First Admission For Heart Failure Research Articles

Identifying Predictors of Heart Failure Readmission in Patients From a Statutory Health Insurance Database: Retrospective Machine Learning Study.

Patients with heart failure (HF) are the most commonly readmitted group of adult patients in Germany. Most patients with HF are readmitted for noncardiovascular reasons. Understanding the relevance of HF management outside the hospital setting is critical to understanding HF and factors that lead to readmission. Application of machine learning (ML) on data from statutory health insurance (SHI) allows the evaluation of large longitudinal data sets representative of the general population to support clinical decision-making. This study aims to evaluate the ability of ML methods to predict 1-year all-cause and HF-specific readmission after initial HF-related admission of patients with HF in outpatient SHI data and identify important predictors. We identified individuals with HF using outpatient data from 2012 to 2018 from the AOK Baden-Württemberg SHI in Germany. We then trained and applied regression and ML algorithms to predict the first all-cause and HF-specific readmission in the year after the first admission for HF. We fitted a random forest, an elastic net, a stepwise regression, and a logistic regression to predict readmission by using diagnosis codes, drug exposures, demographics (age, sex, nationality, and type of coverage within SHI), degree of rurality for residence, and participation in disease management programs for common chronic conditions (diabetes mellitus type 1 and 2, breast cancer, chronic obstructive pulmonary disease, and coronary heart disease). We then evaluated the predictors of HF readmission according to their importance and direction to predict readmission. Our final data set consisted of 97,529 individuals with HF, and 78,044 (80%) were readmitted within the observation period. Of the tested modeling approaches, the random forest approach best predicted 1-year all-cause and HF-specific readmission with a C-statistic of 0.68 and 0.69, respectively. Important predictors for 1-year all-cause readmission included prescription of pantoprazole, chronic obstructive pulmonary disease, atherosclerosis, sex, rurality, and participation in disease management programs for type 2 diabetes mellitus and coronary heart disease. Relevant features for HF-specific readmission included a large number of canonical HF comorbidities. While many of the predictors we identified were known to be relevant comorbidities for HF, we also uncovered several novel associations. Disease management programs have widely been shown to be effective at managing chronic disease; however, our results indicate that in the short term they may be useful for targeting patients with HF with comorbidity at increased risk of readmission. Our results also show that living in a more rural location increases the risk of readmission. Overall, factors beyond comorbid disease were relevant for risk of HF readmission. This finding may impact how outpatient physicians identify and monitor patients at risk of HF readmission.

Patient characteristics, short-term and long-term outcomes after incident heart failure admissions in a regional Australian setting

AimsThis study aims to (1) define the characteristics of patients with a first admission for heart failure (HF), stratified by type (reduced (HFrEF) vs preserved (HFpEF) ejection fraction) in a...

Abstract MP259: The Role Of Sertad4 In Pathological Cardiac Remodeling

Over 6 million Americans suffer from heart failure (HF) while the 5-year mortality rate following first admission for HF is over 40%. Cardiac fibrosis is a clinical hallmark of HF, regardless of the initiating pathology and is thought to contribute to disease progression. Using an epigenomics discovery approach, we uncovered a nuclear protein, Sertad4, as a potential anti-fibrotic target. Our data indicate that Sertad4 is a positive regulator of fibroblast activation. Specifically, cultured cardiac fibroblast experiments demonstrate that Sertad4 targeting with shRNAs blocks fibroblast proliferation and causes cells to arrest in the G2/M phase of the cell cycle. Also, shRNA targeting of Sertad4 dramatically blocked activation of myofibroblast differentiation genes (αSMA/POSTN/COL1A1). Mechanistically, these effects appear to be mediated by Sertad4 regulation of SMAD2 protein stability in the presence of TGF-β1 stimulation as demonstrated by proteasome inhibition experiments. RNA-seq analysis indicate that Sertad4 also regulates the expression of genes involved in ubiquitination and proteasome degradation. Next, we sought to determine the effect of global Sertad4 knockout on post-myocardial infarct (MI) remodeling and cardiac function in mice. After 4 weeks of permanent LAD ligation, echocardiography was performed to measure systolic function. Relative to wild-type (WT) controls, the Sertad4 KO mice showed preserved systolic function as evident by improved ejection fraction (WT 14.4 +/- 3.6 vs. KO 33.9+/-5.9, p=0.035) and fractional shortening (WT 6.5 +/- 1.7 vs. KO 16.4 +/- 3.4, p=0.046). β-gal staining in the Sertad4/LacZ reporter mouse subjected to MI showed robust Sertad4/LacZ expression in the ischemic scar and boarder-zone with almost no expression in control hearts. This data supports the notion that Sertad4 has a key role in cardiac remodeling in response to ischemic injury.

