Outpatient Heart Failure Research Articles

Inflammation as a Prognostic Marker in Heart Failure.

Background: Heart failure (HF) is a chronic cardiac disease of great importance worldwide and responsible for one-fifth of hospitalizations for cardiovascular disease in Brazil. Pro-inflammatory mediators are involved in the pathophysiology of HF. However, the impact of inflammatory markers on the prognosis of the disease remains uncertain.Objective: We aimed to evaluate inflammation as a prognostic marker in chronic HF.Methods: In this prospective, single-center, observational cohort study conducted from June 2018 through December 2019, we included outpatients with HF from a specialized service of a teaching hospital. Patients with decompensated HF requiring hospitalization in the last 30 days were excluded. At the time of inclusion, serum C-reactive protein (CRP) and albumin were collected and the presence of inflammation was defined as CRP/albumin ≥1.2. Patients with CRP/albumin ratio <1.2 (group A) and CRP/albumin ratio ≥1.2 (group B) were compared. The primary outcome was all-cause mortality. The secondary outcomes were hospitalization for decompensated HF, number of hospitalizations, and number of days of hospitalization in the 12-month follow-up.Results: We included 77 patients, 49 (63.3%) in group A and 28 (3.4%) in group B. Six patients in group A (12.2%) and 10 patients in group B (35.7%) required at least one hospitalization during follow-up (p=0.01). The rate of hospitalizations for decompensated HF for every 100 patients was 16.3 in group A vs 50.0 in group B (p=0.0001) and the average in-hospital length of stay was 12.2 vs 14.2 days per hospitalized patient (p=0.36) in groups A and B, respectively. The mortality rate was 6.1% in group A vs 7.1% in group B (p=0.86).Conclusion: In HF outpatients with inflammation evidentiated by the CRP/albumin ratio ≥1.2, the risk of death was similar to patients without inflammation criteria. However, the presence of inflammation led to a three-fold higher risk of hospitalization for HF decompensation.

Comorbidities complicating heart failure: changes over the last 15 years

AimsManagement of comorbidities represents a critical step in optimal treatment of heart failure (HF) patients. However, minimal attention has been paid whether comorbidity burden and their prognostic value changes over time. Therefore, we examined the association between comorbidities and clinical outcomes in HF patients between 2002 and 2017.Methods and resultsThe 2002-HF cohort consisted of patients from The Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH) trial (n = 1,032). The 2017-HF cohort were outpatient HF patients enrolled after hospitalization for HF in a tertiary referral academic hospital (n = 382). Kaplan meier and cox regression analyses were used to assess the association of comorbidities with HF hospitalization and all-cause mortality.Patients from the 2017-cohort were more likely to be classified as HF with preserved ejection fraction (24 vs 15%, p < 0.001), compared to patients from the 2002-cohort. Comorbidity burden was comparable between both cohorts (mean of 3.9 comorbidities per patient) and substantially increased with age. Higher comorbidity burden was significantly associated with a comparable increased risk for HF hospitalization and all-cause mortality (HR 1.12 [1.02–1.22] and HR 1.18 [1.05–1.32]), in the 2002- and 2017-cohort respectively. When assessing individual comorbidities, obesity yielded a statistically higher prognostic effect on outcome in the 2017-cohort compared to the 2002-HF cohort (p for interaction 0.026).ConclusionDespite major advances in HF treatment over the past decades, comorbidity burden remains high in HF and influences outcome to a large extent. Obesity emerges as a prominent comorbidity, and efforts should be made for prevention and treatment.Graphical abstractCreated with BioRender.com.

Statins are associated with reduced likelihood of sarcopenia in a sample of heart failure outpatients: a cross-sectional study

BackgroundSarcopenia is prevalent in heart failure (HF) patients, contributing to its poor prognosis. Statin use is postulated as a probable risk for developing sarcopenia, but little is known regarding this association in HF patients. This work aims at classifying and characterising sarcopenia and at describing the association of statin use with sarcopenia in a sample of Portuguese HF outpatients.MethodsIn this cross-sectional study, a sample of 136 HF patients (median age: 59 years, 33.8% women) was recruited from an HF outpatients’ clinic of a University Hospital in Portugal. Sarcopenia was defined according to the European Working Group on Sarcopenia in Older People 2. Clinical, nutritional, and dietary data were collected.ResultsA total of 25 (18.4%) individuals were categorised as sarcopenic, ranging from 12.2% in younger (< 65 years) participants vs. 30.4% in older ones and from 3.3% in men vs. 47.8% in women. Severe sarcopenia accounted for 7.4% of the sample and sarcopenic obesity was identified in 5.1% of the individuals. A total of 65.4% of the participants were statin users. In multivariable analysis (n = 132, 25 sarcopenic), the use of statins was inversely associated with sarcopenia (OR = 0.03; 95% CI = 0.01, 0.30). Each additional age year was associated with a 9% increase in the likelihood of being sarcopenic (OR = 1.09; 95% CI = 1.01, 1.17), and each Kg.m−2 increment in body mass index was associated with a 21% decrease in the likelihood of sarcopenia (OR = 0.79; 95% CI = 0.65, 0.96). The daily use of five or more medicines was also directly associated with sarcopenia (OR = 26.87; 95% CI = 2.01, 359.26). On the other hand, being a man and being physically active were inversely associated with sarcopenia (OR = 0.01; 95% CI = 0.00, 0.07 and OR = 0.09; 95% CI = 0.01, 0.65, respectively).ConclusionsContrary to what was expected, patients medicated with statins were less likely to be sarcopenic. Although this finding deserves further research, we hypothesise that this might be related to the pleiotropic effects of statins on endothelial function, contributing to better neuromuscular fitness.

