Heart Failure-related Rehospitalization Research Articles

Improving adherence to rehabilitation for heart failure patients through immersive virtual reality (VIRTUAL-HF): A protocol for a randomized controlled trial

BackgroundTo improve symptoms and reduce poor outcomes related to heart failure (HF), international guidelines recommend cardiac rehabilitation (CR), particularly for those with a reduced ejection fraction. Unfortunately, patient adherence to rehabilitation programs remains suboptimal, with dropouts ranging from 15.4 to 63.3%. An innovative and promising intervention that could improve adherence to rehabilitation is virtual reality (VR). This study aims to evaluate the effects of VR in patients with HF who undergo CR using this technology in terms of adherence (primary outcome), functional capacity, perceived exertion, angina, quality of life, heart rate, oxygen saturation, blood pressure, maximum oxygen uptake, minute ventilation/carbon dioxide production slope, oxygen pulse, blood values of NT-proBNP and HF related rehospitalization rates (secondary outcomes). MethodsA randomized controlled trial will be conducted in a sample of 80 patients referred to CR. Participants will be enrolled in a cardiological rehabilitation unit of a large university hospital in Italy and randomized (1:1) to the experimental intervention consisting of CR performed with high-quality immersive VR with PICO 4® Head Mounted Display headset and TREADMILL XR® software (Arm 1) or standard CR (Arm 2). Patients, according to guidelines, will perform 30-min of CR sessions with moderate intensity, twice a week for one month. ResultsSignificant improvements in primary and secondary outcomes are expected in patients in the intervention group. ConclusionsIf proven to be effective, VR could be an innovative, safe, and easy digital health intervention to improve adherence to CR in patients with HF, as well as important clinical outcomes.

The prevalence and prognostic impact of aortic valve diseases in heart failure with mildly reduced ejection fraction

Abstract Objective This study aims to investigate the prevalence and prognostic value of aortic valve diseases in patients hospitalized with heart failure with mildly reduced ejection fraction (HFmrEF). Background Limited data regarding the prognostic impact of aortic valve diseases in patients with HFmrEF is available. Methods A large retrospective study was used including all consecutive hospitalized patients with HFmrEF (i.e., left ventricular ejection fraction (LVEF) 41 – 49%) from 2016 to 2022 according to current European guidelines. The prognostic impact of moderate to severe aortic valve stenosis (AS) and aortic valve insufficiency (AI) was compared to patients without (i.e., non-AS and non-AI, respectively). The primary endpoint was the first heart-failure related re-hospitalization at 3 years. Secondary endpoints comprised amongst others in-hospital mortality. Kaplan-Meier, uni- and multivariable Cox regression analyses were applied for statistics. Results 800 consecutive patients with HFmrEF were included. The prevalence of AS was 10% (moderate 6% and severe 4%) and AI 8% (moderate 7% and severe 1%). The risk of first heart-failure related hospitalization was not significantly affected by the presence of AS (14% vs. 8%; log rank p=0.092; HR= 1.727; 95% CI 0.908 - 3.284; p=0.096), however, HFmrEF patients with moderate to severe AI were associated with an increased risk of heart-failure related re-hospitalization compared to patients without (18% vs. 8%; log rank p=0.010; HR= 2.270; 95% CI 1.193 - 4.317; p=0.012). Even after multivariable adjustment, the risk of heart failure related re-hospitalization was still significantly higher in patients with moderate to severe AI (HR= 2.022; 95% CI 1.030 - 3.969; p=0.041). Finally, patients with moderate or severe AS and patients with moderate or severe AI revealed no significant difference of in-hospital mortality (4% vs. 3%; p=0.807 and 3% vs. 3%; p=0.946). Conclusions In patients hospitalized with HFmrEF between 2016 and 2022, patients with moderate to severe AI – but not AS – had a higher risk of heart failure related re-hospitalization at 3 years.

Are heart failure patients with mildly reduced ejection fraction treated according to current international guidelines?