Insomnia symptoms and subclinical myocardial injury: Data from the Nord-Trøndelag Health (HUNT) study.

Insomnia symptoms are associated with increased risk of heart failure (HF) and cardiovascular (CV) mortality. We hypothesised that insomnia symptoms are cross-sectionally associated with increased cardiac troponin I (cTnI), a biomarker of subclinical myocardial injury, and that phenotyping by insomnia symptoms and cTnI enhances longitudinal risk stratification in the general population. In a population-based study, cTnI was measured in 8,398 participants (median age 49years, 55% women), who had answered questionnaires regarding insomnia symptoms. Association between cTnI and insomnia symptoms was assessed by linear regression analysis for each response category of a sleep questionnaire. Insomnia symptoms were defined as having difficulty falling asleep almost every night, difficulty maintaining sleep almost every night, and/or non-restorative sleep once a week or more. The primary outcome measure was a composite endpoint of CV mortality or first admission for HF. In all, 844 participants reported insomnia symptoms, 585 (69%) were women. Those with insomnia symptoms had marginally, but significantly higher median cTnI than those without insomnia symptoms, (median [interquartile range] 3.4[2.4-5.2]ng/L versus 3.2[2.2-4.9] ng/L; p=.014), but there was no association between any insomnia symptom and cTnI in unadjusted linear regression models (β 0.06, 95% confidence interval [CI] -0.01 to 0.12). In adjusted analyses, participants with insomnia symptoms and increased cTnI were at increased risk of the composite endpoint (hazard ratio 1.71, 95% CI 1.04-2.79) compared to participants with insomnia symptoms and low cTnI. In the general population, insomnia symptoms are not associated with biochemical evidence of subclinical myocardial injury.

Hospitalizations for heart failure: Epidemiology and health system burden based on data gathered in routine practice

PurposeTo analyze the epidemiological characteristics of heart failure (HF) and estimate the burden of the disease on the health service by means of real world data (RWD). Patients and methodsAll patients discharged from any Basque Health Service hospital after a first admission for HF between 2011 and 2015. Data sourcesDatabases of our health service. Outcomes30- and 365-day admissions, potentially avoidable hospitalizations (PAHs), mortality. Statistical analysisDescriptive statistics, age-standardized event rates. ResultsThe cohort was composed of 15,109 patients (mean age 79.8±10.1 years). At discharge patients had a median of 8 chronic conditions. 36% of them had had hospitalizations and 83% had visited a specialist (42% of them a cardiologist) during the previous year. Mortality was 24.5% within 365 days after discharge.Within 30 days after discharge, there were 2608 unplanned admissions, 49% for non-cardiovascular disease (CVD), 36% for HF and 15% for a CVD other than HF. 34% were classified as PAH. In the first 365 days after discharge, there were 14,559 hospitalizations, 54% for non-CVD reasons, 32% for HF and 13% for a CVD other than HF. Overall, 35% were PAHs. Conclusion(1) People admitted for HF are old, and they have multimorbidity and high rates of admissions due to non-CVD reasons and PAHs after discharge. These finding suggest the need of strengthening continuity of care and managing comorbidities. (2) Besides, most people admitted for HF have previous contacts with the Healthcare system, which suggests opportunities for prevention before disease worsening.

