Heart Failure-related Admissions Research Articles

Predictive Factors of Cardiac Mortality Following TEER in Patients with Secondary Mitral Regurgitation

Background: Transcatheter edge-to-edge mitral valve repair (TEER) has emerged as a viable approach to addressing substantial secondary mitral regurgitation. In the contemporary landscape where ultimate heart failure-specific therapies, such as cardiac replacement modalities, are available, prognosticating a high-risk cohort susceptible to early cardiac mortality post-TEER is pivotal for formulating an effective therapeutic regimen. Methods: Our study encompassed individuals with secondary mitral regurgitation and chronic heart failure enlisted in the multi-center (Optimized CathEter vAlvular iNtervention (OCEAN)-Mitral registry. We conducted an assessment of baseline variables associated with cardiac death within one year following TEER. Results: Amongst the 1517 patients (median age: 78 years, 899 males), 101 experienced cardiac mortality during the 1-year observation period after undergoing TEER. Notably, a history of heart failure-related admissions within the preceding year, utilization of intravenous inotropes, and elevated plasma B-type natriuretic peptide levels emerged as independent prognosticators for the primary outcome (p < 0.05 for all). Subsequently, we devised a novel risk-scoring system encompassing these variables, which significantly stratified the cumulative incidence of the 1-year primary outcome (16%, 8%, and 4%, p < 0.001). Conclusions: Our study culminated in the development of a new risk-scoring system aimed at predicting 1-year cardiac mortality post-TEER.

Lower rate limit in cardiac resynchronization therapy defibrillators

Abstract Background There is few data about programmed lower rate limit (LRL) in real world heart failure (HF) patients with cardiac resynchronization therapy–defibrillators (CRT-Ds) and its influence in clinical outcomes. Heart rate score (HRS) is the percentage of all atrial-paced and sensed events in the single tallest 10 beats/min device histogram bin and may indicate impaired heart rate variability. Purpose We hypothesized that higher LRL programming is associated with worse clinical outcomes as arrhythmic events and HF decompensations in chronic HF patients with CRT-Ds. Methods LRL was evaluated and HRS was calculated from remote monitoring in 126 HF patients with CRT-D. Primary outcome was defined as HF hospitalizations and related admissions to the emergency department and secondary outcome as number of device therapies, sustained ventricular tachycardia (VT) and ventricular fibrillation (VF). Results Mean age was 69,03±10,39 years, 81 (64,3%) were males and mean follow-up was 53,72±46,13 months. Mean left ventricular ejection fraction was 30,31±8,33% and 29 (23,0%) were in NYHA III–IV. HF aetiology was idiopathic in 39 (43,3%), ischemic in 32 (25,4%) and alcoholic cardiomyopathy in 8 (6,3%). Thirty-seven (29,4%) patients had atrial fibrillation and 33 (26,2%) coronary disease. LRL ranged from to 40 to 80 bpm and mean LRL was 52,64±9,64 and mean HRS 49,60±23,17%. Programmed LRL was higher in women (p=0,014), patients with atrial fibrillation (AF) (p=0,012) and coronary disease (p=0,015). Higher LRL correlated with HF hospitalizations and related admissions to the emergency department (ED) (r=0,541, p=0,001), VT or VF episodes (r=0,337, p=0,005) and CRT-D number of therapies (r=0,342, p=0,004) and higher HRS (r=0,547, p<0,05). Conclusion Higher LRL programming was associated with higher HRS, HF decompensations with hospitalization or admission to the emergency department, VT or VF episodes and CRT-D therapies in a real world population. More studies are required but lower LRL may be preferred in HF patients. Funding Acknowledgement Type of funding sources: None.

Reducing Heart Failure Hospitalizations Through Enhancement Of Multidisciplinary Roles And Targeted Patient Oversight

Reducing Heart Failure Hospitalizations Through Enhancement Of Multidisciplinary Roles And Targeted Patient Oversight

Optimal Rhythm Control Strategy in Patients With Atrial Fibrillation.

For almost 20 years, data regarding the effect of rhythm control therapy for atrial fibrillation (AF) on cardiovascular prognosis in comparison with rate control therapy has not been conclusive. The safety of rhythm control and anticoagulation therapy has generally improved. Recently, it was revealed that a rhythm-control strategy reduced the risk of adverse cardiovascular events than usual rate control in patients with recent AF (diagnosed within 1 year). Within 1 year after the AF diagnosis, early initiation of rhythm control led to more favorable cardiovascular outcomes than rate control. Early rhythm control reduced the risks of stroke and heart failure-related admission than rate control. Moreover, rhythm control was associated with lower dementia risk than rate control. Finally, early rhythm control treatment was also effective in patients with asymptomatic AF but less effective in older adults. Therefore, in patients with AF, rhythm control should be considered at earlier stages, regardless of symptom.

