more prevalent. The traditional model of hospital-at-home usually relies on care delivery by in-home providers, caring for patients in urban communities through academic medical centers. Our objective is to describe the process and outcomes of Mayo Clinic’s Advanced Care at Home (ACH) program, a hybrid virtual and in-person hospital-at-home model combining a single, virtual provider-staffed command center with a vendor-mediated in-person medical supply chain to simultaneously deliver care to patients living near an urban hospital-at-home command center and patients living in a rural region in a different US state and time zone.MethodsA descriptive, retrospective medical records review of all patients admitted to ACH between July 6, 2020, and December 31, 2021. Patients were admitted to ACH from an urban academic medical center in Florida and a rural community hospital in Wisconsin. We collected patient volumes, age, sex, race, ethnicity, insurance type, primary hospital diagnosis, 30-day mortality rate, in-program mortality, 30-day readmission rate, rate of return to hospital during acute phase, All Patient Refined-Diagnosis Related Groups (APR-DRG) Severity of Illness (SOI), and length of stay (LOS) in both the inpatient-equivalent acute phase and post-acute equivalent restorative phase.ResultsSix hundred and eighty-six patients were admitted to the ACH program, 408 in Florida and 278 in Wisconsin. The most common diagnosis seen were infectious pneumonia (27.0%), septicemia / bacteremia (11.5%), congestive heart failure exacerbation (11.5%), and skin and soft tissue infections (6.3%). Median LOS in the acute phase was 3 days (IQR 2–5) and median stay in the restorative phase was 22 days (IQR 11–26). In-program mortality rate was 0% and 30-day mortality was 0.6%. The mean APR-DRG SOI was 2.9 (SD 0.79) and the 30-day readmission rate was 9.7%.ConclusionsThe ACH hospital-at-home model was able to provide both high-acuity inpatient-level care and post-acute care to patients in their homes through a single command center to patients in urban and rural settings in two different geographical locations with favorable outcomes of low mortality and hospital readmissions.

Telemedicine Consult for Shortness of Breath Due to Sympathetic Crashing Acute Pulmonary Edema.

This simulation is appropriate for senior and junior emergency medicine residents. Shortness of breath is a very common presentation in the emergency department and can range from mild to severe as well as a chronic or acute onset. In sympathetic crashing acute pulmonary edema (SCAPE), patients typically present with acute onset of dyspnea occurring within minutes to hours and have significantly elevated blood pressure.1 The condition of SCAPE falls into the spectrum of acute heart failure syndromes such as fluid overload pulmonary edema and congestive heart failure exacerbation.1. At the completion of the simulation and debriefing, the learner will be able to: 1) recognize the physical exam findings and presentation of SCAPE, 2) utilize imaging and laboratory results to further aid in the diagnosis of SCAPE, 3) initiate treatments necessary for the stabilization of SCAPE, 4) demonstrate the ability to assist with the stabilization and disposition of a patient via tele-medicine as determined by the critical action checklist and assessment tool below, 5) interpret the electrocardiogram (EKG) as atrial fibrillation with rapid ventricular response (AFRVR), and 6) recognize that SCAPE is the underlying cause of AFRVR and continue to treat the former. This simulation was performed using a high-fidelity mannequin. In order to simulate the telemedicine aspect, the learner evaluated the patient using a video conferencing interface while the two confederates were present with the high-fidelity mannequin. A debriefing session was held immediately after the simulation. The educational content was evaluated by debriefing and verbal feedback provided immediately after the case. Additionally, a survey was emailed to participants and observers of the case to provide qualitative feedback. Post-simulation feedback was overall positive with participants and observers. Participants and observers felt this was a safe and realistic simulation of SCAPE and provided them with the opportunity to practice rapid recognition and treatment of this condition. Sympathetic crashing acute pulmonary edema falls into the spectrum of acute heart failure disorders, and rapid recognition and stabilization is vital for the patient's survival. This simulation case provided learners of all levels the chance to assess and treat a life-threatening condition with limited information in a safe and effective learning environment. The telemedicine component was used while conducting weekly didactics via zoom during the COVID-19 pandemic. Simulation is a large component of our didactic curriculum and implementing the telemedicine component into this case was worth the effort. It is important to familiarize our residents with telemedicine since we expect that it will become a larger part of the practice of emergency medicine in the future, allowing board-certified emergency medicine physicians to assist in providing care in rural emergency departments and smaller hospitals that may be staffed with less experienced providers. Medical simulation, tele-medicine, pulmonary edema, respiratory distress, cardiac emergencies, resuscitation.