Global warming, renal function and heart failure over 20 years

BackgroundThe impact of increasing temperatures on renal function in heart failure (HF) outpatients has never been specifically analyzed. MethodsWe retrieved creatinine and estimated glomerular filtration rate (eGFR) values of all HF outpatients followed at a HF clinic and temperature data from 2002 to 2021. For each patient and each year we averaged values of creatinine, eGFR and monthly temperatures during summer and the rest of the year. ResultsThe study cohort included 2167 HF patients undergoing 25,865 elective visits, with a median of 14 visits for each patient (interquartile range 7–23). At the first visit, patients (70% men) had an age of 67 ± 13 years, and a left ventricular ejection fraction of 35 ± 14%. Creatinine was 1.25 ± 0.51 mg/dL, and eGFR was 65 ± 25 mL/min/1.73 m2. When pooling together all average values of creatinine and eGFR measured during summer or in the rest of the year, creatinine was significantly higher in summer (difference 0.04, 95% confidence interval [CI] 0.04 to 0.05, p < 0.001), and eGFR was slightly lower (difference − 2.0, 95% CI -2.3 to −1.8, p < 0.001). Temperature rise during summer increased from 2002 to 2021. The absolute (Δ) and percent (Δ%) elevation in temperature during summer displayed independent associations with Δ and Δ% creatinine and eGFR after adjusting for age, sex, plasma creatinine, and HF therapies. ConclusionsThe magnitude of temperature elevation during summer has increased over 20 years. This elevation correlates with the decline in renal function during summer. This might be an example of how global warming is affecting human health.

Effectiveness of home-based telerehabilitation programs on functional capacity and cardiac function in elderly heart failure patients: A prospective longitudinal study.

Decreased functional capacity and reduced cardiac function were the main symptoms in patients with heart failure (HF) and the incidence increases with advanced age. The guidelines recommend that exercise training should be considered for medically stable HF outpatients. Studies have confirmed that exercise can improve functional capacity, prognosis, and reduced hospitalization rates; however, very few studies have investigated the elderly. It is not clear whether exercise could be feasible in elderly HF. The aim of this study was to evaluate the effect of the 6-month heart failure post-acute care program focused on home-based cardiac telerehabilitation (HCTR) on functional capacity, cardiac function, and readmission rates in HF patients. A prospective longitudinal study was conducted. Study duration was from January 2018 to December 2019. HF patients with a left ventricular ejection fraction <40% and age ≧65 years were included and divided into intervention (n = 40) and control group (n = 41). We arranged a 6-month heart failure post-acute care program that included outpatient cardiac rehabilitation and home exercise for the intervention group. The response to home exercise was followed by telemonitor. The exercise parameters were recorded on the HF health management mobile application system platform by each patient and daily transmission to hospital's cloud database as HCTR, usual care program for the control group. Information such as general data, laboratory data, six-minute walk test, cardiac function, and admission record was collected from all patients. Eighty one patients between the ages of 65 and 92 completed the study. The mean age was 73.3 ± 5.0 and 75.6 ± 6.0 years in control and intervention group, respectively. The intervention group showed a statistically significant improvement in functional capacity, percentage change in the of six-minute walk distance (51.2% vs 17.7%, P < .05, 95% confidence interval -45.9 to -6.3). Left ventricular ejection fraction increased by 7.7%, which corresponds to 25.6% in relative terms (P < .05, 95% confidence interval -7.8 to -0.5). The readmission rate was 4.6% in the intervention group. Six months of post-acute HF focused on HCTR programs was safe, improved functional capacity, cardiac function, and decreased readmission rate in elderly patients with HF patients.

Combining echo-derived haemodynamic phenotypes and myocardial strain for risk stratification of chronic heart failure with reduced ejection fraction.

Echocardiography has shown to categorize heart failure (HF) patients according to haemodynamic profiles. Whether left ventricular (LV) global longitudinal strain (LV-GLS) could integrate echo-derived haemodynamic profiles to risk stratify chronic HF patients is still unknown. Chronic HF outpatients with LV ejection fraction (LV-EF) <50% (n = 351) and LV-GLS assessment were evaluated and divided according to four haemodynamic phenotypes based on LV stroke volume index (SVI), LV filling pressure (LVFP), and right ventricular (RV) function: normal output-normal LVFP (NO-NP), normal output-high LVFP (NO-HP), low output-no RV dysfunction (LO-NRVD), and low output-RV dysfunction (LO-RVD). RV function was defined using the tricuspid annular plane systolic excursion and RV free-wall longitudinal strain. The median follow-up duration was 3.3 years. The combination of all-cause mortality and HF hospitalization was the primary endpoint. Secondary endpoints were all-cause mortality and cardiovascular mortality. The prevalence of NO-NP, NO-HP, LO-NRVD, and LO-RVD were 38%, 22%, 30%, and 10%, respectively. The haemodynamic model independently predicted primary and secondary outcomes, with incremental prognostic information over LV-EF (all P-values <0.001 for C-statistics). When univariate Cox regression analysis was performed to assess the prognostic stratification capability of LV-GLS in different haemodynamic subgroups, we observed a reduction in LV-GLS hazard ratios from the NO-NP to the LO-RVD for every endpoint. There was a continuum in LV-GLS impairment across the spectrum of haemodynamic phenotypes and its prognostic value resulted variable depending on the types of chronic HF patients. The highest prognostic information added by LV-GLS was in patients with normal SVI.