Comparative Effectiveness of Early Rhythm Control Versus Rate Control for Cardiovascular Outcomes in Patients With Atrial Fibrillation.

BackgroundRhythm control is associated with better cardiovascular outcomes than usual care among patients with recently diagnosed atrial fibrillation (AF). This study investigated the effects of rhythm control compared with rate control on the incidence of stroke, heart failure, myocardial infarction, and cardiovascular death stratified by timing of treatment initiation.Methods and ResultsWe conducted a retrospective population‐based cohort study including 22 635 patients with AF newly treated with rhythm control (antiarrhythmic drugs or ablation) or rate control in 2011 to 2015 from the Korean National Health Insurance Service database. Propensity overlap weighting was used. Compared with rate control, rhythm control initiated within 1 year of AF diagnosis decreased the risk of stroke. The point estimates for rhythm control initiated at selected time points after AF diagnosis are as follows: 6 months (hazard ratio [HR], 0.76; 95% CI, 0.66–0.87), 1 year (HR, 0.78; 95% CI, 0.66–0.93), and 5 years (HR, 1.00; 95% CI, 0.45–2.24). The initiation of rhythm control within 6 months of AF diagnosis reduced the risk of hospitalization for heart failure: 6 months (HR, 0.84; 95% CI, 0.74–0.95), 1 year (HR, 0.96; 95% CI, 0.82–1.13), and 5 years (HR, 2.88; 95% CI, 1.34–6.17). The risks of myocardial infarction and cardiovascular death did not differ between rhythm and rate control regardless of treatment timing.ConclusionsEarly initiation of rhythm control was associated with a lower risk of stroke and heart failure–related admission than rate control in patients with recently diagnosed AF. The effects were attenuated as initiating the rhythm control treatment later.

Community-based nurse practitioner support is associated with better self-care behaviour and quality of life in patients with chronic heart failure

Objective: To evaluate the effects of a community based chronic heart failure management program, delivered by nurse practitioners, on self-care behaviour, quality of life and hospital readmissions. Background: Chronic heart failure is a complex condition associated with high rates of hospital readmissions. However, many hospitalisations in patients with chronic heart failure are potentially preventable with better self-management and access to specialised healthcare support. Nurse practitioners have an advanced scope of practice, making them well credentialed to support patients with chronic heart failure. Study design and methods: This study compared self-care behaviour and quality of life in patients who had attended a nurse-practitioner led chronic heart failure management service (SmartHeart) (n=58) compared with patients receiving usual care (n=58), but no nurse practitioner support. Self-care behaviour was assessed using the Self Care Heart Failure Index and quality of life was assessed using the Short Form-36 and Minnesota Living with Heart Failure Questionnaire. Hospitalisation records were extracted from medical records using data-linkage. Results: Patients who received nurse-practitioner support had better self-care behaviour (p<0.05), mental component summary of the Short Form-36 (p<0.05) and heart failure specific quality of life (p<0.05). All-cause hospitalisations were delayed (p<0.05) and length of stay was shorter (p<0.05) in the group receiving nurse practitioner support, but there were no differences in chronic heart failure related admissions. Discussion: A chronic heart failure support program, operating in a community setting and delivered by nurse practitioners, enhanced self-care, improved psychosocial health and reduced time in hospital. Conclusion: Chronic heart failure management delivered by nurse practitioners can improve self-care behaviour and quality of life, and reduced hospital admissions, compared with usual care. What is already known about the topic? Chronic heart failure is a complex health issue requiring disease-specific management that needs to be tailored to the individual. However, many patients with chronic heart failure don’t receive adequate support to manage their condition. What does this paper add: A chronic heart failure management service, delivered in primary care by nurse practitioners, improved self-management and quality of life and was associated with a lower rate of hospitalisations compared with usual care alone.