Impact of intra-atrial reentrant tachycardia management on outcomes in adult patients with congenital heart disease

Atrial arrhythmias are common complications in adults with congenital heart disease (ACHD) and are associated with a high morbidity and mortality. Intra-atrial reentrant tachycardia (IART) is the most prevalent arrhythmia in this population. This study aimed to compare outcomes according to arrhythmia management. All hospitalisations for IART in ACHD patients were retrospectively identified from medico-administrative database from September 2006 to September 2016. Outcomes of patients with IART managed with direct-current cardioversion (DCCV) were compared with patients referred for catheter ablation (CA). Atrial arrhythmia recurrence, death, stroke and first admission for heart failure (HF) were analyzed during follow-up. Ninety-one ACHD patients with IART (baseline median age 38 years [IQR 29-50], male 64%, 45% moderate CHD and 41% complex CHD) were included. Median follow-up was 3 years [IQR 1.6-6.7]. Twenty-six (28.6%) patients underwent DCCV and 65 (71.4%) CA. No significant difference in CHD complexity, past medical history of atrial arrhythmia and HF were observed between the 2 groups. Patients who underwent DCCV were significantly older (43 years [IQR 34–51] vs. 36 years [IQR 26–44], P = 0.03), with a higher CHADS-VASC score (CHADS-VASC ≥ 1 in 61% in DCCV group vs. 44% in CA group, P = 0.001). Atrial arrhythmia recurrence was observed in 52% after CA and 65% after DCCV ( Fig. 1 A, P = 0.28). Most of recurrence were IART, but atrial fibrillation was recorded in 37.5% after DCCV and 25.8% after CA ( P = 0.4). At the end of follow-up, patients who were initially treated by CA were more frequently in sinus rhythm (84% vs. 27%, P = 0.02), with a significant lower incidence of severe cardiovascular events ( Fig. 1 B, P < 0.01). A proactive management of IART by catheter CA is associated with better mid-term outcomes in adult patients with CHD.

Lower admission blood pressure as an independent predictor of 1-year mortality in elderly patients experiencing a first hospitalization for acute heart failure

BackgroundSystolic blood pressure (SBP) is an acknowledged prognostic factor in patients with heart failure (HF). Admission SBP should be a risk factor for 1-year mortality even in elderly patients experiencing a first admission for HF, and this risk may persist in the oldest subset of patients. DesignMethods: We reviewed the medical records of 1031 patients aged 70 years or older admitted within a 3-year period for a first episode of acute heart failure (AHF). The cohort was divided according to admission SBP values in quartiles. We analyzed all-cause mortality as a function of these admission SBP quartiles. ResultsMean age was 82.2 ± 6 years; their mean admission SBP was 138.6 ± 25 mmHg. A statistically significant association was present between mortality at 30 (p < 0.0001), 90 (p < 0.0001), and 365 days (p < 0.0001) after hospital discharge and lower admission SBP quartiles. One-year mortality ranged from 14.7% for patients within the upper SBP quartile to 41.4% for those in the lowest quartile. The multivariate analysis confirmed this association (HR: 0.884; 95% CI: 0.615-0.76; p = 0.0001), which remained significant when admission SBP was evaluated as a continuous variable (HR: 0.980; 95% CI: 0.975–0.985; p = 0.0001). The association between SBP and 1-year mortality remained when the sample was divided into old (70–82 years) and “oldest-old” (>82 years) patients. ConclusionsLower SBP at admission is an independent predictor of midterm postdischarge mortality for elderly patients experiencing a first admission for AHF.

Impact of atrial arrhythmias on outcome in adults with congenital heart disease

BackgroundAdults with congenital heart disease (ACHD) are affected by atrial arrhythmias (AA). To elucidate the impact of AA on prognosis, we aimed to determine the impact of AA on death, heart failure and stroke in ACHD patients in a prospective nationwide clinical registry. MethodsAll patients aged ≥18years included in the CONCOR registry per October 1st 2015 were analysed. Prior AA was defined as atrial fibrillation, atrial flutter or unspecified AA before inclusion in CONCOR and new-onset AA as a first documented AA during follow-up. The outcomes were death, first stroke and first admission for heart failure (HF). ResultsThe study cohort comprised 14,224 patients (baseline median age 33.6 [IQR 23–47], male 49.5%, AA n=1501, complex defect 10.3%, repaired defect 58.9%). Median follow-up was 6.5years [IQR 3–10]. Adjusting for age, sex, repair status and defect severity, patients with prior AA had higher mortality and more HF admissions, but no increased risk of stroke compared to those without AA (HR=2.11; 95% CI=1.79–2.49; p<0.001, HR=4.06; 95% CI=2.66–6.19; p<0.001 and HR=1.09; 95% CI=0.71–1.68; p=0.698, respectively). New-onset AA during follow-up was significantly associated with stroke (HR=2.04; 95% CI=1.05–3.96; p=0.036). ConclusionsACHD patients with prior AA have a 2-fold increased risk of death and a 4-fold increased risk of heart failure, but no increased risk for stroke compared to those without AA. Defect severity and age appear to be more important risk factors for stroke than prior AA. Stroke risk is increased only after conversion of new onset AA.