Anxiety in heart failure patients and its association with socio-demographic and clinical characteristics: a cross-sectional study.

Background:Anxiety is one of the most frequent psychiatric disorders in heart failure (HF) patients. However, it is often neglected in clinical practice and studies about the particular relationship with the New York Heart Association (NYHA) classes for HF are scarce. In this context, this study aims to analyze the presence of anxiety symptoms in HF outpatients and also its association with sociodemographic and clinical characteristics of these patients.Methods:This cross-sectional study is part of the longitudinal Deus Ex-Machina project (NORTE-01-0145-FEDER-000026). HF patients were recruited at an outpatient clinic at a University Hospital. Patients with inability to communicate, severe visual/hearing impairment, or NYHA class IV were excluded. Sociodemographic data and NYHA class were registered. Anxiety was assessed with the 7-item Generalized Anxiety Disorders Scale (with a score ≥10 clinically relevant anxiety). Patients with and without anxiety were compared regarding socio-demographic and clinical variables.Results:The sample (n = 136) had a median age of 59years (Q1: 49; Q3: 68), 66.2% were male and 31.6% presented clinically relevant anxiety. A higher percentage of HF patients with anxiety had psychiatric disorders (58.1% vs 26.9%; P = .001), psychotropic medication (62.8% vs 30.1%; P = .001), and depression (60.5% vs 9.7%; P< .001). No significant differences were found regarding the remaining variables, including NYHA classes.Conclusions:A substantial proportion of HF patients present clinically relevant anxiety, particularly those with psychiatric history, depressive symptoms, or under psychotropic medication. Therefore, integrating routine screening and treatment of this comorbidity in clinical practice is of utmost importance. Further studies are needed to clarify the association of anxiety with HF.

Tendencias temporales en las características, tratamiento y resultados de la insuficiencia cardiaca en octogenarios durante dos décadas

Introduction and objectivesOctogenarians represent the most rapidly expanding population segment in Europe. The prevalence of heart failure (HF) in this group exceeds 10%. We assessed changes in clinical characteristics, therapy, and 1-year outcomes over 2 decades in chronic HF outpatients aged ≥ 80 years enrolled in a nationwide cardiology registry. MethodsWe included 2520 octogenarians with baseline echocardiographic ejection fraction measurements and available 1-year follow-up, who were recruited at 138 HF outpatient clinics (21% of national hospitals with cardiology units), across 3 enrolment periods (1999-2005, 2006-2011, 2012-2018). ResultsAt recruitment, over the 3 study periods, there was an increase in age, body mass index, ejection fraction, the prevalence of obesity, diabetes, dyslipidemia, pre-existing hypertension, and atrial fibrillation history. The proportion of patients with preserved ejection fraction rose from 19.4% to 32.7% (P for trend <.0001). Markers of advanced disease became less prevalent. Prescription of beta-blockers and mineralocorticoid receptor antagonists increased over time. During the 1-year follow-up, 308 patients died (12.2%) and 360 (14.3%) were admitted for cardiovascular causes; overall, 591 (23.5%) met the combined primary endpoint of all-cause mortality or cardiovascular hospitalization. On adjusted multivariable analysis, enrolment in 2006 to 2011 (HR, 0.70; 95%CI, 0.55-0.90; P=.004) and 2012 to 2018 (HR, 0.61; 95%CI, 0.47-0.79; P=.0002) carried a lower risk of the primary outcome than recruitment in 1999 to 2005. ConclusionsAmong octogenarians, over 2 decades, risk factor prevalence increased, management strategies improved, and survival remained stable, but the proportion hospitalized for cardiovascular causes declined. Despite increasing clinical complexity, in cardiology settings the burden of hospitalizations in the oldest old with chronic HF is declining.

Perceived Social Isolation in Heart Failure.

Patients with heart failure (HF) experience social isolation associated with an increased risk of morbidity, mortality, and elevated health care expenditures. The aim of this study was to evaluate the factors associated with perceived social isolation and to assess the impact of fatigue on social isolation. A total of 100 HF outpatients were enrolled by convenience sampling. Data were collected by completion of the Greek version of the Modified Fatigue Impact Scale (MFIS-Greek), which also included patients’ characteristics and their self-report about social isolation. Of the 100 participants (68% men; mean age, 68.6 ± 7.1 years), 78% reported perceiving social isolation. Factors significantly associated with perceived social isolation were female sex (P = .001), New York Heart Association class IV (P = .001), stress about HF (P = .002), paroxysmal nocturnal dyspnea (P = .030), edema in the lower limbs (P = .001), report of receiving many medications (P = .001), change in body image (P = .032), and not following limitations in fluid and sodium intake (P = .001). The MFIS total score determined moderate to high levels of fatigue (median, 70 points; range, 21–105 points). Total fatigue was statistically significantly associated with social isolation as perceived by patients (P = .001). In conclusion, demographic and clinical characteristics as well as fatigue are associated with perceived social isolation. It is essential to evaluate social isolation in routine practice.