Sacubitil/valsartan in systemic right ventricular failure

Abstract Background In patients with heart failure with low ejection fraction (EF) (≤35%) sacubitril/valsartan is proven to be beneficial. We aimed to assess the effects of sacubitril/valsartan in adult congenital heart disease patients with failing systemic right ventricle (sRV) in the setting of congenitally corrected transposition of the great arteries (TGA) or TGA after atrial switch. Purpose To evaluate the feasibility and effect of treatment with sacubitril/valsartan in patients with heart failure in the setting of a sRV on optimal medical heart failure treatment. Methods Data of patients with sRV failure (estimated RVEF ≤35%) treated with sacubitril/valsartan were analyzed. Patients were clinically evaluated at baseline and at six months after initiation of the highest tolerated dose. Results Fourteen patients completed six-month follow-up thus far, of which 6 female (42.8%) and 2 (14.3%) with congenitally corrected transposition of the great arteries (TGA). After 6 months, 9 patients (64.3%) were using the highest dose (97/103 mg twice daily) of sacubitril/valsartan. NT-proBNP was significantly lower after 3 months and after 6 months compared with baseline (64% of baseline, p=0.006 and 53% of baseline, p=0.001, respectively). The kidney function did not change significantly (creatinine at baseline 83.6±12.0 and at 6 months 88.5±13.87, p=0.141) and serum potassium remained within normal limits (4.28±0.36 and 4.49±0.30, p=0.007). There was no significant decrease in systolic blood pressure (p=0.960). The echocardiographic sRV fractional area change (FAC) improved (p=0.002) and Global Longitudinal Strain (GLS) showed a trend towards improvement (p=0.058). During the 6 months of treatment, the exercise capacity remained stable, there was no increase in diuretic use, no serious adverse events and no heart failure related admissions occurred. Conclusion Treatment of sRV heart failure patients with sacubitril/valsartan leads to a significant reduction in NT-proBNP and significant increase in FAC. All patients remained clinically stable and no heart failure related admissions or serious adverse events occurred. Changes after 6 months Funding Acknowledgement Type of funding source: None

Platelet volume indices correlate to severity of heart failure and have prognostic value for both cardiac and thrombotic events in patients with congenital heart disease

Abstract Introduction Patients with heart failure are reported to have activated platelets leading to thrombotic events. Consequently, immature giant platelets are produced, and platelet distribution width (PDW) and mean platelet volume (MPV) increase. These platelet indices are easily, reasonably, and safely available by routine blood test and recently have been proposed as potential markers of cardiac events. However, little is known about the usefulness of platelet indices in patients with congenital heart disease (CHD). Purpose To test whether the hypothesis that PDW and MPV correlate to the severity of heart failure and have prognostic value in both future heart failure-related admission and thrombosis formation in patients with CHD. Methods We performed a retrospective, single-centre study that included 400 patients with CHD (median age, 34 years [range: 12–76]; 49% males; 35% single ventricular morphology), who were admitted in our institute between April 2014 and June 2017. We reviewed patients' medical records to assess their clinical information including medical history, blood sample data, and echocardiologic parameters. At first, we assessed the correlation between platelet indices and patients' clinical parameters. Next, we compared platelet indices before and after treatment for heart failure. Finally, using logistic regression and Kaplan-Meier analyses, we assessed prognostic factors of future heart failure-related admission and thrombosis formation. Results In multivariate analysis, a significant correlation was found between PDW and logBNP (brain natriuretic peptide) (p&amp;lt;0.001), haemoglobin (p=0.01), D-dimer (p=0.019), Fontan operation (p&amp;lt;0.001) and male sex (p&amp;lt;0.001); as well as between MPV and logBNP (p&amp;lt;0.001), D-dimer (p&amp;lt;0.001) and Fontan operation (p=0.002). Throughout treatment of heart failure, significant reduction was found both in PDW (average value before treatment = 14.2, after treatment = 13.2, p=0.002) and MPV (before = 11.2, after = 10.8, p=0.004). In multivariate logistic regression analysis, predictors of future heart failure-related admissions were PDW (hazard ratio [HR]: 1.365; 95% confidence interval [CI]: 1.005–1.768), MPV (HR: 1.472; 95% CI: 1.055–2.052), age (HR: 1.063; 95% CI: 1.010–1.119), and SpO2 under 85% (HR: 5.089; 95% CI: 1.350–19.18). Using the same analysis, predictors of thrombotic formation were PDW (HR: 1.998; 95% CI: 1.461–2.630), MPV (HR: 1.792; 95% CI: 1.155–2.781), logBNP (HR: 1.196, 95% CI: 1.085–1.320), D-dimer (HR: 1.024; 95% CI: 1.007–1.042) and male sex (HR: 3.071; 95% CI: 1.079–8.737). In addition, during median follow-up of 28 months, the Kaplan-Meier analysis showed an improvement in both heart failure and thrombosis-free survival in the low PDW, as well as the low MPV group. Conclusion Platelet volume indices correlate to severity of heart failure and have prognostic value for both cardiac and thrombotic events in patients with congenital heart disease. Funding Acknowledgement Type of funding source: None

