HF Readmission Research Articles

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 > 0.05). Indigenous status was a risk factor of HF readmissions according to one study (p < 0.05). Age or sex did not affect the risk of HF readmissions in adults with HF (p > 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 > 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.

Feasibility and effectiveness of a multidimensional post-discharge disease management programme for heart failure patients in clinical practice: the HerzMobil Tirol programme.

It remains unclear whether transitional care management outside of a clinical trial setting provides benefits for patients with acute heart failure (AHF) after hospitalization. We evaluated the feasibility and effectiveness of a multidimensional post-discharge disease management programme using a telemedical monitoring system incorporated in a comprehensive network of heart failure nurses, resident physicians, and secondary and tertiary referral centres (HerzMobil Tirol, HMT), METHODS AND RESULTS: The non-randomized study included 508 AHF patients that were managed in HMT (n = 251) or contemporaneously in usual care (UC, n = 257) after discharge from hospital from 2016 to 2019. Groups were retrospectively matched for age and sex. The primary endpoint was time to HF readmission and all-cause mortality within 6months. Multivariable Cox proportional hazard models were used to assess the effectiveness. The primary endpoint occurred in 48 patients (19.1%) in HMT and 89 (34.6%) in UC. Compared with UC, management by HMT was associated with a 46%-reduction in the primary endpoint (adjusted HR 0.54; 95% CI 0.37-0.77; P < 0.001). Subgroup analyses revealed consistent effectiveness. The composite of recurrent HF hospitalization and death within 6months per 100 patient-years was 64.2 in HMT and 108.2 in UC (adjusted HR 0.41; 95% CI 0.29-0.55; P < 0.001 with death considered as a competing risk). After 1year, 25 (10%) patients died in HMT compared with 66 (25.7%) in UC (HR 0.38; 95% CI 0.23-0.61, P < 0.001). A multidimensional post-discharge disease management programme, comprising a telemedical monitoring system incorporated in a comprehensive network of specialized heart failure nurses and resident physicians, is feasible and effective in clinical practice.

A-lines and B-lines in patients with acute heart failure.

Lung ultrasound (LUS) relies on detecting artefacts, including A-lines and B-lines, when assessing dyspnoeic patients. A-lines are horizontal artefacts and characterize normal lung, whereas multiple vertical B-lines are associated with increased lung density. We sought to assess the prevalence of A-lines and B-lines in patients with acute heart failure (AHF) and examine their clinical correlates and their relationship with outcomes. In a prospective cohort study of adults with AHF, eight-zone LUS and echocardiography were performed early during the hospitalization and pre-discharge at an imaging depth of 18 cm. A- and B-lines were analysed separately off-line, blinded to clinical and outcome data. Of 164 patients [median age 71 years, 61% men, mean ejection fraction (EF) 40%], the sum of A-lines at baseline ranged from 0 to 19 and B-line number from 0 to 36. One hundred and fifty-six patients (95%) had co-existing A-lines and B-lines at baseline. Lower body mass index and lower chest wall thickness were associated with a higher number of A-lines (P trend < 0.001 for both). In contrast to B-lines, there was no significant change in the number of A-lines from baseline to discharge (median 6 vs. 5, P = 0.80). While B-lines were associated with 90-day HF readmission or death, A-lines were not [HR 1.67, 95% confidence interval (CI) 1.11-2.51 vs. HR 0.97, 95% CI 0.65-1.43]. A-lines and B-lines on LUS co-exist in the vast majority of hospitalized patients with AHF. In contrast to B-lines, A-lines were not associated with adverse outcomes.