Nutritional Status According to the GLIM Criteria in Patients with Chronic Heart Failure: Association with Prognosis.

Background: The Global Leadership Initiative on Malnutrition (GLIM) criteria were recently proposed to build a global consensus on the diagnostic criteria for malnutrition. This study aimed to evaluate the GLIM criteria for its prognostic significance in outpatients with heart failure (HF), and to compare them to a previous validated method, such as the Mini Nutritional Assessment (MNA). Methods: This was a post hoc observational analysis of a prospectively recruited cohort, which included 151 subjects that attended an outpatient HF clinic. At baseline, all patients completed the nutritional screening MNA short form and the nutritional assessment MNA. In a post hoc analysis, we evaluated the GLIM criteria at baseline. The outcomes were based on data from a five-year follow-up. The primary endpoint was all-cause mortality. Secondary endpoints were cardiovascular (CV) mortality and recurrent HF-related hospitalizations. We also investigated whether the GLIM criteria had better prognostic power than the MNA. Results: Abnormal nutritional status was identified in 19.8% of the patients with the GLIM criteria and in 25.1% with the MNA. In the multivariate analyses (age, sex, NYHA functional class, diabetes, and Barthel index), nutritional status assessed by the MNA, but not by the GLIM criteria, was an independent predictor of all-cause mortality, CV mortality, and recurrent HF-related hospitalizations during the five-year follow-up. Conclusions: Malnutrition assessed by MNA, but not by the GLIM criteria, was an independent predictor of all-cause mortality, CV mortality, and recurrent HF-related hospitalization in our cohort of outpatients with HF.

Frequency of hemodynamic response to orthostatic stress in heart failure with reduced ejection fraction, associations with clinical blood pressure

Aim. To assess hemodynamic response to active standing test (AST) with beat-to-beat blood pressure (BP) monitoring, their association with office BP and symptoms of orthostatic intolerance in patients with heart failure (HF).Material and methods. Outpatient HF patients with documented left ventricular ejection fraction &lt;40%, followed up in a HF center and receiving optimal medical therapy, underwent AST with beat-to-beat non-invasive BP monitoring.Hemodynamic response was assessed according to the European Federation of Autonomic Societies criteria.Results. The study included 87 patients (mean age, 57±10 years; men, 76%). Normal hemodynamic response to orthostatic stress was observed in 36 (41,4%) patients. Pathological response prevailed during the first minute of orthostatic stress — initial orthostatic hypotension (OH) (n=29, 33,3%) and delayed BP recovery (n=18, 20,7%). Classical OH was detected in 4 (4,6%) patients. There was no orthostatic hypertension, defined as an increase in systolic BP (SBP) ≥20 mm Hg. According to office BP, hypotension was observed in 19 (21,8%) patients (SBP &lt;90 mm Hg in 4 patients and 90-100 mm Hg in 15), hypertension (SBP &gt;140 mm Hg) in 11 (12,6%) patients. Pathological response to orthostatic stress were more often observed in office SBP &gt;140 mm Hg compared to SBP ≤140 mmHg (90,9% and 53,9%, p=0,020).Orthostatic intolerance was noted in 43 (49,4%) patients and were not associated with the level of office SBP (p=0,398) or pathological responses to orthostatic stress (p=0,758 for initial OH and p=0,248 for delayed BP recovery).Conclusion. The pathological hemodynamic response in AST with beat-to-beat BP monitoring in ambulatory patients with HF is most often represented by initial OH and delayed BP recovery associated with office SBP &gt;140 mmHg. The frequency of symptoms of orthostatic intolerance did not differ between groups depending on the presence of an inadequate response to orthostatic stress.

C78 PREVALENCE AND MECHANISMS OF SEVERE MITRAL AND TRICUSPID REGURGITATION IN A HEART FAILURE OUTPATIENTS POPULATION

Abstract Introduction Mitral regurgitation (MR) and tricuspid regurgitation (TR) are a known cause of morbidity and mortality in heart failure (HF) patients. Maximal up–titration of guideline–directed medical therapy (GDMT) for HF may not be enough to reduce the severity of the valve’s incompetence and patients’ symptoms. The development and successful results of transcatheter therapies for mitral/tricuspid disease have opened new therapeutic opportunities when surgery is not feasible. Accurate valve regurgitation’s mechanisms evaluation is essential to choose the best treatment option. This study aims at evaluating the prevalence and underlying mechanisms of at least moderate–to–severe (≥3+/4+) MR and/or TR in a cohort of HF outpatients. Methods We retrospectively analyzed the medical records of 1260 outpatients evaluated by our HF unit between January 2020 and June 2021. All patients with echocardiographic evidence of ≥ 3+/4+ MR and/or TR were included (treated ones were excluded), and a thorough echocardiographic images review was conducted. A full collection of patients’ clinical, laboratory and therapy regimens details was performed as well. Results Of the 1260 analyzed patients, 173 (13.7%) exhibited ≥3+/4+ MR and/or TR and were included in the registry. Table 1 shows the main clinical/echocardiographic characteristics. Mean age was 80±7 years, median ejection fraction was 45% (IQR=33–55). All patients were treated with maximal tolerated doses of GDMT and, if appropriate, with cardiac devices/myocardial revascularization. ≥3+/4+ MR and/or TR was observed in 92 (7.3%) and 117 (9.3%) patients, respectively. Patients with isolated significant MR were 56 (4.4%), with isolated significant TR were 81 (6.4%); the remaining 36 (2.8%) had both MR/TR. Among patients with significant MR, 50 (54%) had functional/secondary valvular defect (details in Figure 2): the majority (41,82%) presented a ventricular etiology (asymmetric tethering in 18/41) while 9 (18%) an atrial one (atriogenic tethering in 3/9). Conclusion Despite optimized GDMT, the prevalence of patients with hemodynamically significant valvular defects was considerably high in our HF population. This is the first registry to comprehensively detail atrioventricular valve regurgitations’ mechanisms in a wide real–life cohort of HF outpatients. Further studies are needed to identify reasons for potential undertreatment and patients who would benefit the most from percutaneous correction of their valvular defects.