Abstract Objective This study aims to investigate the guideline adherence and prognostic role of guideline recommended heart failure (HF) therapies in patients hospitalized with heart failure with mildly reduced ejection fraction (HFmrEF). Background Limited data regarding the guideline adherence and prognostic impact of different pharmacotherapies in patients with HFmrEF is available. Methods A large retrospective study was used including all consecutive hospitalized patients with HFmrEF (i.e., left ventricular ejection fraction (LVEF) 41 – 49%) from 2016 to 2022 according to current European guidelines. The prescription rates and the prognostic role of angiotensin-converting enzyme and receptor blockers (ACEi/ARB), beta-blockers (BB), mineralocorticoid receptor antagonists (MRA), sodium glucose linked transporter 2 inhibitors (SGLT2i) and angiotensin receptor-neprilysin inhibitor"(ARNi) was assessed. The primary endpoint was the first heart-failure related re-hospitalization at 3 years. Secondary endpoints comprised amongst others cardiovascular re-hospitalization. Kaplan-Meier, uni- and multivariable Cox regression analyses were applied for statistics. Results 775 consecutive patients with HFmrEF surviving index hospitalization were included. Of those, 73% were discharged on ACEi/ARB, followed by BB (26%), 14% MRA, whereas only minor part was treated with SGLT2i (3%). In HFmrEF patients, no prognostic impact of BB (10% vs. 7%; log rank p=0.218; HR=1.474; 95% CI 0.792-2.742; p=0.220), ACEi/ARB (9% vs. 10%; log rank p=0.444; HR=0.822; 95% CI 0.497-1.359; p=0.445), SGLT2i (8% vs. 9%; log rank p=0.821; HR=0.851; 95% CI 0.209-3.470; p=0.445), MRA (8% vs. 9%; log rank p=0.748; HR=0.892; 95% CI 0.443-1.794; p=0.748) regarding the risk of heart-failure related re-hospitalization at 3 years was observed. In line, these pharmacotherapies were not associated with the risk of cardiovascular re-hospitalization. Conclusions In patients hospitalized with HFmrEF between 2016 and 2022, only infrequent treatment with guideline recommended HF therapies was observed, whereas non of the current HF therapies was associated with the risk of heart-failure related rehospitalization.

Outcomes of Upgrading to LBBP in CRT Nonresponders: A Prospective, Multicenter, Nonrandomized, Case-Control Study

BackgroundCardiac resynchronization therapy (CRT) nonresponders account for nearly 30% of CRT candidates. Left-bundle branch pacing (LBBP) is an alternative to CRT. ObjectivesThis study aimed to evaluate the feasibility, clinical efficacy, and outcomes of upgrading to LBBP in CRT nonresponders, using propensity-score matching (PSM) analysis. MethodsCRT nonresponders were defined as those with an implantable CRT-pacemaker or CRT-defibrillator for more than 12 months who remained nonresponsive (a decrease in left ventricular end-systolic volume of <15% or a left ventricular ejection fraction [LVEF] absolute increase of <5%) after optimal medical therapy and device optimization compared with baseline. In total, 145 CRT nonresponders were prospectively enrolled and randomly divided into 2 groups: upgraded to LBBP (n = 48), and continuing biventricular pacing (BVP) (control; n = 97). PSM was performed at a 1:1 ratio, and clinical evaluation and echocardiographic assessments were compared at baseline and follow-up in paired cohorts. The primary composite endpoint for clinical outcomes (heart failure-related rehospitalization events, all-cause death, or heart transplantation) was analyzed. ResultsSuccessful upgrading to LBBP was achieved in 48/49 patients (97.96%), with a significant decrease in QRS duration (P < 0.001). In the paired LBBP group, LVEF significantly increased (baseline: 29.75% ± 7.79%; 6 months: 37.78% ± 9.25% [P < 0.001]; 12 months: 38.84% ± 12.13% [P < 0.001]) with 21/44 patients (47.73%) classified as echocardiographically responsive, whereas in the BVP control group, no significant improvement was observed (29.55% ± 6.74% vs 29.22% ± 8.10%; P = 0.840). In a multivariate logistic regression model, LV end-diastolic volume and baseline LBBB QRS morphology were independent predictors of echocardiographic response after upgrading to LBBP. At a median 24 months, the primary composite endpoint was significantly lower in the LBBP group (HR: 0.31; 95% CI: 0.14-0.72; log-rank P = 0.007). ConclusionsUpgrading to LBBP is feasible and effective in achieving significant heart function improvement and better clinical outcomes in CRT nonresponders, making it a reasonable and promising pacing strategy. (LBBP in CRT Non-Response patients; ChiCTR1900028131)

New insights in acute heart failure

Acute heart failure (AHF) is a clinical complex disease and a worldwide issue due to its inconsistent diagnosis and poor prognosis. The cornerstone of pathophysiology of AHF is systemic venous congestion, which is led by the underlying structural and functional cardiac condition. Systemic venous congestion is a major target for AHF management because it causes symptoms and organs dysfunction, and is associated with poor prognosis. The mainstay of decongestive therapy is diuresis with intravenous loop diuretics combined with other diuretics including thiazides when necessary, and non-invasive ventilation. The presence of unresolved congestion at discharge can lead heart failure related rehospitalization, and careful follow-up is required especially during “vulnerable phase”, several months after discharge. The updated recommendation for management of AHF has been provided by latest guidelines from European Society of Cardiology and American Heart Association/American College of Cardiology/Heart Failure Society of America. Several large studies have currently demonstrated the benefits of guideline-directed oral medical therapies, and trials are ongoing on medication such as selective sodium-glucose transport proteins 2 inhibitors and protocols for congestive therapy. This review aimed to summarize the latest insights in AHF, based primarily on the most recent guidelines and large randomized controlled trials.