Effects of a diuretic adjustment algorithm protocol on heart failure admissions: A randomized clinical trial

Introduction The aim of this study was to evaluate the effectiveness of a diuretic adjustment algorithm (DAA) in maintaining clinical stability and reducing HF readmissions using telemonitoring technologies. Methods Randomized clinical trial of patients with an indication for furosemide dose adjustment during routine outpatient visits. In the intervention group (IG), the diuretic dose was adjusted according to the DAA and the patients received telephone calls for 30 days. In the control group (CG), the diuretic dose was adjusted by a physician at baseline only. Co-primary outcomes were hospital readmission and/or emergency department visits due to decompensated HF within 90 days, and a 2-point change in the Clinical Congestion Score and/or a deterioration in New York Heart Association functional class within 30 days. Results A total of 206 patients were included. Most patients were male (n=119; 58%), with a mean age of 62 (SD 13) years. Four patients (2%) in the IG and 14 (7%) in the CG were hospitalized for HF (odds ratio (OR) 0.31 (0.10–0.91); p=0.04). Multivariate analysis showed a reduction of 67% in readmissions and/or emergency department visits due to decompensated HF in the IG compared with the CG (95% CI 0.13–0.88; p=0.027). Regarding the combined outcome of HF readmission and/or emergency department visits or clinical instability, the IG had 20% fewer events than the CG within 30 days (IG: n=48 (23%), CG: n=70 (34%); OR 0.80 (0.63–0.93); p=0.03). Discussion Using DAA improved the combined outcome in these outpatients, with favorable and significant results that included a reduction in HF admissions and in clinical instability. (NCT02068937)

Temporal Trends of Transcatheter Edge-to-Edge Repair of the Mitral Valve Short-Term Outcomes in the United States: Nationwide Representative Study

ABSTRACT Background: Transcatheter edge-to-edge repair of the mitral valve (TEER) has recently emerged as a viable treatment option in high-risk patients with severe mitral regurgitation. The present study investigated the trends in TEER short-term outcomes during 2014–2018. Methods: We performed a retrospective study using the Nationwide Readmissions Database. We analyzed data on the in-hospital and 30-day outcomes of patients who underwent TEER procedure during 2014–2018. Results: A total of 22,914 patients underwent TEER; 1,674 in 2014, 3,252 in 2015, 4,645 in 2016, 6,000 in 2017, and 7,343 in 2018 with a median age of 78, 80, 81, and 80 years, respectively, with a 4.2 fold increase in TEER utilization. Heart failure was present in 75.6%, and 83.6% of patients, in 2014, and 2018 respectively, while 73.3%, and 85.3% of patients, respectively, had hypertension. In-hospital mortality following TEER was significantly decreased from 3.9% in 2014 to 2% in 2018 (P < 0.001). Similarly, stroke rates were decreased from 1.2% in 2014 to 1% in 2018 (P = 0.093), and the median length of hospital stay was significantly shortened from 4 to 2 days (P < 0.001). The overall 30-day readmission rate was 15.3% and did not change significantly over the study period (P = 0.876); however, the 30-day HF readmission rate exhibited a significant decline from 4.7% in 2014 to 0.6% in 2018 (P < 0.001). Conclusion: Although TEER therapy is now offered to a more critically ill and larger patient population in the United States, the outcomes of patients undergoing TEER are improving with decreasing mortality, morbidity, and hospital stay. Abbreviations: TEER: Transcatheter edge-to-edge repair of the mitral valve (TEER); NRD: National Readmissions Database; MR: Mitral Regurgitation; DMR: Degenerative Mitral Regurgitation; FMR: Functional Mitral Regurgitation; HF: Heart failure; LVEF: Left Ventricular Ejection Fraction; GDMT: Guideline-Directed Management and Therapy; AKI: Acute Kidney Injury; MI: Myocardial infarction

Systolic blood pressure and outcome in patients admitted with acute heart failure: a pooled analysis from 4 randomized clinical trials