Shoulder Abduction While Using the Bougie: A Common Mistake.

A 72-year-old female presented to the emergency department (ED) with exacerbation of chronic obstructive pulmonary disease and congestive heart failure. The patient required intubation for airway protection and hypercapnic respiratory failure. The ED team used a video laryngoscope, Macintosh 3 blade and bougie as the endotracheal tube delivery device. Despite a grade 2a Cormack-Lehane airway view, the bougie repeatedly missed left posterolateral to the airway. During these missed attempts, the emergency medicine (EM) resident's shoulder was noted to be abducted. The EM resident then readjusted his technique by adducting the shoulder. which allowed the tip of the bougie to pass the vocal cords resulting in successful intubation. The bougie is a useful endotracheal tube delivery device when used properly. Optimal body mechanics and device orientation are critical to successful use. Shoulder abduction while using the bougie is a frequent mistake, which can lead to left posterolateral malposition in relation to the glottis/airway. In this brief review our goal is to aid the intubating clinician in optimal use of the bougie, yielding more successful endotracheal tube passage.

Socioeconomic and Health-Related Factors Affecting Congestive Heart Failure Readmissions.

Congestive heart failure (CHF) readmissions are frequent and costly but preventable. The purpose of this study was to analyze socioeconomic and health-related factors of CHF readmissions by examining the relationship between 30-day readmissions of individuals with CHF and their payer status, race, ethnicity, primary language spoken, living arrangement, and comorbidities. This retrospective case-control study used secondary data from 450 CHF patients admitted to a not-for-profit Northern Virginia hospital from July 2014 to December 2017. Data were analyzed using χ 2 and logistic regression. Living arrangements and comorbid chronic renal failure (CRF) were statistically significant predictors of CHF readmissions; all other factors were nonsignificant. Patients who lived with family and those in assisted living facilities were less likely to be readmitted than those who lived alone (odds ratio [OR] = 0.2 and 0.5, respectively). Patients without CRF were less likely to be readmitted than those who had CRF (OR = 0.6). This study contributes data to inform community-based health programs tailored toward frequently readmitted individuals due to CHF exacerbation.

Nurse-in-the-loop smart home detection of health events associated with diagnosed chronic conditions: A case-event series.

BackgroundTelehealth and home-based care options significantly expanded during the SARS-CoV2 pandemic. Sophisticated, remote monitoring technologies now exist that support at-home care. Advances in the research of smart homes for health monitoring have shown these technologies are capable of recognizing and predicting health changes in near-real time. However, few nurses are familiar enough with this technology to use smart homes for optimizing patient care or expanding their reach into the home between healthcare touch points.ObjectiveThe objective of this work is to explore a partnership between nurses and smart homes for automated remote monitoring and assessing of patient health. We present a series of health event cases to demonstrate how this partnership may be harnessed to effectively detect and report on clinically relevant health events that can be automatically detected by smart homes.Participants25 participants with multiple chronic health conditionsMethodsAmbient sensors were installed in the homes of 25 participants with multiple chronic health conditions. Motion, light, temperature, and door usage data were continuously collected from participants’ homes. Descriptions of health events and participants’ associated behaviors were captured via weekly nursing telehealth visits with study participants and used to analyze sensor data representing health events. Two cases of participants with congestive heart failure exacerbations, one case of urinary tract infection, two cases of bowel inflammation flares, and four cases of participants with sleep interruption were explored.ResultsFor each case, clinically relevant health events aligned with changes from baseline in behavior data patterns derived from sensors installed in the participant's home. In some cases, the detected event was precipitated by additional behavior patterns that could be used to predict the event.ConclusionsWe found evidence in this case series that continuous sensor-based monitoring of patient behavior in home settings may be used to provide automated detection of health events. Nursing insights into smart home sensor data could be used to initiate preventive strategies and provide timely intervention.Tweetable abstractNurses partnered with smart homes could detect exacerbations of health conditions at home leading to early intervention