Performance of advanced machine learning algorithms overlogistic regression in predicting hospital readmissions: A meta-analysis

ObjectivesMachine learning algorithms are being increasingly used for predicting hospital readmissions. This meta-analysis evaluated the performance of logistic regression (LR) and machine learning (ML) models for the prediction of 30-day hospital readmission among patients in the US. MethodsElectronic databases (i.e., Medline, PubMed, and Embase) were searched from January 2015 to December 2019. Only studies in the English language were included. Two reviewers performed studies screening, quality appraisal, and data collection. The quality of the studies was assessed using the Quality in Prognosis Studies (QUIPS) tool. Model performance was evaluated using the Area Under the Curve (AUC). A random-effects meta-analysis was performed using STATA 16. ResultsNine studies were included based on the selection criteria. The most common ML techniques were tree-based methods such as boosting and random forest. Most of the studies had a low risk of bias (8/9). The AUC was greater with ML to predict 30-day all-cause hospital readmission compared with LR [Mean Difference (MD): 0.03; 95% Confidence Interval (CI) 0.01–0.05]. Subgroup analyses found that deep-learning methods had a better performance compared with LR (MD 0.06; 95% CI, 0.04–0.09), followed by neural networks (MD: 0.03; 95% CI, 0.03–0.03), while the AUCs of the tree-based (MD: 0.02; 95% CI -0.00-0.04) and kernel-based (MD: 0.02; 95% CI 0.02 (−0.13–0.16) methods were no different compared to LR. More than half of the studies evaluated heart failure-related rehospitalization (N = 5). For the readmission prediction among heart failure patients, ML performed better compared with LR, with a mean difference in AUC of 0.04 (95% CI, 0.01–0.07). The leave-one-out sensitivity analysis confirmed the robustness of the findings. ConclusionMultiple ML methods were used to predict 30-day all-cause hospital readmission. Performance varied across the ML methods, with deep-learning methods showing the best performance over the LR.

Safety and efficacy of ultrafiltration versus diuretics in patients with decompensated heart failure: A systematic review and meta-analysis

BackgroundUltrafiltration (UF) is used for fluid removal patients with acute decompensated heart failure with reduced ejection fraction (HFrEF) refractory to diuretics. However, data on the relative merits of UF and diuretics are limited. MethodsOnline databases were queried to identify clinical trials on the comparison of UF and diuretics. The major adverse cardiovascular (MACE) and its components (mortality and re-hospitalizations) were compared using the random-effects model to calculate the unadjusted odds ratio (OR) with its 95% confidence interval (CI). ResultsA total of 10 clinical trials comprising 838 patients (413 UF, 425 diuretics) were included in the analysis. At a median follow-up of 90 days, there was no significant difference in the odds of MACE (OR 0.71, 95% CI 0.47–1.07) and all-cause mortality (OR 1.08, 95% CI 0.77–1.52) between patients undergoing UF compared with those receiving diuretics therapy. The need for emergency department visits (OR 1.05, 95% CI 0.38–2.90), all-cause admissions (OR 0.97, 95% CI 0.72–1.30) and heart failure-related re-hospitalization (OR 0.47, 95% CI 0.21–1.02) was also similar between the two groups. The in-hospital risk for hypotension (OR 0.49, 0.23–1.04) and post-therapy creatinine rise>0.3 mg/dL (OR 1.18, 95% CI 0.74–1.89) was also not significantly different between the UF and diuretics arms. A sensitivity analysis of MACE and mortality did not show any deviation from the pooled outcomes. ConclusionsIn patients with HFrEF, UF appears to be safe but might not provide significant benefits in terms of reducing the risk of mortality or readmission rates compared with those treated with diuretics.

Human epididymis protein 4: a novel predictor of ischemic cardiomyopathy

BackgroundThe prognostic value of human epididymis protein 4 (HE4) in patients with ischemic cardiomyopathy (ICM) is unknown.MethodsA total of 103 patients with ICM were prospectively enrolled in this study from Hunan Provincial People’s Hospital between February 2019 and June 2019. All patients were tested for HE4 levels at baseline and follow-up. Endpoints of the study included cardiovascular death and heart failure-related hospitalization.ResultsA total of 96 patients with ICM were included for analysis. After a mean follow-up period of 263 (153–313) days, cardiovascular events were observed in 45 patients. Serum HE4 levels in patients with events were significantly higher than those in patients without events [188.70 (113.35–326.82) pmol/L versus 92.90 (61.50–123.20) pmol/L, P < 0.001]. Multivariate Cox regression analysis revealed that HE4 [χ2: 9.602, hazard ratio (HR): 1.003, 95% confidence interval (CI): 1.001–1.005, P = 0.002] and age [χ2: 4.55, HR: 1.044, 95% CI: 1.003–1.085, P = 0.033] were independent predictors of events. After adjusting for age and sex, the risk of events in patients with HE4 > 100.2 pmol/L was higher than that in patients with HE4 ≤ 100.2 pmol/L [HR: 3.372, 95% CI: 1.409–8.065, P < 0.001].ConclusionHE4 is an independent predictor of cardiovascular death and heart failure-related rehospitalization in patients with ICM.