Clinical Support through Telemedicine in Heart Failure Outpatients during the COVID-19 Pandemic Period: Results of a 12-Months Follow Up

Background: Heart failure (HF) patients are predisposed to recurrences and disease destabilizations, especially during the COVID-19 outbreak period. In this scenario, telemedicine could be a proper way to ensure continuous care. The purpose of the study was to compare two modalities of HF outpatients’ follow up, the traditional in-person visits and telephone consultations, during the COVID-19 pandemic period in Italy. Methods: We conducted an observational study on consecutive HF outpatients. The follow up period was 12 months, starting from the beginning of the COVID-19 Italy lockdown. According to the follow up modality, and after the propensity matching score, patients were divided into two groups: those in G1 (n = 92) were managed with traditional in-person visits and those in G2 (n = 92) were managed with telephone consultation. Major adverse cardiovascular events (MACE) were the primary endpoints. Secondary endpoints were overall mortality, cardiovascular death, cardiovascular hospitalization, and hospitalization due to HF. Results: No significant differences between G1 and G2 have been observed regarding MACE (p = 0.65), cardiovascular death (p = 0.39), overall mortality (p = 0.85), hospitalization due to acute HF (p = 0.07), and cardiovascular hospitalization (p = 0.4). Survival analysis performed by the Kaplan–Meier method also did not show significant differences between G1 and G2. Conclusions: Telephone consultations represented a valid option to manage HF outpatients during COVID-19 pandemic, comparable to traditional in-person visits.

Temporal trends in characteristics, treatment, and outcomes of heart failure in octogenarians over two decades

Introduction and objectivesOctogenarians represent the most rapidly expanding population segment in Europe. The prevalence of heart failure (HF) in this group exceeds 10%. We assessed changes in clinical characteristics, therapy, and 1-year outcomes over 2 decades in chronic HF outpatients aged ≥ 80 years enrolled in a nationwide cardiology registry. MethodsWe included 2520 octogenarians with baseline echocardiographic ejection fraction measurements and available 1-year follow-up, who were recruited at 138 HF outpatient clinics (21% of national hospitals with cardiology units), across 3 enrolment periods (1999-2005, 2006-2011, 2012-2018). ResultsAt recruitment, over the 3 study periods, there was an increase in age, body mass index, ejection fraction, the prevalence of obesity, diabetes, dyslipidemia, pre-existing hypertension, and atrial fibrillation history. The proportion of patients with preserved ejection fraction rose from 19.4% to 32.7% (P for trend <.0001). Markers of advanced disease became less prevalent. Prescription of beta-blockers and mineralocorticoid receptor antagonists increased over time. During the 1-year follow-up, 308 patients died (12.2%) and 360 (14.3%) were admitted for cardiovascular causes; overall, 591 (23.5%) met the combined primary endpoint of all-cause mortality or cardiovascular hospitalization. On adjusted multivariable analysis, enrolment in 2006 to 2011 (HR, 0.70; 95%CI, 0.55-0.90; P=.004) and 2012 to 2018 (HR, 0.61; 95%CI, 0.47-0.79; P=.0002) carried a lower risk of the primary outcome than recruitment in 1999 to 2005. ConclusionsAmong octogenarians, over 2 decades, risk factor prevalence increased, management strategies improved, and survival remained stable, but the proportion hospitalized for cardiovascular causes declined. Despite increasing clinical complexity, in cardiology settings the burden of hospitalizations in the oldest old with chronic HF is declining.

Abstract 252: 12 Months Outcomes For Heart Failure Patients Attending Outpatient Clinics In Tanzania.