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation Background In acute heart failure (AHF), low systolic blood pressure (SBP) has been associated with poor outcome. Less is known of the risk related to normal versus elevated SBP and interaction with left ventricular ejection fraction. Purpose The aim of the present study was to assess the association between baseline SBP and short- and long-term outcome in a large cohort of AHF-patients. Methods A pooled cohort of four randomized controlled trials investigating the vasodilator serelaxin versus placebo in patients admitted with AHF and an SBP from 125 to 180 mmHg. Endpoints were 180-day all-cause mortality and a short-term composite endpoint (worsening heart failure, all-cause mortality or hospital readmission for HF through Day 14). Left ventricular ejection fraction (LVEF) was categorized into HFrEF (&amp;lt;40%) and HFpEF (= &amp;gt;40%). Multivariable Cox regression was used and adjusted for age, sex, baseline body mass index, HFrEF, serum estimated glomerular filtration rate, allocated treatment (placebo/serelaxin), diabetes mellitus, ischemic heart disease, and atrial fibrillation/flutter. Measurements and Main Results A total of 10.533 patients with a mean age of 73 (±12) years and median SBP of 140 (130-150) mmHg were included within mean 8.2 hours from admission. LVEF was assessed in 8493 (81%), and of these, 4294 (51%) had HFrEF. Increasing SBP as a continuous variable was inversely associated with 180-day mortality (HRadjusted: 0.93 [0.88-0.98], p = 0.004 per 10 mmHg increase) and with the composite endpoint (HRadjusted: 0.90 [0.85-0.95], p &amp;lt; 0.0001 per 10 mmHg increase). A significant interaction was observed regarding LVEF, revealing that SBP was not associated with mortality in patients with HFpEF (HRadjusted: 1.01 [0.94-1.09], p = 0.83 per 10 mmHg increase), but SBP was associated with increased mortality in HFrEF (HRadjusted: 0.80 [0.73-0.88], p &amp;lt; 0.001 per 10 mmHg increase) (Figure). Conclusions Elevated SBP is independently associated with favorable short- and long-term outcome in AHF-patients. The association between SBP and mortality was, however, not present in patients with preserved LVEF. Abstract Figure. Survival plots by SBP and LVEF

Impact of readmissions on octogenarians with heart failure with preserved ejection fraction: PURSUIT-HFpEF registry.

AimsHeart failure (HF) readmissions with preserved ejection fraction (HFpEF) are increasing in the elderly, which is a major socioeconomic problem. We investigated the clinical impact of HF readmissions (HFR) on octogenarians with HFpEF.Methods and resultsWe enrolled consecutive octogenarians (≥80 years old) from June 2016 to February 2020 in PURSUIT‐HFpEF registry. We divided them into HFR group readmitted for HF during the follow‐up period and non‐HF readmission (non‐HFR) group. We evaluated the impact of HFR on all‐cause mortality, cardiac death, and quality of life (QOL). Additionally, we evaluated the factors at discharge correlated with HFR. HFR group comprised 116 patients (21.4%). Among all‐cause deaths, 40 patients suffered cardiac deaths (48.2%). The Kaplan–Meier analysis revealed a similar prognosis between HFR and non‐HFR groups as well as similar incidences of HF deaths. The QOL scores had significantly deteriorated by 1 year later in the HFR group (0.71 ± 0.19 vs. 0.59 ± 0.21, P < 0.001), while it was similar at 1 year in the non‐HFR group. In the multivariate analysis, diabetes mellitus (DM) (P = 0.019), N‐terminal pro‐B‐type natriuretic peptide (NT‐pro BNP) levels ≥ 1611 pg/mL (P < 0.001), and serum albumin level ≤ 3.7 g/dL (P = 0.011) were useful markers for HFR in octogenarians.ConclusionsIn octogenarians with HFpEF, HF readmission was not directly correlated with the prognosis but was well correlated with the QOL. Close follow‐up is essential to decrease HFR of octogenarians with HFpEF with DM, high NT‐pro BNP (≥1611 pg/mL) and low albumin (≤3.7 g/dL) levels at discharge.

Disease Management and Outcomes in Patients Hospitalized for Acute Heart Failure in Japan.