Abstract 87: Comparative Outcomes Of TAVR In African Americans Versus Non-African Americans

Introduction: African Americans (AA) experience more postoperative complications compared to non-African Americans (NAA) after certain procedures. Few studies compare clinical outcomes between AA and NAA post Transcatheter Aortic Valve Replacement (TAVR). Our aim is to further explore racial disparities among TAVR patients. Methods: Retrospective analysis of electronic medical records from March 2018-November 2020 of a major academic center and affiliated Veterans Affairs hospital in Chicago, IL identified all TAVR patients. Participants self-identified by race and were stratified into AA and NAA groups. The primary outcome was 3-point composite major adverse cardiac outcomes (MACE) (all cause death, myocardial infarction, cerebrovascular accident). Secondary outcomes included major differences in comorbidities, creatinine, baseline mean gradient, congestive heart failure (CHF) exacerbations, and hospital admissions. Outcomes were analyzed at 6- and 12-months post TAVR. Results: We included 151 patients in the analysis; 22% female, 65% were non-AA (44.7% white, 16.4% Hispanic, and 3.9% other) and 35% AA. They were 74 +/- 14 years old for the AA and 74 +/- 10 years old for non-AA. At 6 months (AA:15.1% v NAA:8.1%; p=.2) and at 12 months (AA:22.6% v NAA:16.2%; p=.3), there was no difference in MACE between the two populations. At 6 months post TAVR, AA were more likely to have a CHF exacerbation compared to NAA (AA:15.1% v NAA:3.1%; p=.007) despite a similar prevalence of heart failure at baseline, hypertension, hyperlipidemia, diabetes, coronary artery disease, atrial fibrillation and smoking. AA were found to have a higher baseline mean gradient when compared to NAA (AA: 36.2 v NAA:31.9 mmHg; p=.049). Creatinine at time of procedure was higher in AA when compared to NAA (Cr: 2.37 vs. 1.49 mg/dL; p=.015) and AA trended towards higher rates of end stage renal disease compared to NAA (AA:22.6% v NAA:11.1%; p=.059). Conclusion: We observed significant disparities between AA and their NAA counterparts. While both groups had similar rates of composite MACE events post TAVR at 6 and 12 months, AA tend to be a higher risk post-operative population. AA were more likely to have CHF exacerbations and were evaluated for TAVR at a later stage in their disease course.

Abstract 51: Too Little, Too Late: Diuresing Inefficiencies At A Veterans Affairs Hospital

Background: Between 2016 and 2021, the average length of stay for congestive heart failure (CHF) patients at our Veterans Affairs (VA) Hospital has ranged from 0.8 to 1.9 days longer than comparable VA hospitals. This extended length of stay (LOS) results in increased healthcare costs and is an institutional focus to increase quality of care. Current cardiology guidelines for patients admitted with an acute CHF exacerbation recommend aggressive diuresis, defined as high-dose loop diuretics at least twice a day. We sought to analyze our institution’s compliance with this guideline-directed care. Methods: We performed a retrospective chart review of Veterans admitted between July and September 2021 with a primary diagnosis of CHF exacerbation. We tabulated the average LOS, days IV diuretics were administered, time(s) of administration, and the number of IV diuretic doses per day. Results: 44 patients were identified. The average LOS and number of days of IV diuretics a Veteran received was 7.5 (SD 3.5) and 4.5 (SD 1.4) days, respectively. The average number of IV diuretics given during days of IV diuresis was 1.4 (SD 0.5). We noted that 11.5% of IV diuretic doses were given before 8AM. Conclusions: Our results demonstrate that the diuresing patterns at our VA hospital fall short of the recommended guidelines. Receiving an average of 1.4 doses of IV diuretic, rather than at least 2, likely contributes to extended length of stay and cost. Additionally, we note that very few doses of diuretics are administered prior to 8AM, which may delay or prevent subsequent dosing. This project identifies clear targets for future quality improvement projects at our institution aimed at improving length of stay and Veteran care by increasing the number of IV diuretic doses per day.