CardioMEMS Device Implantation Reduces Repeat Hospitalizations In A Veterans Affairs Patient Population: A Single Center Experience

Introduction Little is known about the use of a wireless pulmonary artery pressure monitoring device, CardioMEMS, in the Veteran's Affair (VA) patient population. We report our results of the effectiveness of this wireless device in reducing heart failure re-admissions in the largest known VA patient cohort. Methods We retrospectively analyzed all patients with heart failure-related admissions pre- and post-implantation of their CardioMEMS device. Results A total of 63 patients (93% male, 44% Caucasian and 54% HFrEF), with NYHA Class 3 HF were followed for 12 months. At device implantation, average pulmonary artery systolic/ diastolic /mean pressures were 51/24/34 mgHg while at 6 months were 45/22/31 mmHg and 12 months were 43/21/29 mmHg. The total number of heart failure hospital admissions for patients who were followed for 12 months prior to device implantation was 130, while the total number for the post-implantation period was 57. Post implant patients had 0.47 times the rate of heart failure hospitalizations compared to pre-implant patient (95% CI: 0.31, 0.70; p-value Conclusion In the largest patient population at a VA real-world setting, the implantation of a CardioMEMS results in decreased pulmonary artery pressures and decreased heart failure re-admissions. Further studies are needed to confirm these preliminary findings.

Skeletal muscle index determined by bioelectrical impedance analysis is a determinant of exercise capacity and a prognostic predictor in patients with congenital heart disease

BackgroundPatients with congenital heart disease (CHD) reportedly have reduced exercise capacity. Underlying cardiac anatomy and a sedentary lifestyle are thought to be associated with exercise impairment. However, little has been reported regarding the relationship between quantitative body composition and exercise capacity. Bioelectrical impedance analysis (BIA) is a rapid and safe assessment method that has been widely used in clinical research. We hypothesized that bioelectrical impedance parameters are determinants of exercise capacity, and the skeletal muscle index (SMI) determined by BIA is a prognostic predictor in patients with CHD. MethodsWe conducted a retrospective single-center study of 305 consecutive patients with CHD [median age, 26 years (range 12–60]; 48% males] admitted between 2014 and 2017. The BIA parameters were reviewed, including the edema index (EI, extracellular water to total body water ratio), SMI (skeletal muscle mass/height2), mineral index (MI, mineral mass/height2), percent body fat (%BF), and exercise capacity [peak oxygen uptake (peakVO2)] via a cardiopulmonary exercise test. ResultsThe multivariate analysis revealed a significant correlation between peakVO2 and EI (r=0.55) and peakVO2 and SMI (r=0.49). The receiver operating characteristic curve analysis showed that the EI cut-off for peakVO2<20ml/kg/min was 0.386 [area under the curve (AUC), 0.77; sensitivity, 0.67; specificity 0.76], and the SMI cut-off was 7.6kg/m2 (AUC, 0.78; sensitivity, 0.76; specificity 0.75). Compared with patients who had biventricular morphology, patients with single ventricular morphology had a higher EI (mean, 0.381 vs. 0.387, respectively) and lower SMI (8.5 vs. 7.7, respectively), resulting in a lower peakVO2 (27.1 vs. 20.8, respectively). The Kaplan–Meier analysis showed that a low SMI was associated with an increased risk of future heart failure-related admissions. ConclusionsSMI determined by BIA is a determinant of exercise capacity and can be used as a prognostic predictor in patients with CHD.

P6471Pronostic impact of significant valvular disease in long-term survivors of out-of-hospital-cardiac arrest