Natural product inhibitors of acetyl-lysine erasers in the prevention and treatment of heart failure

Background: Heart failure (HF) is a major public health concern, with five-year mortality rates following first admission for HF being approximately 50%, thereby stressing the need for novel therapeutic approaches. Histone deacetylases (HDACs) govern lysine acetylation of histone tails that regulates nucleosmal DNA. HDAC inhibitors have emerged as efficacious therapies in pre-clinical models of HF. Interest in diet-gene interactions has given rise to the study of ‘food bioactives’ as epigenetic regulators of gene expression that control human health and disease. These reports demonstrate that bioactive food compounds regulate epigenetic marks that link diet to gene regulation. In fact, others have also shown that bioactive compounds can target HDACs for inhibition; accordingly, bioactive food compounds offer unique opportunities for therapeutic intervention and prevention of heart failure. Lastly, there is emerging interest into how these food bioactives function together or as additives within foods ‘functional foods’ to regulate epigenetic disease. This review will highlight bioactive compound HDAC inhibitors and their role in the heart.Keywords: acetylation, bioactive compounds, dietary HDAC inhibitors, HDACs, histone deacetylases

Statin Treatment and Clinical Outcomes of Heart Failure Among Africans: An Inverse Probability Treatment Weighted Analysis.

BackgroundRandomized control trials of statins have not demonstrated significant benefits in outcomes of heart failure (HF). However, randomized control trials may not always be generalizable. The aim was to determine whether statin and statin type–lipophilic or –hydrophilic improve long‐term outcomes in Africans with HF.Methods and ResultsThis was a retrospective longitudinal study of HF patients aged ≥18 years hospitalized at a tertiary healthcare center between January 1, 2009 and December 31, 2013 in Ghana. Patients were eligible if they were discharged from first admission for HF (index admission) and followed up to time of all‐cause, cardiovascular, and HF mortality or end of study. Multivariable time‐dependent Cox model and inverse‐probability‐of‐treatment weighting of marginal structural model were used to estimate associations between statin treatment and outcomes. Adjusted hazard ratios were also estimated for lipophilic and hydrophilic statin compared with no statin use. The study included 1488 patients (mean age 60.3±14.2 years) with 9306 person‐years of observation. Using the time‐dependent Cox model, the 5‐year adjusted hazard ratios with 95% CI for statin treatment on all‐cause, cardiovascular, and HF mortality were 0.68 (0.55–0.83), 0.67 (0.54–0.82), and 0.63 (0.51–0.79), respectively. Use of inverse‐probability‐of‐treatment weighting resulted in estimates of 0.79 (0.65–0.96), 0.77 (0.63–0.96), and 0.77 (0.61–0.95) for statin treatment on all‐cause, cardiovascular, and HF mortality, respectively, compared with no statin use.ConclusionsAmong Africans with HF, statin treatment was associated with significant reduction in mortality.

