Heart Failure-related Readmissions Research Articles

Impact of Changes in Rectus Femoris Cross-Sectional Area Measured by Ultrasound on the Prognosis of Patients With Acute Heart Failure.

Low muscle mass in patients with acute heart failure (AHF) is associated with poor prognosis; however, this is based on a single baseline measurement, with little information on changes in muscle mass during hospitalization and their clinical implications. This study investigated the relationship between changes in rectus femoris cross-sectional area (RFCSA) on ultrasound and the prognosis of patients with AHF.Methods and Results: This is a retrospective evaluation of 284 AHF patients (mean [±SD] age 79.1±11.9 years; 116 female). RFCSA assessments at admission (pre-RFCSA), ∆RFCSA (i.e., the percentage change in RFCSA from admission to 2 weeks), and composite prognosis (all-cause death and heart failure-related readmission) within 1 year were determined. Patients were divided into 4 groups according to their median pre-RFCSA and ∆RFCSA after sex stratification: Group A, higher pre-RFCSA/better ∆RFCSA; Group B, higher pre-RFCSA/worse ∆RFCSA; Group C, lower pre-RFCSA/better ∆RFCSA; Group D, lower pre-RFCSA/worse ∆RFCSA. In the Cox regression analysis, with Group A as the reference, the cumulative event rate of Group C (hazard ratio [HR] 3.39; 95% confidence interval [CI] 0.71-16.09; P=0.124) did not differ significantly; however, the cumulative event rates of Group B (HR 7.93; 95% CI 1.99-31.60; P=0.003) and Group D (HR 9.24; 95% CI 2.57-33.26; P<0.001) were significantly higher. ∆RFCSA during hospitalization is useful for risk assessment of prognosis in patients with AHF.

Procedural Insights and Clinical Outcomes of a Novel Superior Vena Cava Occlusion Device for Acute Heart Failure: A Single-Center Experience.

The preCARDIA system is a device combining a balloon-mounted catheter and an extracorporeal system designed for intermittent occlusion of the superior vena cava. Studies have established safety and efficacy in acute decompensated heart failure. We present a single-center experience detailing 90 days outcomes and procedural insights. A 24 hours therapy session demonstrated reduced pulmonary wedge pressures and increased urine output, with cardiac output remaining unchanged. There was one readmission and no heart failure-related readmissions at 90 days. The preCARDIA device appears to be a safe mechanical diuretic strategy to manage patients with acute decompensated heart failure beyond current therapeutic strategies.

Abstract 13389: Outcomes of Transcatheter Aortic Valve Replacement in Patients With Prior Mediastinal Radiation in the United States

Introduction: Although prior mediastinal radiation is associated with significantly worse clinical outcomes after SAVR, it is unknown if the same holds true for patients undergoing transcatheter aortic valve replacement (TAVR). Hypothesis: We hypothesized that the presence of prior mediastinal radiation may affect the outcomes of patients undergoing TAVR and tested this hypothesis using data from a nationally representative sample of the US population. Methods: The National Readmissions Database was analyzed from 2016-2019 to identify patients ≥ 18 years old undergoing TAVR. Patients with prior mediastinal radiation were then identified by using ICD-10 CM codes. Propensity score matching was used to adjust for confounders. Results: Our cohort included 173,743 patients undergoing TAVR, of which 2,780 (1.6%) had prior mediastinal radiation. Patients with prior mediastinal radiation undergoing TAVR were younger, had a higher proportion of females, and had a lower burden of comorbidities including hypertension, diabetes, and renal failure. Crude percentages are reported in Figure 1. On propensity score-matched analysis, the presence of prior mediastinal radiation was associated with similar odds of in-hospital mortality and peri-procedural complications including cardiovascular complications, peripheral vascular complications, pulmonary complications, neurological complications, major bleeding, and new pacemaker implantation along with similar odds of 30-day and 180-day all-cause, stroke-related, bleeding-related, and heart failure-related readmissions compared to those without prior mediastinal radiation. Conclusion: In conclusion, our data suggest that patients with prior mediastinal radiation undergoing TAVR have similar outcomes compared to those who have no history of mediastinal radiation.