Role of Cardiosphere‐Derived Cell Extracellular Vesicles (CDC‐EVs) in Modulating CCR2 Mediated Pro‐inflammatory Signaling following Cardiac Injury

BackgroundFollowing myocardial injury, CCL2 (a cytokine released by the injured cardiac tissue) recruits CCR2+ monocytes to the site of injury to begin the repair process. Heightened CCL2 levels, however, over‐activate the CCR2+ mediated pro‐inflammatory response which in turn leads to poor cardiac healing and gives rise to downstream complications like congestive heart failure (CHF) and arrhythmias. Cardiosphere‐derived cell extracellular vesicles (CDC‐EVs) have been shown to down regulate this CCL2‐mediated inflammatory response by decreasing CCR2 expression on monocytes in healthy patients. We hypothesized that patients with acute myocardial infarction (MI) and decompensated heart failure would have higher levels of peripheral monocyte CCR2 expression compared with healthy controls and treatment with CDC‐EVs would suppress CCR2 expression regardless of patient presentation.MethodsA prospective single arm observational study was performed to investigate the immune response in patients presenting with cardiac injury. We recruited inpatients at Buffalo General Medical Center who met the following inclusion criteria: 1) &gt; 18 years of age AND 2) a type I MI or 3) acute on chronic CHF exacerbation or 4) chronic compensated CHF. Subjects were excluded from the study for the following: 1) fever in last 2 days/infection, 2) is or may be pregnant, and 3) currently undergoing cancer treatment. For part 1 of the study, blood samples from 32 patients with recent MI, acute CHF, or compensated CHF (between day 1 to 3 of admission) were drawn. Human monocytes were isolated from peripheral blood using Ficoll/centrifugation followed by magnetically activated cell sorting. Isolated monocytes were incubated with either PBS, normal human dermal fibroblast‐EVs (NHDF‐EVs) or CDC‐EVs and analyzed for CCR2 expression by flow cytometry. Multi‐variate analysis was performed to investigate the relationship of CCR2 expression and specific clinical risk factors for heart disease.ResultsCDC‐EVs significantly reduced classical monocyte (CD14hiCD16‐) surface expression of CCR2 expression by 35% as quantified by flow cytometry when compared with PBS and NHDF‐EVs (p&lt;0.005, Kruskal‐Wallis, n=31) in patients with recent MI, acute CHF exacerbation and chronic compensated CHF. This reduction was seen regardless of patients’ pre‐existing co‐morbidities like hypertension, diabetes, hyperlipidemia, chronic kidney disease, ongoing treatment with chronic medications (Aspirin, statins or ACE inhibitors), cardiac ejection fraction, prior history of coronary stents, CCR2 genotype, sex, or age. Smoking was associated with decreased response to CDC‐EV mediated CCR2 suppression when compared to PBS (linear regression model R ‐0.93, p&lt;0.05, n=26).ConclusionsCDC‐EVs down regulated CCR2 expression in non‐smoking patients with recent MI, acute CHF, or chronic compensated CHF. This immune‐modulatory effect of CDC‐EVs may be used in the future as an adjunct to current clinical therapy to improve cardiac healing.

Association Between Hospital Private Equity Acquisition and Outcomes of Acute Medical Conditions Among Medicare Beneficiaries