Abstract Background There is scarce evidence about the prevalence and clinical relevance of moderate to severe valvular heart disease (VHD) in survivors of out of hospital cardiac arrest (OHCA). Purpose To determine whether VHD influence prognosis of OHCA survivors. Methods All consecutive patients admitted to the Acute Cardiac Care Unit after OHCA and surviving until hospital discharge were included. All patients received targeted-temperature management according to our local protocol. Univariate and multivariate Cox-proportional hazard models were employed. Results A total of 201 patients were included in the analysis. Mean age was 57.6±14.2 years and 168 (83.6%) were male. Eighteen patients (9.0%) had moderate or severe VHD during index admission (Table 1). Patients with VHD were less frequently of male sex, [11 (61.1%) vs 157 (85.8%), p=0.014], experienced less acute coronary syndrome-related arrhytmias [2 (11.1%) vs 85 (46.5%), p=0.005], and had a lower pH at hospital admission (6.9±1.6 vs 7.2±0.15, p=0.008). During a median follow-up of 40.3 (18.9–69.1) months, patients with VHD showed higher mortality [7 (38.9%) vs 28 (15.3%), p=0.004] and more heart failure-related admissions [7 (38.9%) vs 15 (8.2%), p&lt;0.001]. Only five patients received surgical or percutaneous treatment for VHD during follow-up, with no deaths in this subgroup. Moderate or severe VHD proved to be an independent predictor of global cardiovascular events and specifically heart failure episodes (Figure 1). Table1 Variable With valvular disease Without valvular disease p value Age, mean±DS, years 63.5±13.2 57.0±14.1 0.066 Hypertension, n (%) 12 (66.7) 95 (51.9) 0.231 Diabetes, n (%) 5 (27.8) 24 (13.1) 0.149 Dyslipidaemia, n (%) 7 (38.9) 79 (43.2) 0.726 Smokin habit, n (%) 4 (22.2) 90 (49.2) 0.045 Witnessed cardiac arrest, n (%) 18 (100) 175 (95.6) 1.000 Time from CA to ROSC, mean±DS, minute 19.1±7.5 21.2±13.1 0.506 Shockable rhythm, n (%) 13 (72.2) 163 (89.1) 0.055 LVEF at hospital discharge (%) 42.8±12.1 46.9±14.6 0.254 Figure 1 Conclusion The presence of significant VHD in survivors after OHCA is a predictor of poor outcomes. Specific management of VHD may be specially relevant in this high-risk patients and guideline-oriented therapy, including surgery and percutaneous intervention should be encouraged when indicated.

P769Quality of life in outpatients with heart failure in relation to mortality and admissions for heart failure

Abstract Studies report relation between quality of life and outcome. However, less is known about how various aspects of quality of life relates to mortality and admissions for heart failure. Method Mortality was examined in 7001 patients with completed Minnesota Living with Heart Failure Questionnaire (MLWHFQ) at the first visit to specialised hospital outpatient clinics included in our registry. A subset of 4264 patients with a second MLWHFQ at a late follow-up visit was assessed for the number of admissions and days in hospital for reason of heart failure during a six months period prior to the late visit. Results In multivariate Cox proportional hazard regression model for time to death after the first visit with a median 19 months follow-up and 1001 deaths, the MLWHFQ score for the subset of the “physical domain” (question 2 to 9) was a significant independent predictor for mortality (P=0.002) adjusted for gender, NYHA-class, blood pressure, s-sodium, stroke, obstructive lung disease, eGFR, anemia, age, daily dose diuretic, and ischemic cause for heart failure. The total MLWHFQ score and the Minnesota “emotional domain” (question 17–21) were not significant variables when the MLWHFQ “physical domain” was entered in the analysis. The number of admissions for heart failure and the number of days in hospital for these admissions in a six months period prior to the late visit were analysed by linear regression for related variables. The total MLWHFQ score at the late visit was highly significant for the number of admissions in the six months period (p&lt;0.001) adjusted for the daily dose diuretic, NYHA functional class and proBNP. The MLWHFQ “physical domain” and the MLWHFQ “emotional domain” were not significant variables when the total score was entered. The number of days in hospital was related to the daily dose diuretic, NYHA functional class, proBNP, and in addition anaemia at the late visit again with the MLWHFQ total score being a significant predictor (=0.001) Conclusions Disease specific quality of life measured with MLWHFQ “physical domain” was a highly significant predictor for mortality after the first visit. The late total MLWHFQ score was a better predictor for heart failure related admissions and days in hospital than the subset domains in multivariate analysis. Acknowledgement/Funding None

First hospital admission due to heart failure: In-hospital mortality and patient profile

ObjectivesWe evaluated the patient profile and outcomes of first heart failure (HF) related hospital admission patients in the 2010–2014 period. DesignRetrospective, single-center, cohort study. SettingWe used administrative data from a tertiary care hospital (Hospital Universitari de Bellvitge, Barcelona, Spain). ParticipantsAll patients with primary diagnosis of HF registered at the hospital discharge database from 2010 to 2014 were included, ruling out that HF was present 10 years prior to the current episode. InterventionPrimary care HF diagnosis status was assessed in order to distinguish new onset from no-new onset patients. Main measuresDescriptive, bivariate and multivariate analysis were performed using age, previous primary care HF diagnosis and in-hospital death as grouping variables. Significant variables were fitted into a Linear logistic regression model for each outcome. ResultsWe selected 3868 first HF-related admissions (56.8% of all HF episodes). In 1220 patients (31.7%) HF was diagnosed by their primary care physician. Main pattern was a woman (OR=2.4), with higher prevalence of hypertension (OR=1.7), atrial fibrillation (OR=1.3), chronic kidney disease (OR=1.6) and mortality rate (9.8%). In-hospital death rate was 5.8%, age over 85 (OR=5.57), chronic kidney disease (OR=1.44) and length of stay over 7 days (OR=1.90) being the main contributors. ConclusionsFirst HF related admissions account for 56.7% of all HF episodes. Roughly one third of patients were already diagnosed by the time of their first hospital admission. Elderly women were the most frequent, but not the only, group of patients. Age, hospital stay and chronic kidney disease were the main contributors for in-hospital death.