Left ventricular underfilling in PAH: A potential indicator for adaptive-to-maladaptive transition.

Pulmonary arterial hypertension (PAH) still remains a life-threatening disorder with poor prognosis. The right ventricle (RV) adapts to the increased afterload by a series of prognostically significant morphological and functional changes, the adaptive nature should also be understood in the context of ventricular interdependence. We hypothesized that left ventricle (LV) underfilling could serve as an important imaging marker for identifying maladaptive changes and predicting clinical outcomes in PAH patients. We prospectively enrolled patients with PAH who underwent both cardiac magnetic resonance and right heart catheterization between October 2013 and December 2020. Patients were categorized into four groups based on their LV and RV mass/volume ratio (M/V). LV M/V was stratified using the normal value (0.7 g/mL for males and 0.6 g/mL for females) to identify patients with LV underfilling (M/V ≥ normal value), while RV M/V was stratified based on the median value. The primary endpoint was all-cause mortality, and the composite endpoints included all-cause mortality and heart failure-related readmissions. A total of 190 PAH patients (53 male, mean age 37 years) were included in this study. Patients with LV underfilling exhibited higher NT-proBNP levels, increased RV mass, larger RV but smaller LV, lower right ventricular ejection fraction, and shorter 6-min walking distance. Patients with LV underfilling had a 2.7-fold higher risk of mortality than those without and LV M/V (hazard ratio [per 0.1 g/mL increase]: 1.271, 95% confidence interval: 1.082-1.494, p = 0.004) was also independent predictors of all-cause mortality. Moreover, patients with low LV M/V had a better prognosis regardless of the level of RV M/V. Thus, LV underfilling is an independent predictor of adverse clinical outcomes in patients with PAH, and it could be an important imaging marker for identifying maladaptive changes in these patients.

High 30-day readmission rates in hospitalized patients with heart failure: Strengthening the need for a multidisciplinary and integrated approach

Background: Heart failure (HF) is a common disease which is one of the most common causes of hospitalization. Although mortality rates are decreasing, readmission rates are still quite high. Objectives: We aimed to investigate the risk factors for readmission and death in patients who were hospitalized due to HF. Design and Setting: Retrospective study, Hacettepe University, Ankara, Turkey Methods: Patients hospitalized between 1 January 2014 to 31 December 2018 with the primary diagnosis of HF were included. Outcome variables were risk factors for 30-day all- caused readmission, 30-day HF related readmission, mortality. Results: All-cause 30-day readmission rate was 34.8% and HF-related 30-day readmission rate was 21.2%. The factors associated with increased all-caused 30-day readmission were male gender, hyperlipidemia, chronic liver disease, malignancy. The factors associated with increased HF-related 30-day readmission were hyperlipidemia, chronic liver disease, inflammatory rheumatologic diseases, malignancy. Use of ACE-i was found to be protective against all-cause and HF-related 30-day readmission. Factors associated with mortality were ejection fraction &lt;30%, chronic liver disease, acute kidney injury, hypoalbuminemia at the time of admission. Conclusions: Nearly one third of patients in this cohort who were hospitalized with a primary diagnosis of HF were readmitted in the following 30 days. Having certain chronic diseases and conditions were associated with an increased risk for readmission and mortality. These findings point out to the special needs of HF patients, who require a proactive, integrated and multidisciplinary management strategy to control the risk factors and to improve the inpatient and transitional stages in the hospital.