Association of Soluble ST2 Serum Levels With Outcomes in Pediatric Dilated Cardiomyopathy

BackgroundPrognosis in patients with pediatric dilated cardiomyopathy (PDCM) is urgently required to identify high-risk patients. Elevated soluble ST2 (sST2) is associated with prognosis in adult patients with heart failure. This study aimed to assess the prognostic value of sST2 in PDCM. MethodsNinety-four patients with PDCM were enrolled after admission from 2 centres in China and followed up for adverse events (death, cardiac transplantation, and heart-failure–related rehospitalization). B-type natriuretic peptide (BNP) and sST2 levels were measured. ResultsOver a median of 678 (interquartile range [IQR]: 533-785) days, 28 (29.8%) adverse events occurred. Patients in the highest tertile of sST2 levels had increased risk of short-term (< 6 months) (adjusted hazard ratio [HR]: 8.36, 95% confidence interval [CI], 1.02-73.52; P < 0.05) and long-term adverse events (2 years) (adjusted HR: 4.23; 95% CI, 1.32-13.60; P < 0.01) than those in lower tertiles. The C-statistic was increased with addition of sST2 to BNP from 0.697 (95% CI, 0.541-0.852) to 0.812 (95% CI, 0.697-0.939) for short-term and from 0.712 (95% CI, 0.604-0.819) to 0.798 (95% CI, 0.697-0.899) for prediction of long-term adverse events. An intermediate-risk subgroup was identified, and 24% had adverse events. When serial measurements were taken in a nested case-control subgroup, sST2 levels were constantly high in patients with late adverse events (> 6 months) but gradually decreased in nonadverse-event controls compared with 3-month and 6-month baseline levels. ConclusionsIn patients with PDCM, serum sST2 levels are associated with adverse events and have robust prognostic value. Serial measurements of sST2 could help in managing patients for monitoring outcomes of treatment.

Prognostic impact of left ventricular ejection fraction in patients with electrical storm.

The study sought to assess retrospectively the prognostic impact of left ventricular ejection fraction (LVEF) in patients with electrical storm (ES). Data regarding the prognostic impact of impaired LVEF in ES patients is rare. Consecutive patients presenting with ES from 2002 to 2016 were included retrospectively. Patients with LVEF ≤ 35% were compared to patients with LVEF > 35%. The primary prognostic endpoint was long-term all-cause mortality, and secondary endpoints wererates of in-hospital mortality, rehospitalization, major adverse cardiac events (MACE), and ES recurrences (ES-R) at long-term follow-up. A total of 80 patients with ES were included at 2.5years of follow-up. 69% of patients suffered from LVEF ≤ 35%. ES patients with LVEF ≤ 35% were associated with higher rates of the primary endpoint of all-cause mortality (53% versus 8%, log-rank p = 0.0001; HR 8.524; 95% CI 2.030-35.793, p = 0.003), as well as the secondary endpoints of MACE (53% versus 20%; log rank p = 0.011; HR 3.213, 95% CI 1.241-8.316, p = 0.016) and ES-R (35% versus 8%; log rank p = 0.019; HR 4.821, 95% CI 1.122-20.706, p = 0.034). Furthermore, ES patients with LVEF ≤ 35% showed higher rates of rehospitalization due to acute heart failure (24% versus 8%, statistical trend p = 0.096). Notably, ES patients with LVEF > 35% were associated with increased rates of rehospitalization due to ventricular tachycardia(36% versus 18%, statistical trend p = 0.083). ES patients with LVEF ≤ 35% were associated with increased rates of all-cause mortality, MACE, ES-R andheart failure-related rehospitalization at long-term follow-up. This study evaluated retrospectivelythe prognostic impact of LVEF in patients with ES. LVEF ≤ 35% was associated with increased long-term all-cause mortality (53% versus 8%; HR 8.524; 95% CI 2.030-35.793, p = 0.003), MACE (53% versus 20%; HR 3.213, 95% CI 1.241-8.316, p = 0.016), and ES recurrences (35% versus 8%; HR 4.821, 95% CI 1.122-20.706, p = 0.034), while trends were observed for higher rates of heart-failure related rehospitalization (24% versus 8%, p = 0.096) and MACE (49% versus 28%; p = 0.081).