CardioMems® device implantation reduces repeat hospitalizations in heart failure patients: A single center experience.

IntroductionHospital readmission for congestive heart failure remains one of the most important economic burdens on healthcare cost. The implantation of a wireless pressure monitoring device (CardioMEMS®) had led to nearly 40% reduction in readmission rates in the landmark CHAMPION trial. We aim to study the effectiveness of this wireless device in reducing heart failure admissions in a real-world setting.MethodsThis is a retrospective chart review of patients with recurrent admissions for heart failure implanted with the wireless pressure monitoring system (CardioMEMS®) at our institution. We studied the total number of all-cause hospital admissions as well as heart failure-related admissions pre- and post-implantation.ResultsA total of 27 patients were followed for 6–18 months. The total number of all-cause hospital admissions prior to device implantation was 61 admissions for all study patients, while the total number for the post-implantation period was 19, correlating with 2.26 + 1.06 admissions/person-year prior to device implantation versus 0.70 + 0.95 admissions/person-year post-implantation (p-value < 0.001). For heart failure-related admissions, the total number prior to device implantation was 46 compared to 9 admissions post device implantations, correlating with 1.70 + 1.07 admissions/person-years pre-implantation versus 0.33 + 0.62 admissions/person-years post-implantation (p-value < 0.001). This translates to 80.4% and 68.9% reduction in heart failure and all-cause admissions, respectively.ConclusionIn a real-world setting, the implantation of a wireless heart failure monitoring system in patients with heart failure and class III symptoms has resulted in 80.4% reduction in heart failure admissions and 69% reduction in all-cause admissions.

Primera hospitalización por insuficiencia cardiaca: mortalidad hospitalaria y perfil del paciente

ObjectivesWe evaluated the patient profile and outcomes of first heart failure (HF) related hospital admission patients in the 2010-2014 period. DesignRetrospective, single-centre, cohort study. SettingWe used administrative data from a tertiary care hospital (Hospital Universitari de Bellvitge, Barcelona, Spain). ParticipantsAll patients with primary diagnosis of HF registered at the hospital discharge database from 2010 to 2014 were included, ruling out that HF was present 10 years prior to the current episode. InterventionPrimary care HF diagnosis status was assessed in order to distinguish new onset from no-new onset patients. Main measuresDescriptive, bivariate and multivariate analysis were performed using age, previous primary care HF diagnosis and in-hospital death as grouping variables. Significant variables were fitted into a Linear logistic regression model for each outcome. ResultsWe selected 3,868 first HF-related admissions (56.8% of all HF episodes). In 1,220 patients (31.7%) HF was diagnosed by their primary care physician. Main pattern was a woman (OR=2.4), with higher prevalence of hypertension (OR=1.7), atrial fibrillation (OR=1.3), chronic kidney disease (OR=1.6) and mortality rate (9.8%). In-hospital death rate was 5.8%, age over 85 (OR=5.57), chronic kidney disease (OR=1.44) and length of stay over 7 days (OR=1.90) being the main contributors. ConclusionsFirst HF related admissions account for 56.7% of all HF episodes. Roughly one third of patients were already diagnosed by the time of their first hospital admission. Elderly women were the most frequent, but not the only, group of patients. Age, hospital stay and chronic kidney disease were the main contributors for in-hospital death.

An assessment of the UK inpatient care for heart failure patients with diabetes.