Introduction: The burden of cardiovascular disease is growing at an alarming pace in low- and middle-income countries, especially in Sub-Saharan Africa (SSA). Heart failure (HF) in SSA is associated with higher rates of rehospitalization, poor quality of life and high mortality. In SSA, it is estimated that 3-7% of all admissions to hospitals are due to HF. For inpatient HF patients in Tanzania, studies have found greater than 50% mortality rate at 12 months post discharge. In developed countries, outpatient HF clinics have been associated with reduction of 30-day readmission and mortality rates. However, there is limited published data on HF outcomes for HF patients seen at outpatient clinics in SSA. The purpose of this study was to determine frequency of hospitalization, occurrence of stroke, and mortality at two HF outpatient clinics in Mwanza city, Tanzania. Methods: From February 2017 to September 2018 HF patients at Bugando Medical Center and Sekou Toure Regional Hospital outpatient clinics were recruited and followed for 12 months. HF was confirmed by Framingham criteria and the severity was determined by New York Heart Association (NYHA) classification. Participant’s data were collected in four waves over the course of 12 months. Demographic data were collected at baseline and data on hospitalization, occurrence of stroke, and mortality were collected during the follow up period. Results: Four hundred and eighteen patients were enrolled and 369 were included in the final analysis. Most were female (n=264, 63%), small scale farmers (n=278, 66.5%) and from Mwanza City (n=299, 71.5%). More than two-thirds did not have health insurance (n=295, 70.6%) and the majority were in the NYHA I and II classification (n=267, 64.7%) during the study period. Twenty-one, 25, 11 and 13 HF patients were hospitalized at least once in the 1 st , 2 nd , 3 rd , and 4 th data collection periods respectively. Fifty patients died (14%) and 7 sustained stroke (2%) over the 12 months period. Conclusion: Moderate levels of hospitalization, mortality, occurrence of stroke was reported in this study compared published inpatient studies in Tanzania. Interventions are needed to improve the long-term health and survival of HF patients attending HF outpatient clinics in Mwanza City.

Baseline characteristics of 547 new onset heart failure patients in the PREFERS heart failure study.

AimWe present the baseline characteristics of the PREFERS Stockholm epidemiological study on the natural history and course of new onset heart failure (HF) aiming to improve phenotyping focusing on HF with preserved left ventricular ejection fraction (HFpEF) pathophysiology.Methods and results New onset HF patients diagnosed in hospital or at outpatient HF clinics were included at five Stockholm hospitals 2015–2018 and characterized by N‐terminal pro brain natriuretic peptide (NT‐proBNP), biomarkers, echocardiography, and cardiac magnetic resonance imaging (subset). HFpEF [left ventricular ejection fraction (LVEF) ≥ 50%] was compared with HF with mildly reduced LVEF (HFmrEF; LVEF 41–49%) and with HF with reduced LVEF (HFrEF; LVEF ≤ 40%). We included 547 patients whereof HFpEF (n = 137; 25%), HFmrEF (n = 61; 11%), and HFrEF (n = 349; 64%). HFpEF patients were older (76; 70–81 years; median; interquartile range) than HFrEF (67; 58–74; P < 0.001), more often women (49% vs. 30%; P < 0.001), and had significantly higher comorbidity burden. They more often had atrial fibrillation, hypertension, and renal dysfunction. NT‐proBNP was lower in HFpEF (896; 462–1645 ng/L) than in HFrEF (1160; 563–2370; P = 0.005). In HFpEF, left ventricular (LV) diameters and volumes were smaller (P < 0.001) and septal and posterior wall thickness and relative wall thickness higher (P < 0.001). E/é ≥ 14 was present in 26% of HFpEF vs. 32% of HFrEF (P = 0.017) and left atrial volume index > 34 mL/m2 in 57% vs. 61% (P = 0.040). HFmrEF patients were intermediary between HFpEF and HFrEF for LV mass, LV volumes, and RV volumes but had the highest proportion of left ventricular hypertrophy and the lowest proportion of elevated E/é.ConclusionsPhenotype data in new onset HF patients recruited in a broad clinical setting showed that 25% had HFpEF, were older, more often women, and had greater comorbidity burden. PREFERS is well suited to further explore biomarker and imaging components of HFpEF pathophysiology and may contribute to the emerging knowledge of HF epidemiology.Clinical trial registration: Clinicaltrials.gov identifier: NCT03671122.

"I Guess I'm On Alert All The Time": Dyadic Symptom Appraisal In Heart Failure With And Without An LVAD