Prevalence and Prognostic Significance of Right Ventricular Dysfunction in Patients With Hypertrophic Cardiomyopathy

Few data are available regarding the prevalence and clinical significance of right ventricular systolic dysfunction (RVSD) in hypertrophic cardiomyopathy (HC) patients. This study aimed to evaluate right ventricular (RV) systolic function by cardiovascular magnetic resonance and explore the prevalence and prognostic significance of RVSD in HC patients. A total of 226 patients with HC assessed by cardiovascular magnetic resonance were included in this retrospective study. RVSD was defined by RV ejection fraction (RVEF) ≤45% and was present in 26 (11.5%) patients. Association between RVSD, clinical characteristics, and outcomes were analyzed. RVEF was significantly lower in patients with RVSD than without RVSD (36.2 ± 7.0% vs 60.5 ± 7.4%, p < 0.001). There was a positive correlation between RVEF and left ventricular ejection fraction (r = 0.45; p < 0.001). During a mean follow-up of 30.5 ± 23.9 months, there were 22 (9.7 %) all-cause mortality, including 12 (5.3%) cardiovascular death. Kaplan-Meier analysis showed a significantly higher risk for cardiovascular mortality in patients with RVSD (p = 0.026), but no significant difference in all-cause mortality (p = 0.118) and heart failure related rehospitalization (p = 0.485). On multivariate Cox regression analysis, RVSD (hazard ratio 5.36; confidence interval 1.39 to 20.77; p = 0.015) and RVEF (hazard ratio 0.94; confidence interval 0.89 to 0.98; p = 0.011) were independent predictors of cardiovascular mortality. In conclusion, RVSD is a common phenotype and a strong independent predictor of cardiovascular mortality in HC patients.

Effects of a multidisciplinary disease management programme with or without exercise training for heart failure patients: Secondary analysis of a randomized controlled trial

BackgroundHeart failure is a complex syndrome that causes substantial functional impairment and poor outcomes. Although multidisciplinary disease management programmes are effective, the role of additional outpatient-based exercise training and the effects of multidisciplinary disease management programmes for patients with contraindications to exercise training are unclear. ObjectivesTo compare the effects of the multidisciplinary disease management programme with and without exercise training on heart failure-related rehospitalization, disease knowledge, and functional capacity. DesignSecondary analysis of a randomized controlled trial. Participants and SettingData for 212 patients hospitalized for heart failure at a local teaching hospital in Taiwan were analysed. MethodsPatients’ data were assigned to three groups: control (n = 71), multidisciplinary disease management programme without exercise training (n = 70) or multidisciplinary disease management programme with exercise training (n = 71). The multidisciplinary disease management programme included comprehensive assessments, individualized education, optimizing medications, pre-scheduled clinic visits, and encouraging regular physical activity at home. Outpatient-based exercise training was performed only in the multidisciplinary disease management programme with exercise training group. The control and the multidisciplinary disease management programme without exercise training groups were further divided into subgroups with and without contraindications to exercise training. Patients were followed up monthly for heart failure-related rehospitalizations for 1 year. Cox proportional hazard models and Kaplan-Meier analyses were used to identify the significant predictors of heart failure-related rehospitalizations. A generalized estimation equation model was used to analyse the secondary outcomes, including disease knowledge and 6-min walking distance at baseline and 6 and 12 months after discharge. ResultsAt 12 months after discharge, the multidisciplinary disease management programme with and without exercise training groups had significantly lower heart failure-related rehospitalization rates and better disease knowledge compared with the control group (p < 0.01). Only the multidisciplinary disease management programme with exercise training group had a significant improvement in 6-min walking distance (p < 0.05). For patients with contraindications to exercise, the multidisciplinary disease management programme significantly reduced heart failure-related rehospitalization rates at 12 months after discharge (p < 0.05). For those without contraindications, the event-lowering effect was only noted for the multidisciplinary disease management programme with exercise training group (p < 0.05). ConclusionsOutpatient-based exercise training is recommended to be incorporated into multidisciplinary disease management programmes for patients without exercise contraindications to improve disease outcomes and functional capacity. For patients with contraindications to exercise, a multidisciplinary disease management programme is recommended to improve patient outcomes.