Clinical Impact of ACE-I/ARB for Conservatively Treated Patients with Moderate to Severe Mitral Regurgitation: A Single Center Observational Study

(1) Background: Mitral regurgitation (MR) is associated with increased mortality and frequent hospital admissions. Although mitral valve intervention offers improved clinical outcomes for MR, it is not feasible in many cases. Moreover, conservative therapeutic opportunities remain limited. The aim of this study was to evaluate the impact of ACE inhibitors and angiotensin receptor blockers (ACE-I/ARB) on elderly patients with moderate-to-severe MR and mildly reduced to preserved ejection fraction. (2) Methods: In total, 176 patients were included in our hypothesis-generating, single-center observational study. Hospitalization for heart failure and all-cause death have been defined as the combined 1-year primary endpoint. (3) Results: Patients treated with ACE-I/ARB showed a lower risk for the combined endpoint of death and heart failure-related readmission (HR 0.52 95%CI 0.27-0.99; p = 0.046), even after adjustment for EUROScoreII and frailty (HR 0.52 95%CI 0.27-0.99; p = 0.049) (4) Conclusions: The use of an ACE-I/ARB in patients with moderate-to-severe MR and preserved to mildly reduced left-ventricular ejection fraction (LVEF) significantly associates with improved clinical outcome and might be indicated as a valuable therapeutic option in conservatively treated patients.

Frailty as apredictor of mortality and readmission rate in secondary mitral regurgitation.

Selection in patients with functional mitral regurgitation (MR) to identify responders to interventions is challenging. In these patients, frailty might be used as amultidimensional parameter to summarize the resilience to stressors. Our objective was to evaluate frailty as apredictor of outcome in patients with moderate to severe secondary MR. We conducted asingle-center retrospective observational cohort study and included 239 patients with moderate to severe secondary MR aged 65years or older between 2014 and 2020. Echocardiography was performed at baseline; frailty was evaluated using the clinical frailty scale (CFS). The combined primary endpoint was hospitalization for heart failure and all-cause mortality. Atotal of 53% (127) of all patients were classified as CFS 4 (living with mild frailty) or higher. Frail patients had ahigher risk for the combined endpoint (hazard ratio, HR 3.70, 95% confidence interval, CI 2.12-6.47; p < 0.001), 1‑year mortality (HR 5.94, 95% CI 1.76-20.08; p < 0.001) even after adjustment for EuroSCORE2. The CFS was predictive for the combined endpoint (AUC 0.69, 95% CI 0.62-0.75) and outperformed EuroSCORE2 (AUC 0.54, 95% CI 0.46-0.62; p = 0.01). In sensitivity analyses, we found that frailty was associated with adverse outcomes at least in trend in all subgroups. For older, medically treated patients with moderate to severe secondary mitral regurgitation, frailty is an independent predictor for the occurrence of death and heart failure-related readmission within 1 year and outperformed the EuroSCORE2. Frailty should be assessed routinely in patients with heart failure to guide clinical decision making for mitral valve interventions or conservative treatment.

Survival and readmission among patients with advanced cardiomyopathy undergoing transcatheter edge-to-edge mitral valve repair:Are we applying COAPT findings too broadly?

Transcathether edge-to-edge mitral valve repair (TEER) has been shown to be an effective treatment for secondary mitral regurgitation (MR). However, the outcomes of TEER in patients with severe cardiomyopathy is less clear. The objective of this study is to determine the outcomes of such patients who underwent TEER at our institution. A retrospective review of patients with severe cardiomyopathy, defined as ejection fraction ≤30% or the requirement of inotropic support preoperatively, undergoing TEER for secondary MR at our institution from 11/2016 to 11/2020 was performed. Univariate analysis associating preoperative characteristics with our primary endpoint of 1-year death or orthotopic heart transplant (OHT) was performed. Kaplan-Meier analysis was conducted for the composite outcome of death or OHT, as well as for heart failure-related readmission. Finally, an assessment of changes in MR severity from the preoperative, to immediate postoperative period, to 30-day postoperative period was conducted. There were 48 patients identified. Median age was 74.5 years (IQR 65.5-79.5), median ejection fraction was 21.5% (IQR 16.0-27.5), and 81.4% of patients had severe or torrential mitral regurgitation preoperatively. The composite endpoint of 1-year mortality or OHT occurred in 15 of 48 patients (31.3%, 14 deaths and 1 OHT). One-year heart failure readmission rate was 47.9%. Mortality or OHT at 2 years occurred in 45.8%. Patients at extremes of heart failure who underwent TEER had poor outcomes when assessed at 1-year. Our study may suggest that the results of cardiovascular outcomes assessment of the mitraclip percutaneous therapy for heart failure patients with secondary mitral regurgitation may not be applicable to patients with severe cardiomyopathy.