0545: 3 years experiences of a heart failure management unit in Bordeaux: results and prognosis factors

Heart failure is the leading cause of hospital admissions and economic burden. In accordance with guidelines, a dedicated heart failure unit has been created in Bordeaux (France) in May 2011. Evaluate the impact of a heart failure management unit with ambulatory sector on readmission rate and mortality; and identify prognosis parameters at diagnosis and 6 months after. Descriptive study of mortality and heart-failure-related readmission rates after a first admission for heart failure, from May 2011 to July 2014 (inclusion stopped in July 2013). Student’s test and Cox’s regression have been performed. Since the creation of this unit, its activity has been growing by 30% in the first year and 10%, in the second. 421 patients with less than 40% left ventricular ejection fraction (LVEF) have been included; 181 had been treated before May 2011 while 240 were news patients treated during the study. Average age was 57±14 years old and average LVEF was 28%±7%. Therapeutics drugs cover was good compared to previous studies: 98% of patients has been treated by beta blockers, 94% by an antagonist of reninangiotensin-aldosteron system and 82% by an antagonist of mineralocorticoid receptor. Survival after 3 years of treatment was 87.5%. Re-admission rate was less than one readmission per patient and per year. No diagnosis parameter was a prognosis factor. But after 6 months of treatment, univariate analysis found significant prognosis factors of survival: dyspnea I-II, 6 minutes walking test >300m, BNP<400ng/ml (p<0,001). In multivariate analysis only BNP<400ng/ml at 6 months was associated with survival (p=0,012). Heart failure management unit in Bordeaux is conformed to European guidelines. Ambulatory sector is a good solution to cope with increasing activity. The most predictive factor of survival in our unit experience was evaluation at 6 months after diagnosis (like BNP<400ng/ml).

0214: Classifying heart failure patients to describe outpatient and inpatient care pathways in the French region Languedoc-Roussillon. First results of the cohort named “CarPathes”

Care pathways are quickly developing involving hospital and out-of hospital cares for patients with heart failure (HF). To improve the clinical managment and optimize the insurance economics, we aimed at decribing the care pathways and the consistency with clinical status and care access. A retrospective cohort of patients living in the French region Languedoc-Roussillon was built. Inclusion criteria were mainly: first admission for HF in 2012; follow-up more than 1 year. The database we used (the SNIIRAM) include outpatient care claim data and hospitalization data. Patients were classified by a hierarchical ascending classification on principal components, using variables describing clinical status, use of specialized and non-specialized care, and main clinical outcomes (hospitalization, death). 2751 patients were included and followed during a median of 22 months. Mean age was 78, 484 (18%) died, 818 (30%) were readmitted at least once for heart failure. The cluster analysis revealed three different significant groups: 1/ group 1 (N=734) is characterized by a younger age, more cares with cardiologists and less main clinical outcomes. Groups 2 and 3 are not different as regards age and comorbidities. 2/group 2 (N=1060) differs from the group 3 (N=957): less cares out-of the hospital contrasting with more cares at hospital, especially at emergencies. This cohort enables to evaluate consistency and adequation between cares and clinical status, following mail clinical outcomes. As this cohort is built in a heterogeneous region in terms of medical density or health organization, it should be a powerful tool for the study of spatial determinants.

Abstract 12715: Aortic Arch Width Adds to Coronary Artery Calcium for Prediction of Incident Adverse Cardiovascular Disease Events: The Framingham Heart Study

Introduction: Aortic arch width (AAW) is cross-sectionally associated with multiple cardiovascular disease (CVD) risk factors. We sought to determine whether AAW would add to standard Framingham risk factors (FRF) and coronary artery calcium (CAC) as a predictor of incident adverse CVD events. Methods: AAW, the distance between the centroids of the ascending and descending aorta at the level of main pulmonary artery bifurcation, was measured in 3026 Framingham Offspring and Third Generation cohort members who underwent computed tomography (CT) for CAC assessment over 2002-2005. Upper 90th percentile (P90) limits, based on sex, age and body surface area, were determined from a healthy referent group (no hypertension, diabetes, dyslipidemia, smoking; N=1471). Participants with prevalent CVD (N=119) or missing covariates (N=27) were excluded from further analysis, leaving 2880 who were dichotomized by AAW ≥P90 (high AAW) or &lt;P90. Cox proportional hazards models were used to estimate hazard ratio (HR) of high AAW on time-to-CVD (composite of: CVD death; myocardial infarction, MI; unstable angina, USA; stroke; first admission for heart failure, HF) after adjustment for FRF (listed in Table) and log(CAC+1). The category-free net reclassification improvement (NRI) metric was used to assess the effect of adding AAW to the baseline FRF+CAC model. Results: Overall prevalence of high AAW was 19.2%. There were 135 incident CVD events (6 CVD death, 49 MI, 4 USA, 42 stroke, 34 HF) over median 8.9-y follow up. High AAW was independently predictive of CVD, HR=1.55, p=0.032, and improved prediction over FRF+CAC (Table) with NRI=0.31; 95%CI=0.15-0.48. Conclusions: AAW is commonly visualized on MRI or CT of the chest and is simple to measure. High AAW adds to traditional CVD risk factors and CAC for prediction of incident CVD events among community dwelling adults. These data suggest AAW has utility for CVD risk stratification; findings remain to be replicated in other cohorts.