Galectin-3 is associated with left ventricular reverse remodeling and outcome after percutaneous mitral valve repair

BackgroundPlasma Galectin-3 is a marker of myocardial inflammation and fibrosis, was associated with left ventricular (LV) reverse remodeling after conventional surgical mitral valve repair (MVR) and predicted clinical events in patients undergoing transcatheter aortic valve replacement (TAVR). We aimed to evaluate the association between pre-interventional Galectin-3 levels and (1) reverse LV remodeling and (2) major adverse cardiovascular events (MACE) in patients undergoing percutaneous MVR. MethodsForty-four consecutive patients (median age 79 years, LV ejection fraction 39.5 ± 11.4%, 91% in NYHA functional class ≥III) with symptomatic moderate to severe mitral regurgitation undergoing percutaneous MVR were prospectively included. Plasma Galectin-3 levels were measured before the procedure. Echocardiographic and clinical assessment was performed at baseline and after 3 months. LV reverse remodeling was prospectively defined as a ≥10% increase in global longitudinal strain. MACE included death, myocardial infarction, heart failure related rehospitalization and stroke and was assessed after a mean follow-up time of 2 years. Results72.7% of the patients showed LV reverse remodeling. Pre-interventional Galectin-3 < 10 ng/ml was an independent predictor of LV reverse remodeling (OR 10.3, 95% CI 1.2–83.9, p = 0.036). 25 patients (56.8%) experienced a MACE. Patients with Galectin-3 levels ≥ 10 ng/ml had significantly more MACE than patients with Galectin-3 levels < 10 ng/ml (100% vs. 45.5%, p = 0.003). Diabetes independently predicted MACE (HR 3.1, 95% CI 1.0–9.4, p = 0.049); Galectin-3 ≥ 10 ng/ml was of borderline significance (HR 2.2, 95% CI 0.9–5.4, p = 0.088). ConclusionsPre-interventional plasma Galectin-3 levels are associated with LV reverse remodeling and with clinical outcome after percutaneous MVR.

Persistent increase in cardiac troponin T at hospital discharge predicts repeat hospitalization in patients with acute decompensated heart failure

BackgroundHigh-sensitive cardiac troponin T (hsTnT) is a sensitive biomarker of myocardial damage and predictor of acute decompensated heart failure (ADHF). However, there is little information on changes over time in hsTnT level during ADHF management. The aim of this prospective study was to evaluate changes in hsTnT levels between admission and at discharge in patients with ADHF, and identify factors that determine such levels and their prognostic significance.Methods and resultsWe evaluated 404 ADHF patients with abnormal hsTnT levels (≥0.0135 ng/ml) on admission. The median (interquartile ranges) hsTnT levels on admission, at discharge, and percent changes in hsTnT levels were 0.038 (0.026 to 0.065), 0.032 (0.021 to 0.049) ng/ml, and -12.0 (-39.8 to 7.4) % respectively. The numbers of patients with falling (hsTnT decrease > -15%), stable (hsTnT change between -15 and +15%) and rising (hsTnT increase > +15%) hsTnT level at discharge were 190, 146, and 68, respectively. The percent change in B-type natriuretic peptide (BNP) levels was greater in the falling group, compared to the stable (p<0.001) and rising groups (p<0.001). Changes in hsTnT levels correlated significantly with changes in BNP levels (ρ = 0.22, p<0.001). Multivariate Cox regression analysis identified rising or stable hsTnT at discharge as a significant predictor of heart failure-related rehospitalization (hazard ratio: 1.69; 95% confidence interval: 1.06 to 2.70; p = 0.03).ConclusionsPersistent increase in hsTnT levels at discharge correlated with inadequate decrease of BNP levels, and was a predictor of poor clinical outcome, with repeat heart failure hospitalizations.

The Effectiveness of a Pre-Discharge Educational Program on Promoting One-Year Clinical Outcomes in Patients with Heart Failure

Background: Patient education is important to promote self-care in patients with heart failure. Objective: The purpose of this study was to test a nurse-led pre-discharge patient educational program on promoting self-care, quality of life, depression, sleep disturbances, and heart failure-related rehospitalizations in patients with heart failure over one-year period after hospital discharge. Methods: A quasi-experimental research design with a convenience sampling was used. A 42-page pamphlet with large font size and pictorial format was developed as the teaching material. Participants were recruited from two medical centers located in southern Taiwan with 34 participants were assigned to the experimental group and 35 to the control group. After completing the questionnaires at baseline, the experimental group received a pre-discharge education session and telephone follow-ups or outpatient follow-ups. The control group received the usual hospital discharge teaching only. Post tests were done one month, 3 months, 6 months, and 12 months after both groups were discharged. Generalized estimation equation analyses were used to examine the changes over time between the two groups. Results: The results showed that no statistical differences were found in demographic data, heart failure characteristics, and any major variable scores between the two groups at the baseline. The intervention group showed significant improvements in self-care maintenance and self-care management, but not for quality of life, sleep disturbances, and depression at the end of the study. Although a significant difference was not detected, the intervention group had fewer readmission events than the control group (10 vs. 27). Conclusion: The study supports the effectiveness of the patient education program on promoting self-care maintenance and management in patients with heart failure during the one-year period after discharge from hospital. The study findings can be served as a reference for healthcare providers and researchers to promote self-care and conduct research studies in people with heart failure.