Hemodynamic Aberrancies in Left Ventricular Assist Device–Associated Heart Failure Syndromes

Hemodynamic Aberrancies in Left Ventricular Assist Device–Associated Heart Failure Syndromes

Abstract 217: Assessing Medication Non-Adherence In Heart Failure Patients: A Resident Driven Quality Improvement Initiative

Introduction: Non-adherence to guideline directed medical therapies (GDMT) is responsible for significant health care costs, morbidity, and mortality in heart failure (HF) patients. Assessing and improving medication adherence (MA) is challenging in this patient population given its multifactorial nature. We aimed to evaluate trainee assessment of MA in HF patients while identifying potential barriers to addressing MA during patient encounters. Methods: This was a single-institution study performed at a large safety net hospital in Atlanta. An anonymous questionnaire was used to assess MA strategies of interns, residents, and medical students for HF patients. This data was compiled and analyzed to identify the most commonly perceived barriers to medication non-adherence. Results: 100 surveys were returned. 99% (99/100) noted that addressing MA is important in HF patients. However, only 83% (83/100) reported that they discussed the specific reasons for non-adherence with their HF patients, with 9%, 12%, and 78% addressing MA in the outpatient, inpatient, and both settings, respectively; the lack of time was reported as the most common contributor in all settings. The most common reasons reported by trainees for patient non-adherence include misunderstanding of their regimen (71%), cost (62%), and polypharmacy (57%). Although, 40% (40/100) of survey responders believed that ≥50% of their HF patients were nonadherent, strikingly, only 12% (12/100) discussed these MA barriers at all HF patient visits. Conclusion: Improving outcomes in HF patients is multifactorial. Medicine teaching teams can play a crucial role in this process by recognizing and addressing the specific barriers to MA in HF patients while promoting GDMT adherence. Our study demonstrates that although trainees recognize the importance of MA, the unique patient characteristics that contribute to non-adherence are under appreciated. Our long-term goal is to not only identify these barriers, but to implement educational interventions, then re-assess trainee comfort level with discussing MA, to demonstrate that trainee driven interventions can improve MA in HF patients while simultaneously reducing HF related re-admissions and hospital costs.

Abstract EP28: SO CLOSE YET SO FAR : HOW WELL ARE WE DOING WITH GDMT FOR HEART FAILURE WITH REDUCED EJECTION FRACTION - A COMMUNITY HOSPITAL ANALYSIS

Background: The use of maximum tolerated doses of guideline directed medical therapy (GDMT) for patient with heart failure with reduced ejection fraction (HFrEF) has been suboptimal in routine clinical practice. In particular, the rate of adoption of the angiotensin receptor blocker-neprilysin inhibitor (ARNI) has lagged. In this study, we aim to evaluate the use of optimal GDMT and the effect of ARNI on heart failure related re-admission (HFRR) in a real life setting from a single center community hospital. Method: Retrospective chart review was conducted in patients who were admitted to our hospital system for HFrEF between December 2019-January 2021. Data was collected for patient demographics, comorbidities, admission and discharge medications, length of stay and rate of 30-day HFRR. Results: 357 patients were included in the analysis. 92.7% were discharged on beta blockers, 50% were discharged on ACE-I/ARB, 6.4% were discharged on ARNI and 47.75% were discharged on MRAs. The target doses of each were only achieved in 7.3%, 27%, 100% and &lt;1% respectively. 43% patients were not discharged on either ACE-I/ARB/ARNI. Patients discharged on ARNI had numerically lower rates of chronic kidney disease &gt; stage 3, and lower BNP levels than those discharged on ACE-I/ARB. HFRR was lower in patient discharged on ARNI vs ACE-I/ARB (4.17% vs 16%), although this was not statistically significant due to low sample volume (p = 0.20). Conclusion: Our study shows that the rate of adoption of GDMT, especially ARNI, in hospitalized HFrEF patients in clinical practice lags significantly behind from that reported in clinical trials. Although there was no statistical significance achieved in comparison due to small sample size, we see a trend of decreased heart failure readmission in patients discharged on ARNI. The wide gap of adoption of GDMT in the real world remains a challenge, and adversely impacts patient outcomes.