Background Symptom monitoring is an essential component of heart failure (HF) self-care for HF patients with and without a left ventricular assist device (LVAD). Attention to HF symptoms by the caregiving dyad is important for prompt recognition and response. The purpose of this analysis was to characterize patient and caregiver agreement within dyads on appraisals of patient HF symptoms, and explore dyadic agreement across dyads, comparing LVAD and non-LVAD experiences. Methods This was a post-hoc analysis of a mixed-methods descriptive study of HF caregiving in dyads with and without an LVAD. We recruited HF patients and their caregivers from outpatient HF and LVAD clinics at Johns Hopkins Hospital. We administered surveys and qualitative interviews with each dyad. Symptom burden was measured using the Heart Failure Somatic Perception Scale (HFSPS; higher scores = higher burden). We used raw difference scores to quantify the magnitude and direction of agreement within dyads. Dyads with difference scores of <|5| were considered in agreement. Dyads with difference scores ≥|5| were grouped based on the direction of agreement ([+] caregiver scored patient symptoms higher; [-] patient scored their symptoms higher). We integrated these appraisal patterns with qualitative quotations relevant to symptom appraisal. Results We enrolled 10 LVAD and 12 non-LVAD dyads. There were 7 dyads with agreement and 15 dyads with disagreement of which 6 had [+] agreement scores and 9 had [-] agreement scores. Qualitative data analysis revealed a theme common to both types of dyad relevant to symptom appraisal: “monitoring/vigilance”. However, the monitoring/vigilance described differed between LVAD and non-LVAD dyads (figure). In LVAD dyads, vigilance related to monitoring of the LVAD while non-LVAD dyads described monitoring symptoms and signs of disease progression. Dyads with agreement spoke less about monitoring/vigilance than dyads with disagreement. Dyads with higher caregiver rating of symptoms spoke of specific actions they take to monitor the patient's symptoms. Dyads with higher patient rating of symptoms described monitoring and vigilance in ways that were similar to stress. Conclusions Although quantitative comparisons were not powered to detect statistical significance, this study showed differences in HF symptom appraisal agreement and symptom monitoring behaviors between LVAD and non-LVAD dyads. Additional investigation may suggest targets for dyadic interventions to improve symptom burden, appraisal, and management. Symptom monitoring is an essential component of heart failure (HF) self-care for HF patients with and without a left ventricular assist device (LVAD). Attention to HF symptoms by the caregiving dyad is important for prompt recognition and response. The purpose of this analysis was to characterize patient and caregiver agreement within dyads on appraisals of patient HF symptoms, and explore dyadic agreement across dyads, comparing LVAD and non-LVAD experiences. This was a post-hoc analysis of a mixed-methods descriptive study of HF caregiving in dyads with and without an LVAD. We recruited HF patients and their caregivers from outpatient HF and LVAD clinics at Johns Hopkins Hospital. We administered surveys and qualitative interviews with each dyad. Symptom burden was measured using the Heart Failure Somatic Perception Scale (HFSPS; higher scores = higher burden). We used raw difference scores to quantify the magnitude and direction of agreement within dyads. Dyads with difference scores of <|5| were considered in agreement. Dyads with difference scores ≥|5| were grouped based on the direction of agreement ([+] caregiver scored patient symptoms higher; [-] patient scored their symptoms higher). We integrated these appraisal patterns with qualitative quotations relevant to symptom appraisal. We enrolled 10 LVAD and 12 non-LVAD dyads. There were 7 dyads with agreement and 15 dyads with disagreement of which 6 had [+] agreement scores and 9 had [-] agreement scores. Qualitative data analysis revealed a theme common to both types of dyad relevant to symptom appraisal: “monitoring/vigilance”. However, the monitoring/vigilance described differed between LVAD and non-LVAD dyads (figure). In LVAD dyads, vigilance related to monitoring of the LVAD while non-LVAD dyads described monitoring symptoms and signs of disease progression. Dyads with agreement spoke less about monitoring/vigilance than dyads with disagreement. Dyads with higher caregiver rating of symptoms spoke of specific actions they take to monitor the patient's symptoms. Dyads with higher patient rating of symptoms described monitoring and vigilance in ways that were similar to stress. Although quantitative comparisons were not powered to detect statistical significance, this study showed differences in HF symptom appraisal agreement and symptom monitoring behaviors between LVAD and non-LVAD dyads. Additional investigation may suggest targets for dyadic interventions to improve symptom burden, appraisal, and management.

Effects Of Decreased Access To Outpatient Care During The Covid-19 Pandemic

IntroductionIn 2020, the Covid-19 pandemic caused a decrease in access to routine healthcare. The question posed was if decreased clinic hours of an outpatient congestive heart failure (CHF) clinic affected admissions or readmissions.HypothesisThe hypothesis was that decreased hours of the CHF clinic would lead to increased hospital admissions and readmissions.MethodsA retrospective data analysis using the Epic system slicer dicer application at an independent hospital in Phoenix, Arizona. The patient population was defined as patients seen with a heart failure diagnosis at the independent hospital.The time frames used for comparison include the years of 2019 and 2020 that were further broken down. January-March the CHF clinic operated 2 days a week in 2020, May 2020 the CHF clinic was closed and July- September 2020 the CHF clinic returned to 5 days a week. The proportion of the total patient population with at least one heart failure admission for each time period was calculated and the 2019 vs. 2020 proportions were compared using a two sample test of proportions and correspond confidence intervals.The percentage of patients readmitted for heart failure within 30 days out of the number patients who were admitted at least once were also compared for 2019 and 2020 during the time frames specified. Confidence intervals and p-values were calculated using a two sample test of proportions to determine if there was a statistically significant difference between the proportion of patients readmitted for heart failure in the years 2019 versus 2020 during the time frame specified.ResultsFor the time periods considered, the proportions of patients admitted at least once as well as the proportion of patients readmitted were higher in 2019 compared to 2020.When the entire years of 2019 and 2020 were compared there was a 2.5% higher admission rate in 2019 compared to 2020 (p=0.003, 95% CI=[0.9%, 4.2%]) and 3.2% higher readmission rate (p=0.04, 95% CI=[0.1%, 6.3%]). January- March was compared in 2019 vs. 2020, there was a 2.5% higher admission rate in 2019 (p=0.001, 95% CI=[1.0%, 4.0%]). There was no significant statistical difference for readmissions. May of 2019 had a 1.7% higher admission rate than May of 2020 (p<0.001, 95% CI=[0.7%, 2.6%]). We observed 5.0% higher readmissions in May 2019 compared to May 2020 but was not statistically significant (p=0.31, 95% CI=[-4.5%, 14.4%]).July-September of 2019 had a 2.6% higher admission rate compared to 2020 (p<0.001, 95% CI=[1.3%, 3.9%]). The percentage of readmissions was estimated to be 3.2% higher in July- September 2019 vs 2020, but was not statistically significant.ConclusionIn conclusion there was a decrease in admissions in 2020 vs 2019 despite decreased access. Factors to consider that may affect the outcome are travel and restaurant restrictions, as well as hesitancy to seek care during the 2020 pandemic. This may have led to care at different hospitals and more adherence to dietary restrictions at home. Improvement in guideline directed medical therapy and individual provider outreach also cannot be excluded.