Burden of Recurrent Hospitalizations Following an Admission for Acute Heart Failure: Preserved Versus Reduced Ejection Fraction

Introduction and objectivesHeart failure with preserved ejection fraction and reduced ejection fraction share a high mortality risk. However, differences in the rehospitalization burden over time between these 2 entities remains unclear. MethodsWe prospectively included 2013 consecutive patients discharged for acute heart failure. Of these, 1082 (53.7%) had heart failure with preserved ejection fraction and 931 (46.2%) had heart failure with reduced ejection fraction. Cox and negative binomial regression methods were used to evaluate the risks of death and repeat hospitalizations, respectively. ResultsAt a median follow-up of 2.36 years (interquartile range: 0.96-4.65), 1018 patients (50.6%) died, and 3804 readmissions were registered in 1406 patients (69.8%). Overall, there were no differences in mortality between heart failure with preserved ejection fraction and heart failure with reduced ejection fraction (16.7 vs 16.1 per 100 person-years, respectively; P=0794), or all-cause repeat hospitalization rates (62.1 vs 62.2 per 100 person-years, respectively; P=.944). After multivariable adjustment, and compared with patients with heart failure with reduced ejection fraction, patients with heart failure with preserved ejection fraction exhibited a similar risk of all-cause readmissions (incidence rate ratio=1.04; 95%CI, 0.93-1.17; P=.461). Regarding specific causes, heart failure with preserved ejection fraction showed similar risks of cardiovascular and heart failure-related rehospitalizations (incidence rate ratio=0.93; 95%CI, 0.82-1.06; P=.304; incidence rate ratio=0.96; 95% confidence interval, 0.83-1.13; P=.677, respectively), but had a higher risk of noncardiovascular readmissions (incidence rate ratio=1.24; 95%CI, 1.04-1.47; P=.012). ConclusionsFollowing an admission for acute heart failure, patients with heart failure with preserved ejection fraction have a similar rehospitalization burden to those with heart failure with reduced ejection fraction. However, patients with heart failure with preserved ejection fraction are more likely to be readmitted for noncardiovascular causes.

Carga de hospitalizaciones recurrentes tras una hospitalización por insuficiencia cardiaca aguda: insuficiencia cardiaca con función sistólica conservada frente a reducida

Introduction and objectivesHeart failure with preserved ejection fraction and reduced ejection fraction share a high mortality risk. However, differences in the rehospitalization burden over time between these 2 entities remains unclear. MethodsWe prospectively included 2013 consecutive patients discharged for acute heart failure. Of these, 1082 (53.7%) had heart failure with preserved ejection fraction and 931 (46.2%) had heart failure with reduced ejection fraction. Cox and negative binomial regression methods were used to evaluate the risks of death and repeat hospitalizations, respectively. ResultsAt a median follow-up of 2.36 years [interquartile range: 0.96-4.65], 1018 patients (50.6%) died, and 3804 readmissions were registered in 1406 patients (69.8%). Overall, there were no differences in mortality between heart failure with preserved ejection fraction and heart failure with reduced ejection fraction (16.7 vs 16.1 per 100 person-years, respectively; P=.794), or all-cause repeat hospitalization rates (62.1 vs 62.2 per 100 person-years, respectively; P=.944). After multivariable adjustment, and compared with patients with heart failure with reduced ejection fraction, patients with heart failure with preserved ejection fraction exhibited a similar risk of all-cause readmissions (incidence rate ratio=1.04; 95%CI, 0.93-1.17; P=.461). Regarding specific causes, heart failure with preserved ejection fraction showed similar risks of cardiovascular and heart failure-related rehospitalizations (incidence rate ratio=0.93; 95%CI, 0.82-1.06; P=.304; incidence rate ratio=0.96; 95% confidence interval, 0.83-1.13; P=.677, respectively), but had a higher risk of noncardiovascular readmissions (incidence rate ratio=1.24; 95%CI, 1.04-1.47; P=.012). ConclusionsFollowing an admission for acute heart failure, patients with heart failure with preserved ejection fraction have a similar rehospitalization burden to those with heart failure with reduced ejection fraction. However, patients with heart failure with preserved ejection fraction are more likely to be readmitted for noncardiovascular causes.Full English text available from: www.revespcardiol.org/en

Defining the role of ultrafiltration therapy in acute heart failure: a systematic review and meta-analysis.