Health Literacy Impacts Knowledge and the Use of Education App in Heart Failure: A Pilot Study

Background and Introduction: The chronicity of heart failure (HF) requires patients to follow complex self-care regimen. Many factors impede patients’ ability to follow the prescribed multi-component self-care regimen that include lack of knowledge attributed to inadequate health literacy. Objective: This prospective pre- and post-intervention study assessed the usability and potential efficacy of a HFeducational application (APP) in a smartphone. The HF education App included ten educational modules at a reading level of 6th grade. The study examined the association of health literacy level of participants at baseline with HF knowledge improvement after using the App for 30-days. HF related hospital readmissions was assessed at 30, 60 and 90-days. Results: A total of 31 patients with HF and (15) family member dyads were recruited for the study. Health Literacy level was measured using the Rapid Estimate of Adult Literacy in Medicine - Short Form showed a strong association with HF knowledge measured using the validated Atlanta HF Knowledge Test (t=3.629; p=0.001). Knowledge of patients with HF improved significantly after 30-days of using the HF education App (t=13.03; p=0.001); as well the knowledge of caregivers (t=9.08; p=0.001). None of the patients with HF were hospitalized during 30-days and 60-days follow-up, while one patient was hospitalized in 90-days. Conclusion: Our data suggests evaluating alternative methods of communicating health information including written material at a low literacy level verbal communication that a person with inadequate literacy may understand, and presentations using videos and Apps targeting individuals with limited literacy at 6th grade level.

Outcomes of remote pulmonary artery hemodynamic monitoring in heart failure patients with obstructive sleep apnea

Abstract Introduction Obstructive sleep apnea (OSA) is often associated with heart failure (HF). Remote pulmonary artery (PA) hemodynamic monitoring has shown to decrease HF related readmissions. However, there is paucity of data regarding its efficacy and mortality in patients with OSA. Purpose Real-world analysis of outcomes of remote PA hemodynamic monitoring using CardioMEMS device in reducing HF hospitalization in patients with OSA [apnea–hypopnea index (AHI) ≥5]. Methods Retrospective data was collected for patients with HF who had CardioMEMS device implanted based on FDA indications from April 2015 to August 2020. The number of hospitalizations, emergency department (ED) and HF clinic visits data was collected for 1-year pre and 1-year post device implantation. Mortality data was also collected at 1-year post-implantation. Patients who were diagnosed with OSA based on AHI ≥5 on sleep study at the time of implantation were included in the study. Analysis was done using Kruskal-Wallis test for comparison between heart failure patients with and without OSA. Mortality was compared with Pearson's chi-squared test. Results CardioMEMS device was implanted in 177 patients during the study period. Of this population, 108 (61%) patients had known OSA at the time of implantation. There was a statistically significant decrease in overall mean HF admissions from 1.80 (± 1.55) to 0.62 (± 1.07), 65.6%, p&amp;lt;0.001 and mean HF ED visits from 1.37 (± 1.50) to 0.5 (± 0.95), 63.5%, p&amp;lt;0.001 in 1-year pre- and post-implantation among OSA patients. When comparing outcomes between HF patients with and without OSA, there was no statistically significant difference observed between them in all-cause admissions, HF admissions, ED visits, ED HF visits, and HF clinic visits 1-year pre and post implantation. Also, no statistically significant difference was observed in mortality between the groups at 1-year post-implantation. Conclusions PA hemodynamic monitoring using CardioMEMS device had a net benefit in reducing HF admissions and HF ED visits in OSA patients which was similar in patients without OSA. Funding Acknowledgement Type of funding sources: None.