Diabetes is a common co-morbidity for patients with heart failure. Diabetes as a co-morbidity means that inpatient care should focus on both conditions to maximize the treatment regimen. However, this pressing issue is not widely researched and so it is unclear whether the acute care management needs of these patients are being met. (1) To assess the differences in the number of hospital readmissions between patients with heart failure and patients with heart failure-diabetes; (2) to assess the use of integrated care approach for patients with heart failure-diabetes during the index heart failure-related admission; (3) to explore patient experiences of admissions. A mixed methods design was used: we identified heart failure-related admissions between 1 April 2011 and 31 March 2012 in two hospitals, then reviewed medical records and interviewed 14 patients. Over a 12 month period patients with heart failure-diabetes ( n=172) had more heart failure-related Accident and Emergency attendance episodes (incident rate ratio 1.24, p<0.01) and hospital readmissions (incident rate ratio 1.23, p=0.01) than patients with heart failure ( n=370). We reviewed 72 medical records which met inclusion criteria (adults with heart failure-diabetes, ejection fraction <45%): during admission most of them were reviewed by heart failure specialists but less than one-third were reviewed by diabetes specialists. The interview respondents addressed the need for better integration and co-ordination of care. This is one of the first UK studies to assess the integration of inpatient care for those with heart failure and multi-morbidities. The findings suggest that maximal care management during admission should be explored as a way of reducing the frequent readmissions and improving patient outcomes.

Association of Abnormal Liver Function Tests to Outcomes in Patients with a New Diagnosis of Heart Failure with Reduced Ejection Fraction in the Outpatient Clinic

Aim: To evaluate the relationship of abnormal Liver Function Tests (LFTs) to outcomes in patients with heart failure due to reduced ejection fraction (HFREF) at the time of diagnosis in the heart failure clinic. Methods: We undertook a retrospective analysis of all patients diagnosed with HFREF in the heart failure outpatient clinic of a tertiary teaching hospital from 2007 to 2011. Ninety-five patients with abnormal LFTs at presentation were compared with 127 contemporaneous randomly chosen patients with normal LFTs and their outcomes were analyzed. Time to event data mortality and admission rates, as well as length of hospital stay during admissions were assessed. Results: Of 222 patients 69% were Male. The mean age across both the groups was 69.2 ± 13.2 years. The major ethnic group was of white background (78%). Majority of patients were in NYHA class 2 (54.5%). On multivariate analysis, low albumin at the time of diagnosis was the strongest predictor of all cause death (OR 1.24, 95% CI 1.15-1.35, p<0.0001). Patients in the abnormal LFT group had a longer in-hospital stay compared to those in the normal LFT group (25.9 ± 29.1 days vs. 17.2 ± 20.5 days, p=0.01). Low albumin and elevated alkaline phosphatase (ALP) were the strongest predictors of increased length of in-hospital stay following heart failure related admissions on multivariate analysis (OR -0.583, CI -1.119, -0.046, p=0.035 and OR 0.033, CI 0.005, 0.061, p=0.02, respectively). Every unit increase of albumin resulted in reduction of in hospital stay by 0.875 days. Time to event analysis showed more deaths in the abnormal LFT group when compared to the normal LFT group (log rank test p=0.012). Although an elevated ALP was seen to be associated with readmission, multivariate analysis found this to be a trend only, with none of the LFTs being predictive. Conclusion: Abnormal LFTs in the outpatient setting in patients with HFREF was associated with higher mortality in this study. Low Albumin was independently associated with mortality and length of hospital stay due to heart failure. An elevated alkaline phosphatase also seems to be important in predicting length of stay in hospital. Triaging acute heart failure patients due to Left Ventricular Systolic Dysfunction (LVSD) using abnormal LFTs as biomarkers for more intensive treatment and monitoring would seem advisable. However, this is a retrospective analysis of a relatively small number of patients and the conclusions must be seen in that light.

261 - Application of a Multi-Disciplinary Approach to Reduce Heart Failure Readmissions in the Post-Acute (Home Care) Setting