Ultrafiltration (UF) has emerged as an alternative therapy for acute decompensated heart failure (ADHF) due to its physiological benefits such as improvement in neurohormonal activation. We performed a systematic review and a meta-analysis to evaluate the efficacy, safety, and the impact on outcomes for UF therapy as compared to conventional medical treatment. The PubMed and Cochrane databases were searched from inception to December 2015 for randomized controlled trials that examined UF therapy in ADHF and used diuretic-based regimens as the control group. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, we explored the impact on weight change, fluid removal, renal function, rehospitalization rate, and mortality. Mantel-Haenszel odds ratio (OR) was calculated for dichotomous data and weighted mean difference (WMD) for continuous data. Seven studies with a total of 771 patients met our selection criteria. UF therapy led to greater weight loss (WMD 1.35, 95% CI 0.49-2.21, p<0.01) and fluid removal (WMD 1.81, 95% CI 1.01-2.62, p=<0.01) while the impact of UF on renal function was comparable with medical treatment (WMD 0.06, 95% CI -0.11 to 0.22, p=0.48), UF decreased heart failure rehospitalization rate (OR 0.60, 95% CI 0.37-0.98, p=0.04) but did not change mortality (OR 1.03, 95% CI 0.68-1.57, p=0.89). Compared with diuretic-based medical treatment, UF therapy is more efficient in decongestion of patients with ADHF. It does not have a deleterious impact on renal function and can improve heart failure-related rehospitalization rate, albeit without conferring a survival benefit.

Effect of multidisciplinary disease management for hospitalized heart failure under a national health insurance programme.

Multidisciplinary disease management programmes (MDPs) for heart failure have been shown to be effective in Western countries. However, it is not known whether they improve outcomes in a high population density country with a national health insurance programme. In total, 349 patients hospitalized because of heart failure were randomized into control and MDP groups. All-cause death and re-hospitalization related to heart failure were analyzed. The median follow-up period was approximately 2 years. Mean patient age was 60 years; 31% were women; and 50% of patients had coronary artery disease. MDP was associated with fewer all-cause deaths [hazard ratio (HR) = 0.49, 95% confidence interval (CI) = 0.27-0.91, P = 0.02] and heart failure-related re-hospitalizations (HR = 0.44, 95% CI = 0.25-0.77, P = 0.004). MDP was still associated with better outcomes for all-cause death (HR = 0.53, 95% CI = 0.29-0.98, P = 0.04) and heart failure-related re-hospitalization (HR = 0.46, 95% CI = 0.26-0.81, P = 0.007), after adjusting for age, diuretics, diabetes mellitus, chronic kidney disease, hypertension, sodium, and albumin. However, MDPs' effect on all-cause mortality and heart failure-related re-hospitalization was significantly attenuated after adjusting for angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers or β-blockers. A stratified analysis showed that MDP combined with guideline-based medication had synergistic effects. MDP is effective in lowering all-cause mortality and re-hospitalization rates related to heart failure under a national health insurance programme. MDP synergistically improves the effectiveness of guidelines-based medications for heart failure.

Rationale and design of the Aquapheresis Versus Intravenous Diuretics and Hospitalization for Heart Failure (AVOID-HF) trial

In patients hospitalized with acutely decompensated heart failure, unresolved signs and symptoms of fluid overload have been consistently associated with poor outcomes. Regardless of dosing and type of administration, intravenous loop diuretics have not reduced heart failure events or mortality in patients with acutely decompensated heart failure. The results of trials comparing intravenous loop diuretics to mechanical fluid removal by isolated venovenous ultrafiltration have yielded conflicting results. Studies evaluating early decongestive strategies have shown that ultrafiltration removed more fluid and was associated with fewer heart failure-related rehospitalization than intravenous loop diuretics. In contrast, when used in the setting of worsening renal function, ultrafiltration was associated with poorer renal outcomes and no reduction in heart failure events. The AVOID-HF trial seeks to determine if an early strategy of ultrafiltration in patients with acutely decompensated heart failure is associated with fewer heart failure events at 90 days compared with a strategy based on intravenous loop diuretics. Study subjects from 40 highly experienced institutions are randomized to either early ultrafiltration or intravenous loop diuretics. In both treatment arms, fluid removal therapies are adjusted according to the patients' hemodynamic condition and renal function. The study was unilaterally terminated by the sponsor in the absence of futility and safety concerns after the enrollment of 221 subjects, or 27% of the originally planned sample size of 810 patients. The AVOID-HF trial's principal aim is to compare the safety and efficacy of ultrafiltration vs that of intravenous loop diuretics in patients hospitalized with acutely decompensated heart failure. Because stepped treatment approaches are applied in both ultrafiltration and intravenous loop diuretics groups and the primary end point is time to first heart failure event within 90 days, it is hoped that the AVOID-HF trial, despite its untimely termination by the sponsor, will provide further insight on how to optimally decongest patients with fluid-overloaded heart failure.