The biomedical, socioeconomic and demographic predictors of heart failure readmissions

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Sydney Local Health District Introduction Heart failure hospitalisations and readmissions pose a significant clinical and economic burden internationally. Current studies support a range of biomedical and sociodemographic factors as predictors of HF readmissions; however, there are a paucity of studies synthesising the research on this topic. Purpose The purpose of this systematic review was to identify biomedical, socioeconomic and demographic predictors of heart failure-related readmissions in adults with heart failure. Methods Electronic databases (Medline, Embase and Scopus) were searched using a structured search strategy. The particular risk factors of interest were left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) function class, brain natriuretic peptide (BNP), heart rate, blood pressure, employment status, income, age, sex, ethnicity, indigenous status, marital status, and socioeconomic indexes for areas (SEIFA) scores. After the removal of duplicates, the article selection process was conducted by two independent authors according to an inclusion and exclusion criteria. The articles were first filtered by title and abstract against the inclusion and exclusion criteria. The remaining articles were then assessed by reviewing the studies in full text. The relevant Critical Appraisal Skills Programme (CASP) tools were then used to appraise the final articles included for review. Results In total 1,516 papers were retrieved from the search. Of the 1,516 papers, 666 were from Medline, 567 were from CINAHL, 282 were from Embase, and one paper was from an independent search. After the removal of duplicates, 1296 papers were filtered according to title and abstract and 1183 papers were excluded from this process. 95 papers were assessed by reading them in full and of the 95 papers, 77 were excluded. This resulted in eighteen studies being included for review. Unemployment was the only socioeconomic factor predictive of HF readmissions (HR = 1.09; 95%CI= 1.05-1.14; p = 0.03) and SEIFA scores did not predict HF readmissions in adults with HF (p &amp;gt; 0.05). Indigenous status was a risk factor of HF readmissions according to one study (p &amp;lt; 0.05). Age or sex did not affect the risk of HF readmissions in adults with HF (p &amp;gt; 0.05). NYHA function class, BNP levels, and heart rate predicted HF readmissions in the population of interest. LVEF and blood pressure were non-significant predictors of HF readmissions (p &amp;gt; 0.05). Conclusions Current HF guidelines have a strong biomedical focus in the management of HF patients. This review however, shows there are sociodemographic factors that are predictive of HF readmissions in addition to the biomedical predictors that have been more extensively studied. Future studies should examine their combined effect on readmission risk and the early interventions to prevent readmissions.

Simultaneous Use of Hypertonic Saline and IV Furosemide for Fluid Overload: A Systematic Review and Meta-Analysis.