La hiponatremia como marcador de riesgo en pacientes sometidos a implante de desfibrilador en prevención primaria

Introduction and objectivesHyponatremia is a prognostic factor in patients with heart failure. Our objective was to assess the impact of hyponatremia in the evolution of patients undergoing cardioverter implantation in primary prevention. MethodThis is a multicenter retrospective observational study in which serum sodium periimplant and adverse events (all-cause and cardiovascular mortality, first admission for heart failure, first appropriate and inappropriate therapy) were assessed in a Spanish cohort receiving cardioverter in primary prevention. Patients with mild hyponatremia (Na≤135mEq/L) and those with moderate to severe hyponatremia (Na≤131mEq/L) were compared to those without hyponatremia. Results725 patients, with a mean value of sodium in blood peri-implant of 139±3.6mEq/L and a mean follow-up was 34.1±18.5months. In patients with Na≤135mEq/L (n=105), an increased incidence of first admission for heart failure was observed (Odds Ratio: 1.701; P=.031). In patients with moderate to severe hyponatremia (n=18), higher total mortality (Hazard Ratio: 3.552; P=.002) and increased cardiovascular mortality (Hazard Ratio: 4.24; P=.003) were observed. None of those values of hyponatremia were associated with increased incidence of appropriate or inappropriate therapies ConclusionsMild hyponatremia at the time of cardioverter implantation is related with a higher incidence of hospitalization for heart failure during follow-up, while moderate to severe hyponatremia increases the risk of death during follow-up

Association of Left Ventricular Strain with 30-Day Mortality and Readmission in Patients with Heart Failure

Heart failure (HF) readmissions are a common and serious problem of heterogeneous etiology. Left ventricular (LV) ejection fraction has not been found to be a consistent risk marker. However, LV strain has been shown to predict outcomes in other settings, so the aim of this study was to determine the association of LV strain with 30-day HF readmission, independent of and incremental to clinical and basic echocardiographic parameters. A total of 468 patients who underwent echocardiography at the time of the first admission for HF from July 2009 to June 2012 were retrospectively studied. Clinical parameters were comprehensively assessed, and standard echocardiographic parameters and two strain parameters (global longitudinal strain [GLS] and global circumferential strain) were measured using speckle-tracking. Patients were followed for all-cause 30-day hospital readmission or death after discharge, and the associations of parameters with outcome were assessed using Cox proportional hazards models. Readmission within 30days (n= 92 patients [20%]) was associated with greater impairment of LV GLS (-8.6% [interquartile range, -10.9% to -5.9%] vs -11.1% [interquartile range, -14.6% to -7.7%], P<.01). The association of GLS with readmission (hazard ratio, 1.13; 95% confidence interval, 1.07-1.19; P<.01) was independent of age, male gender, systolic blood pressure, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, and comorbidity, as well as renal function, sodium, hematocrit, LV mass, left atrial size, and mitral regurgitation. Global circumferential strain was associated with outcome but not was independent after adjustment with echocardiographic parameters. In sequential models for 30-day outcome, GLS added incremental information to clinical parameters and LV ejection fraction and significantly improved reclassification (categorical net reclassification improvement, 0.34; P= .04) when LV ejection fraction was >50%. GLS is associated with HF readmission, independent of and incremental to clinical and basic echocardiographic parameters.