As private equity (PE) acquisitions of short-term acute care hospitals (ACHs) continue, their impact on the care of medically vulnerable older adults remains largely unexplored. To investigate the association between PE acquisition of ACHs and access to care, patient outcomes, and spending among Medicare beneficiaries hospitalized with acute medical conditions. This cross-sectional study used a generalized difference-in-differences approach to compare 21 091 222 patients admitted to PE-acquired vs non-PE-acquired short-term ACHs between January 1, 2001, and December 31, 2018, at least 3 years before to 3 years after PE acquisition. The analysis was conducted between December 28, 2020, and February 1, 2022. Differences were estimated using both facility and hospital service area fixed effects. To assess the robustness of findings, regressions were reestimated after including fixed effects of patient county of origin to account for geographic differences in underlying health risks. Two subset analyses were also conducted: (1) an analysis including only hospitals in hospital referral regions with at least 1 PE acquisition and (2) an analysis stratified by participation in the Hospital Corporation of America 2006 acquisition. The study included Medicare beneficiaries 66 years and older who were hospitalized with 1 of 5 acute medical conditions: acute myocardial infarction (AMI), acute stroke, chronic obstructive pulmonary disease exacerbation, congestive heart failure exacerbation, and pneumonia. Acquisition of hospitals by PE firms. Comorbidity burden (measured by Elixhauser comorbidity score), hospital length of stay, in-hospital mortality, 30-day mortality, 30-day readmission, and 30-day episode payments. Among 21 091 222 total Medicare beneficiaries admitted to ACHs between 2001 and 2018, 20 431 486 patients received care at non-PE-acquired hospitals, and 659 736 received care at PE-acquired hospitals. Across all admissions, the mean (SD) age was 79.45 (7.95) years; 11 727 439 patients (55.6%) were male, and 4 550 012 patients (21.6%) had dual insurance; 2 996 560 (14.2%) patients were members of racial or ethnic minority groups, including 2 085 128 [9.9%] Black and 371 648 [1.8%] Hispanic; 18 094 662 patients (85.8%) were White. Overall, 3 083 760 patients (14.6%) were hospitalized with AMI, 2 835 777 (13.4%) with acute stroke, 3 674 477 (17.4%) with chronic obstructive pulmonary disease exacerbation, 5 868 034 (27.8%) with congestive heart failure exacerbation, and 5 629 174 (26.7%) with pneumonia. Comorbidity burden decreased slightly among patients admitted with acute stroke (difference, -0.04 SDs; 95% CI, -0.004 to -0.07 SDs) at acquired hospitals compared with nonacquired hospitals but was unchanged across the other 4 conditions. Among patients with AMI, a greater decrease in in-hospital mortality was observed in PE-acquired hospitals compared with non-PE-acquired hospitals (difference, -1.14 percentage points, 95% CI, -1.86 to -0.42 percentage points). In addition, a greater decrease in 30-day mortality (difference, -1.41 percentage points; 95% CI, -2.26 to -0.56 percentage points) was found at acquired vs nonacquired hospitals. However, 30-day spending and readmission rates remained unchanged across all conditions. The extent and directionality of estimates were preserved across all robustness assessments and subset analyses. In this cross-sectional study using a difference-in-differences approach, PE acquisition had no substantial association with the patient-level outcomes examined, although it was associated with a moderate improvement in mortality among Medicare beneficiaries hospitalized with AMI.

A Resident-driven Quality Improvement Project to Increase Primary Care Follow-up after Congestive Heart Failure Exacerbation: Use of a Quality and Safety Award.

Congestive heart failure (CHF) is the most common cause of 30-day inpatient readmission. Studies have found that early follow-up with primary care physicians (PCP) within 7 days of discharge may improve 30-day readmission rates; however, many have used a multidisciplinary discharge coordination team, which is not a resource at all centers. Here, the authors present a resident-driven quality improvement initiative using a monthly quality and safety award to increase early PCP follow-up for veterans discharged following admissions due to a CHF exacerbation. Primary outcomes were percentage of PCP follow-up within 7 days and median time to PCP follow-up. Secondary outcomes included percentage of patients attending a PCP visit within 7 days, 30-day readmission, and 30-day mortality. This prepost quasi-experimental cohort study evaluated 3 concurrent quality improvement interventions to increase PCP follow-up after CHF exacerbation. Process maps and Ishikawa diagrams examined the discharge process. Interventions included a standardized discharge scheduling order, monthly education on the process, and monthly aggregated performance feedback for each medical resident. A patient safety and quality award was given to the team with the highest rate of PCP appointments scheduled within 7 days. Patient characteristics and outcomes were gathered for a 6-month historic period and 6-month intervention period. Test of proportions and Wilcoxon Rank-Sum test were used to compare groups. A total of 294 patients were discharged (161 in historic group and 133 in intervention group). Appointments scheduled within 7 days of discharge increased from 43% to 79% ( P < 0.001). Median time to PCP follow-up decreased from 8 to 6 days ( P < 0.001). Patients who completed (showed up to) a PCP appointment within 7 days increased from 16% to 41% ( P < 0.001). There was no impact on 30-day readmission or mortality; however, the number of study subjects was too small to rule out an effect. A standardized discharge scheduling order, more robust resident education, and a monthly patient safety and quality award resulted in a significant increase in the rate of primary care follow-up within 7 days of CHF exacerbation.