To evaluate the efficacy of the simultaneous hypertonic saline solution and IV furosemide (HSS+Fx) for patients with fluid overload compared with IV furosemide alone (Fx). Electronic databases (MEDLINE, EMBASE, CENTRAL, Cochrane Database of Systematic Reviews, PsycINFO, Scopus, and WOS) were searched from inception to March 2020. Randomized controlled trials on the use of HSS+Fx in adult patients with fluid overload versus Fx were included. Data were collected on all-cause mortality, hospital length of stay, heart failure-related readmission, along with inpatient weight loss, change of daily diuresis, serum creatinine, and 24-hour urine sodium excretion from prior to post intervention. Pooled analysis with random effects models yielded relative risk or mean difference with 95% CIs. Eleven randomized controlled trials comprising 2,987 acute decompensated heart failure patients were included. Meta-analysis demonstrated that HSS+Fx was associated with lower all-cause mortality (relative risk, 0.55; 95% CI, 0.46-0.67; p < 0.05; I2 = 12%) and heart failure-related readmissions (relative risk, 0.50; 95% CI, 0.33-0.76; p < 0.05; I2 = 61%), shorter hospital length of stay (mean difference, -3.28 d; 95% CI, -4.14 to -2.43; p < 0.05; I2 = 93%), increased daily diuresis (mean difference, 583.87 mL; 95% CI, 504.92-662.81; p < 0.05; I2 = 76%), weight loss (mean difference, -1.76 kg; 95% CI, -2.52 to -1.00; p < 0.05; I2 = 57%), serum sodium change (mean difference, 6.89 mEq/L; 95% CI, 4.98-8.79; p < 0.05; I2 = 95%), and higher 24-hour urine sodium excretion (mean difference, 61.10 mEq; 95% CI, 51.47-70.73; p < 0.05; I2 = 95%), along with decreased serum creatinine (mean difference, -0.46 mg/dL; 95% CI, -0.51 to -0.41; p < 0.05; I2 = 89%) when compared with Fx. The Grading of Recommendation, Assessment, Development, and Evaluation certainty of evidence ranged from low to moderate. Benefits of the HSS+Fx over Fx were observed across all examined outcomes in acute decompensated heart failure patients with fluid overload. There is at least moderate certainty that HSS+Fx is associated with a reduction in mortality in patients with acute decompensated heart failure. Factors associated with a successful HSS+Fx utilization are still unknown. Current evidence cannot be extrapolated to other than fluid overload states in acute decompensated heart failure.

Association of Positive Fluid Balance at Discharge After Sepsis Management With 30-Day Readmission

Although early fluid administration has been shown to lower sepsis mortality, positive fluid balance has been associated with adverse outcomes. Little is known about associations in non-intensive care unit settings, with growing concern about readmission from excess fluid accumulation in patients with sepsis. To evaluate whether positive fluid balance among non-critically ill patients with sepsis was associated with increased readmission risk, including readmission for heart failure. This multicenter retrospective cohort study was conducted between January 1, 2012, and December 31, 2017, among 57 032 non-critically ill adults hospitalized for sepsis at 21 hospitals across Northern California. Kaiser Permanente Northern California is an integrated health care system with a community-based population of more than 4.4 million members. Statistical analysis was performed from January 1 to December 31, 2019. Intake and output net fluid balance (I/O) measured daily and cumulatively at discharge (positive vs negative). The primary outcome was 30-day readmission. The secondary outcomes were readmission stratified by category and mortality after living discharge. The cohort included 57 032 patients who were hospitalized for sepsis (28 779 women [50.5%]; mean [SD] age, 73.7 [15.5] years). Compared with patients with positive I/O (40 940 [71.8%]), those with negative I/O (16 092 [28.2%]) were older, with increased comorbidity, acute illness severity, preexisting heart failure or chronic kidney disease, diuretic use, and decreased fluid administration volume. During 30-day follow-up, 8719 patients (15.3%) were readmitted and 3639 patients (6.4%) died. There was no difference in readmission between patients with positive vs negative I/O (HR, 1.00; 95% CI, 0.95-1.05). No association was detected between readmission and I/O using continuous, splined, and quadratic function transformations. Positive I/O was associated with decreased heart failure-related readmission (HR, 0.80 [95% CI, 0.71-0.91]) and increased 30-day mortality (HR, 1.23 [95% CI, 1.15-1.31]). In this large observational study of non-critically ill patients hospitalized with sepsis, there was no association between positive fluid balance at the time of discharge and readmission. However, these findings may have been limited by variable recording and documentation of fluid intake and output; additional studies are needed to examine the association of fluid status with outcomes in patients with sepsis to reduce readmission risk.