Background/Objective: American Outcomes Management's (AOM) Heart Failure (HF) program was designed to support national quality initiatives focused on reducing the rate of HF readmissions. The guidelines to lowering readmission rates called for (1) implementation of HF specific quality improvement efforts and performance monitoring, (2) medication management and (3) implementation of sound transitional practices for effective discharge and follow-up processes. The objective of this program is to validate the importance of utilizing multi-disciplinary approach for early symptom recognition of decompensating heart failure and implementing timely interventions to prevent re-admissions. Methods: Data was obtained from 77 patients treated by the pharmacy between June 2013 and September 2015. Data included 30 day re-admissions for HF and non-HF related admissions, all cause re-admissions, all-cause mortality, HF mortality, and improvements in both Karnofsky (KPS) and Minnesota Living with Heart Failure Questionnaire (MLWHFQ) 30 days from Start of Care (SOC). We utilized a comparative outcomes database correlating real time services rendered with health-related quality of life (HR-QoL) and functional status. Results: Results show 6 out of 77 patients (7.8%) with a heart failure related admissions (HFRA) and 13 out of 77 patients with an all cause related admissions (ACRA) in the two year period of the program as shown in the tables 1 and 2 below. The average Karnofsky Performance went from 65 at start of care (SOC) to 72 at 30 days (11% improvement) while the Minnesota Living with Heart failure (MLWHFQ) score went from 78 at SOC to 36 at 30 days (54% improvement). The combination of implementing sound transitional care practices, utilizing CHFNs, incorporating a MNT and HF dedicated pharmacists in HF care validates the importance of utilizing a multi-disciplinary approach for early symptom recognition of decompensating heart failure and completing critical assessments to avoid treatment failures, implement timely interventions to prevent re-admission and formulate effective teaching plans for inotrope patients in the post-acute care (home care) setting. This approach allowed AOM, prescribers, patients and caregivers to address and answer questions regarding transitional care readmission risk to yield the best clinical outcomes for patient management. Conclusions: Utilizing a multi-disciplinary approach in application of expert consensus endorsed measures plays an important role in reducing HF re-admissions and optimizing functional status and HR-QoL in patients with advanced heart failure on inotrope therapy in the post-acute (home care) setting.

Tenckhoff Catheter Implantation In Refractory Ascites Due To Right Heart Failure

Tenckhoff catheter implantation and modified peritoneal dialysis as a novel therapeutic approach in diuretic resistant congestive heart failure: a single-centre case-series.Background: Progressive renal insufficiency and diuretic resistance represent significant challenges in the management of advanced heart failure, particularly in the context of intractable ascites due to Right Heart Failure (RHF). There is growing interest in the potential use of intermittent paracentesis and peritoneal dialytic ultra-filtration in this setting but clinical experience is limited.Methods: We undertook retrospective analysis of changes in the following clinical parameters in six patients (66% males, average age 53 years) who underwent Tenckhoff catheter implantation (TCI) for the management of RHF-related intractable ascites i) body weight; ii) number of heart failure related admissions and time spent in hospital; and iii) diuretic requirements. Student t-test was performed to analyse statistical significance.Results: Follow-up ranged from 4 to 16 weeks post TCI. Compared to immediately prior to TCI: i) 83% (5/6) of patients experienced an improvement in renal function; ii) average weight fell from 72.2 + 4.7 to 67.7 + 3.9 kg (mean + SEM, p = 0.054); iii) none of the patients have required heart failure related admission compared to an average number of 40 days in hospital over 6.7 admissions in the twelve months preceding TCI and iv) frusemide dose decreased from 263 + 49 to 140 + 50 mg/day, p = 0.051). All patients report a subjective improvement in overall wellbeing and quality of life. One patient developed peritonitis which was controlled with antibiotic treatment without needing catheter removal.Conclusion: Our experience supports the use of TCI as a therapeutic modality in patients with RHF and intractable ascites resistant to medical management.

Chronic Heart Failure Management in Rural Primary Care.

Background: Heart failure has been identified as a diagnosis associated with significant morbidity and mortality with inconsistent outcomes. As of October 1, 2012, the Centers for Medicare and Medicaid Services (CMS) began reducing payments to penalize hospitals for excessive heart failure readmissions and publicly reporting readmission rates. The rationale for the reduction in payments is that many heart failure-related admissions could have been prevented through improved outpatient management. In 2013, Medicare reimbursement cuts were applied to critical access hospitals. This most recent decrease in reimbursement to critical access hospitals paired with lack of reimbursement for heart failure related 30-day hospital readmissions provided the basis for implementing a heart failure management program. Participants: Thirteen adult patients, older than the age of 19 years, voluntarily participated in the heart failure management program in a rural primary care clinic located in the Midwest. Methods: The project was a quality improvement design. A chronic heart failure management program was implemented using the American Heart Association and the Institute for Health Care Improvement guidelines for heart failure management. Educational resources with monitoring logs for weights and symptoms were provided to each patient at the initial visit. Nursing staff filled out a heart failure flow sheet at each heart failure-related visit, and each patient who presented was then contacted 1 month from his or her initial visit date to discuss patient concerns. Results: Of the 13 individuals who presented for the initial visit, 11 had the flow record completed. One patient came in for subsequent visits because of changes in medications and follow-up. The flow record was filled out entirely on these 2 subsequent visits. There were 2 heart failure admissions during the 12-week implementation period, and neither were readmissions. Both patients followed up within 1 week of hospital discharge. There were no heart failure readmissions during the 12-week implementation period. Discussion: The findings of this project support the long-term feasibility of a chronic heart failure management program.