Impact of Clinical Characteristics and Management on the Prognosis of Unselected Heart Failure Patients

Heart failure (HF) is a major public health issue. This study conducted a real-life analysis of the impact of clinical characteristics and medical management of HF on its prognosis. Analysis was based on the EGB ("Echantillon Généraliste des Bénéficiaires") database. A cohort comprising 1825 adult patients with a first admission for HF between 2009 and 2011 was created and followed until June 2013 (median 22.3 [7.7-34.5] months) for survival analysis. Mean age was 77.3 ± 13.2years (53% ≥80years). The overall incidence of HF admission was 117 [112-122] per 100,000 population with a marked increase in patients >80years (1297 [1217-1348]). At discharge, only 8% of patients received recommended combination of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB), beta-blockers (BB) and mineralocorticoid receptor antagonists (MRA). Only prescription levels of BB and vitamin K antagonists, at discharge, increased during the study period. In-hospital mortality was 9% and survival was 71.6%[69.5-73.6] and 52.0%[49.4-54.6] at 12 and 36months, respectively. In multivariate analysis, female gender [HR:0.78 (0.67-0.91), p = 0.001], ACEi/ARB + BB + MRA [0.41 (0.28-0.60), p < 0.001] and ACEi/ARB + BB [0.47 (0.39-0.57) p < 0.001] treatments were associated with improved survival, conversely to age 70-79 [1.90 (1.20-3.00), p = 0.003] and ≥80 [3.50 (2.30-5.40), p < 0.001], cardiogenic shock [3.00 (2.10-4.40), p < 0.001], acute pulmonary edema [1.70 (1.10-2.50), p = 0.01], denutrition [1.80 (1.45-2.24), p < 0.001], dilated cardiomyopathy [1.20 (1.00-1.40), p = 0.02] and in-hospital acute renal failure [1.36 (1.05-1.78), p = 0.002]. These real-life HF data provide insight into prognostic factors and "real-world" pharmacological management in this unselected HF population, confirming the benefit of ACEi/ARB + BB ± MRAs on patient survival.

0369: Heart failure octogenarians are poorly managed and treated: a cohort study in the French national healthcare insurance database

Part of over 80-year-old heart failure (HF) patients is increasing. These patients are poorly studied. The present study undertook a ‘real-life’ analysis of various aspects of the prognosis of over 80-year-old HF patients in France. Analysis was based on the EGB (“Echantillon Généraliste des Bénéficiaires”) database, a continuously updated representative sample of the population covered by the French national health insurance system. A cohort of adult patients with a first admission for HF was created between 2009 and 2011 and followed until June 2013 for survival analysis. Over 80-year-old patients represented 53% (n=969/1825) of hospitalizations for HF. In octogenarians, in-hospital mortality was 10.9% [9.6-12.2] and mean 12 –, and 24-months survival 62.3% (range, 59.1-65.4) and 48.2% (44.8-51.5). Only prescription levels for beta-blockers (BB) (p=0.02) increased during the follow-up period. Only 5% of patients received at discharge an optimal treatment [association of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) +BB+mineralocorticoid receptor antagonists (MRA)]. During this period there was no increase of ACEi and ACEi/ ARB+BB+MRA prescription at discharge (p=0.48 and p=0.87, respectively). On multivariate analysis, atrial fibrillation [HR: 0.77(0.65–0.91), p=0.003], female gender [0.80(0.67–0.95), p=0.01] and the associations ACEi/ ARB+BB+MRA [0.49(0.29–0.85), p=0.01] and ACEi/ARB+BB [0.54(0.43– 0.68), p<0.001] were associated with improved survival, in contrast to denutrition [1.64(1.27–2.13), p<0.001] and cardiogenic shock at admission [3.11(1.78–5.46), p<0.001]. Octogenarians HF patients are poorly managed and treated according to international guidelines despite the clinical benefit of such drugs confirmed in this un-selected cohort with several comorbidities.

Heart failure prognosis and management in over-80-year-old patients: data from a French national observational retrospective cohort.