Long-Term and Short-Term Prognostic Value of Circulating Soluble Suppression of Tumorigenicity-2 Concentration in Chronic Heart Failure: A Systematic Review and Meta-Analysis

Introduction: Soluble suppression of tumorigenicity-2 (sST2) has been considered as a prognostic factor of cardiovascular disease. However, the prognostic value of sST2 concentration in chronic heart failure remains to be summarized. Methods: We searched PubMed, Embase, and Web of Science for eligible studies up to January 1, 2020. Data extracted from articles and provided by authors were used in agreement with the PRISMA statement. The endpoints were all-cause mortality (ACM), cardiovascular mortality (CVM)/heart failure-related hospitalization (HFH), and all-cause mortality (ACM)/heart failure-related readmission (HFR). Results: A total of 11 studies with 5,121 participants were included in this analysis. Higher concentration of sST2 predicted the incidence of long-term ACM (hazard ratio [HR]: 1.03, 95% confidence interval [CI]: 1.02–1.04), long-term ACM/HFR (HR: 1.42, CI: 1.27–1.59), and long-term CVM/HFH (HR: 2.25, CI: 1.82–2.79), regardless of short-term ACM/HFR (HR: 2.31, CI: 0.71–7.49). Conclusion: Higher sST2 concentration at baseline is associated with increasing risk of long-term ACM, ACM/HFR, and CVM/HFH and can be a tool for the prognosis of chronic heart failure.

Late kidney injury after transcatheter aortic valve replacement

Information on early to late-phase kidney damage in patients who underwent transcatheter aortic valve replacement (TAVR) is scarce. We aimed to identify the predictive factors for late kidney injury (LKI) at 1-year and patient prognosis beyond 1-year after TAVR. We retrospectively reviewed 1,705 patients' data from the Japanese TAVR multicenter registry. Acute kidney injury (AKI) and LKI, defined as an increase of at least 0.3 mg/dL in creatinine level, a relative 50% decrease in kidney function from baseline to 48 hours and 1-year, were evaluated. The patients were categorized into the 4 groups as AKI-/LKI- (n = 1.362), AKI+/LKI- (n = 95), AKI-/LKI+ (n = 199), and AKI+/LKI+ (n = 46). The cumulative 3-year mortality rates were significantly increased across the four groups (12.5%, 15.8%, 24.6%, 25.8%, P < .001). Multivariate analysis revealed that chronic kidney disease, coronary artery disease, periprocedural AKI, and heart failure-related re-admission within 1-year were significantly associated with LKI. The Cox regression analysis revealed that AKI-/LKI+ and AKI+/LKI+ were independent predictors of increased late mortality beyond 1-year after TAVR (P = .001 and P = .01). LKI was influenced by adverse cardio-renal events and was associated with increased risks of late mortality beyond 1-year after TAVR.

Impact of Central Sleep Apnea on the Cost of Heart Failure Readmissions

Background Central sleep apnea (CSA) has a high prevalence in hospitalized patients with heart failure with reduced ejection fraction and is independently associated with increased readmissions in these patients. However, the economic impact of previously undiagnosed CSA on heart failure related readmissions remains poorly understood. Methods We used an established inception cohort of heart failure patients who had surveillance inpatient sleep testing (The OSU-Sleep Heart Program) during their hospitalization. Patients were followed up post-discharge and the number and cost of readmissions and vital status were tracked. Sleep disordered breathing (SDB) status was classified based on the sleep study into CSA, obstructive sleep apnea (OSA) or no SDB. The primary comparisons were between the CSA and no SDB groups. Results Between 2008 and 2012, 1547 consecutive patients admitted for heart failure underwent sleep studies during hospitalization. Of those, 438 patients had CSA and 393 had no SDB. The 3-month readmission rate was 33.6% for CSA and 20.4% with no SDB (p Conclusions Previously undiagnosed CSA is associated with increased readmissions in heart failure patients regardless of underlying ejection fraction. Furthermore, CSA was independently associated with increased cost of heart failure readmissions at both 3 months and 6 months. Patients with HF and CSA represent a high cost cohort of patients admitted for heart failure and can be considered a target population for potential readmission reduction interventions.

The impact of an integrated heart failure service in a medium-sized district general hospital

ObjectivesAssessing the impact of a new integrated heart failure service (IHFS) in a medium-sized district general hospital (DGH) on heart failure (HF) mortality, readmission rates, and provision of HF care.MethodsA...