Challenges in Using ICD-10 Codes for Case Ascertainment in Pediatric Heart Failure

Purpose Many epidemiological studies in pediatric heart failure (HF) use administrative databases, defining patient cohorts by the presence of a single HF ICD code. However, the precision of ICD codes to identify true HF patients is unknown in pediatrics. The study aim is to describe the accuracy of HF ICD-10 codes alone and in combination with medication billing codes, in identifying pediatric patients with HF through electronic health records. Methods Clinical notes were reviewed for 378 patients 18 years old and younger in a pediatric HF clinic at a tertiary care medical center within 01/2016-12/2020. The initial outpatient note for each patient was reviewed. Patients were adjudicated as having HF if the provider note: 1) stated the patient had current/prior HF or was receiving HF-specific treatment or 2) described the patient as NYHA/Ross Class II-IV HF or ACC/AHA HF Stage C or D. ICD-10 codes for HF and medication billing codes during the month before and 6 months after the clinic encounter were obtained. Algorithms were developed to identify HF patients based on the presence of 1 or more inpatient or outpatient HF ICD codes, in combination with HF medications. Using the clinical note review as the adjudicated positive HF diagnosis, algorithms were assessed by sensitivity, specificity, positive and negative predictive values. For inpatient algorithms that could be applied to administrative databases, receiver operating characteristics curves were generated and accuracy reported. Results Median age was 10.1 years (IQR 4.5,14.8) with 39/378 adjudicated HF patients. Algorithm performance is shown in Table 1. Conclusion This is the first study to describe characteristics of ICD code algorithms for case ascertainment in pediatric HF. Results suggest that a combination of an ICD code and carvedilol can identify a cohort of HF patients however many patients will be missed. Natural language processing approaches may improve the accuracy of patient identification for pediatric HF outcomes research, and should be tested. Many epidemiological studies in pediatric heart failure (HF) use administrative databases, defining patient cohorts by the presence of a single HF ICD code. However, the precision of ICD codes to identify true HF patients is unknown in pediatrics. The study aim is to describe the accuracy of HF ICD-10 codes alone and in combination with medication billing codes, in identifying pediatric patients with HF through electronic health records. Clinical notes were reviewed for 378 patients 18 years old and younger in a pediatric HF clinic at a tertiary care medical center within 01/2016-12/2020. The initial outpatient note for each patient was reviewed. Patients were adjudicated as having HF if the provider note: 1) stated the patient had current/prior HF or was receiving HF-specific treatment or 2) described the patient as NYHA/Ross Class II-IV HF or ACC/AHA HF Stage C or D. ICD-10 codes for HF and medication billing codes during the month before and 6 months after the clinic encounter were obtained. Algorithms were developed to identify HF patients based on the presence of 1 or more inpatient or outpatient HF ICD codes, in combination with HF medications. Using the clinical note review as the adjudicated positive HF diagnosis, algorithms were assessed by sensitivity, specificity, positive and negative predictive values. For inpatient algorithms that could be applied to administrative databases, receiver operating characteristics curves were generated and accuracy reported. Median age was 10.1 years (IQR 4.5,14.8) with 39/378 adjudicated HF patients. Algorithm performance is shown in Table 1. This is the first study to describe characteristics of ICD code algorithms for case ascertainment in pediatric HF. Results suggest that a combination of an ICD code and carvedilol can identify a cohort of HF patients however many patients will be missed. Natural language processing approaches may improve the accuracy of patient identification for pediatric HF outcomes research, and should be tested.

Challenges Facing Heart Failure Patients With Limited English Proficiency: A Qualitative Analysis Leveraging Interpreters’ Perspectives

BackgroundLimited English proficiency (LEP) heart failure (HF) patients experience worse HF outcomes, including higher readmission rates and emergency department visits. To elucidate the challenges this population faces, the authors interviewed interpreters to identify gaps in care quality and ways to improve care for LEP HF patients. ObjectivesThe authors sought to understand the challenges facing HF patients with LEP using medical interpreters’ perspectives. MethodsThe authors conducted a qualitative study using semistructured interviews with interpreters working at an academic medical center. All interpreters employed by the medical center were eligible to participate. Interviews were analyzed using thematic analysis. ResultsThe authors interviewed 20 interpreters from 9 languages (mean age: 48 ± 14.3 years; mean experience: 16.3 ± 10.6 years). Two themes regarding the challenges of care delivery to LEP HF patients emerged: 1) LEP patients often had a limited understanding of HF etiology, prognosis, and treatment options, and interpreters cited difficulty explaining HF given the complexity of the subject; and 2) practical steps to improve the discharge process for LEP HF patients. Integrating interpreters into both the inpatient and outpatient HF teams was a strongly supported intervention. Additionally, conducting pre-encounter huddles, providing the interpreter service phone number at the time of discharge, involving family members when appropriate, and considering nutrition referrals were all important steps highlighted by interpreters. ConclusionsThis study illuminates challenges that LEP HF patients face and provides potential solutions to improve care for this vulnerable group. Integrating interpreters as part of the HF team and designing practical discharge plans for LEP HF patients could reduce current disparities.