The aim of the study was to assess the impact of clinical characteristics and management on the mid- to long-term follow-up prognosis of unselected over-80-year-old patients hospitalized for a first heart failure (HF) episode in a real-life setting. Despite the increasing proportion of HF patients over 80 years of age, the latter remain a poorly studied population. Analysis was based on the EGB ("Echantillon Généraliste des Bénéficiaires") database. A cohort comprising 1825 adult patients with a first admission for HF between 2009 and 2011 was created and followed until June 2013 for survival analysis. Over-80-year-old patients represented 53 % of this cohort, with a median follow-up of 18.6 (3.3-29.5) months. Only 5 % of patients over 80 years received an optimal treatment at discharge [combination of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB), beta-blockers (BB), and mineralocorticoid receptor antagonists (MRA)]. During the follow-up period, only BB prescription levels (p = 0.02) increased. In over-80-year-olds, in-hospital mortality was 12 % (range, 10-14) and survival was 62.8 % (59.6-65.7) and 48.7 % (45.4-51.9) at 12 and 24 months, respectively. On multivariate analysis, dyslipidemia [0.74 (0.58-0.94), p = 0.02], vitamin K antagonists [0.55 (0.44-0.69), p < 0.001], ACEi/ARB + BB + MRA [0.56 (0.32-0.96), p = 0.04], and ACEi/ARB + BB [0.57 (0.45-0.72), p < 0.001] were associated with improved survival, conversely to cardiogenic shock [3.37 (1.90-5.98), p < 0.001], denutrition [1.61 (1.24-2.09), p < 0.001], and age over 90 [1.35 (1.09-1.67), p = 0.01]. These real-life HF data provide insight into prognostic factors and demonstrate that over-80-year-old HF patients displaying several comorbidities are poorly managed, despite the confirmed clinical benefit of HF drugs.

Comparison of the clinical outcome of different beta‐blockers in heart failure patients: a retrospective nationwide cohort study

To compare survival on different beta-blockers in heart failure. We identified all Danish patients ≥35 years of age who were hospitalized with a first admission for heart failure and who initiated treatment with a beta-blocker within 60 days of discharge. The study period was 1995-2011. The main outcome was all-cause mortality and all-cause hospitalization. Cox proportional hazard models were used to compare survival. The study included 58 634 patients of whom 30.121 (51.4%) died and 46.990 (80.1%) were hospitalized during follow-up. The mean follow-up time was 4.1 years. In an unadjusted model carvedilol was associated with a lower mortality [hazard ratio (HR) 0.737, 0.714-0.761] compared with metoprolol (reference) while bisoprolol was not associated with an increased mortality (HR 1.020, 0.973-1.069). In a model adjusted for possible confounders and stratified according to beta-blocker dosages, patients that received high-dose carvedilol (≥50 mg daily) had a lower all-cause mortality risk (HR 0.873, 0.789-0.966) than patients receiving high-dose (≥200 mg daily) metoprolol (reference). High-dose bisoprolol (≥10 mg daily) was associated with a greater risk of death (HR 1.125, 1.004-1.261). High-dose carvedilol was associated with significantly lower all-cause hospitalization risk (HR 0.842, 0.774-0.915) than high-dose metoprolol (reference), while high-dose bisoprolol had insignificantly lower risk than high-dose metoprolol (HR 0.948, 0.850-1.057). Heart failure patients receiving high-dose carvedilol (≥50 mg daily) showed significantly lower all-cause mortality risk and hospitalization risk, compared with other beta-blockers.

Identifying patients with chronic heart failure for palliative care: a comparison of the gold standards framework with a clinical prognostic model

References [1] British Heart Foundation (2007) Coronary heart disease statistics. BHF, London. *2+ Stewart S, MacIntyre K, Hole DJ, Capewell S, McMurray JJ. More ‘malignant’ than cancer? Five-year survival following a first admission for heart failure. Eur J Heart Fail 2001; 3: 315-322. [3] Murray S, Kendall M, Boyd K and Sheikh A. Illness trajectories and palliative care. BMJ 330; 2005: 1007-1011. Discussion  Neither the GSF or the SHF accurately identified patients, with chronic heart failure, who were nearing the end of life.  Declining/poor renal function is the best predictor in this patient group.  Neither the SHF nor the GSF include renal function in their estimations or guidelines.  The traditional “end of life” model used in cancer patients may not be appropriate for heart failure. Instead need a more “needs based” approach, as death, itself, may remain unpredictable. VARIABLE Mean /% Range/n