IntroductionThis study described patients hospitalized for acute heart failure (AHF) in Japan who received intravenous (IV) diuretics and/or vasodilators as the initial therapy.MethodsThe Japan Medical Data Vision database was used to identify adult patients hospitalized for AHF during 2013–2017, who were hemodynamically stable at presentation and treated with IV diuretics and/or IV vasodilators as initial therapy. Treatment patterns and use of cardiac rehabilitation, as well as outcomes (e.g., length of stay [LOS], in-hospital mortality, HF-readmission) were reported overall and by year of AHF hospitalization.ResultsOf 30,360 patients (mean age = 80.0 years; 52.2% male), 87.0% were treated during the hospitalization with IV diuretics, 63.9% with IV vasodilators, and 13.8% with intensified therapies. On average, the duration of IV therapy was 10.6 days. In-hospital cardiac rehabilitation was utilized by 51.7% of the patients for 11.7 days on average. Mean LOS was 23.3 days, while in-hospital mortality and 30-day HF readmission post-discharge were 13.2 and 9.5%, respectively. Hospitalization outcomes remained stable between 2013 and 2017 despite important changes in AHF management such as a decrease in carperitide use (55.9–40.0% in 2017), and increases in use of tolvaptan (from 14.2% in 2013 to 31.3% in 2017) and of cardiac rehabilitation (from 43.2% in 2013 to 56.1% in 2017). Patients with intensified therapies had the longest IV therapy duration (mean 23.8 days vs. 5.5–9.9 days), the highest cardiac rehabilitation services use (60.2 vs. 38.3–57.0%), the longest LOS (mean 36.7 vs. 16.3–22.2 days), and the highest in-hospital mortality (37.4 vs. 3.1–12.4%) compared to the other treatment groups.ConclusionsContemporary treatment for AHF hospitalization in Japan comprises a long duration of IV therapy followed by extended use of oral medications and in-hospital cardiac rehabilitation prior to discharge. Patients requiring intensified therapies had much longer LOS and higher in-hospital mortality.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40119-021-00212-y.

Risk Stratification of Percutaneous Edge-to-Edge Repair by MitraClip in Patients with Mitral Regurgitation.

Edge-to-edge repair using the MitraClip system is indicated in patients with severe mitral regurgitation (MR) who are at high risk for open-heart surgery due to comorbidity or reduced cardiac function. However, less is known about pre-procedural risk factors for mortality and morbidity following MitraClip implantation. Consecutive 25 patients with severe MR who underwent MitraClip therapy (mean age, 77 years old, 14 males) were included. Right heart catheterization and echocardiographic data before and after the procedure were collected and their prognostic impacts were investigated. Acute procedural success was 96%. At one week following MitraClip repair, left ventricular ejection fraction (LVEF) remained unchanged and left ventricular end-diastolic volume tended to be smaller. Cardiac index and mean pulmonary artery pressure (mPAP) were markedly improved following the procedure (P < 0.001 for both). In the multivariate analyses using baseline characteristics, both lower LVEF (hazard ratio 0.57, 95% confidence interval 0.30-0.89) and higher mPAP (hazard ratio 1.23, 95% confidence interval 1.06-1.56) were independently associated with post-procedural 1-year death or heart failure readmission (P < 0.05 for both). The lower LVEF and higher mPAP group had lower 1-year survival free from HF readmission compared with those without (16.7% versus 100%; P < 0.001). In conclusion, a combination of baseline mPAP and LVEF might be a useful tool in predicting post-MitraClip procedural clinical outcomes.

Abstract 15007: Association Of Dual Eligibility For Medicare And Medicaid With Heart Failure Quality And Outcomes Among Gwtg-hf Hospitals

Introduction: The Centers for Medicare &amp; Medicaid Services (CMS) is using a new peer group-based payment system to compare hospital performance which classifies hospitals into quintiles based on their share of dual eligible beneficiaries for Medicare and Medicaid. This study evaluated the association of percent dual eligibility for Medicare Medicaid with HF quality of care and outcomes. Methods: This is a retrospective analysis of patients hospitalized for HF using the Get With The Guidelines-HF (GWTG-HF) registry between July, 1 2010 - December 31, 2017. Study endpoints included HF process of care measures, in-hospital mortality, 30-day all-cause or HF readmissions, 30-day all-cause mortality. We included patients aged ≥65 years old with available data on dual eligibility status. Hospitals were divided into quintiles based on their share dual eligible patients. Quality and outcomes were analyzed using unadjusted and adjusted multivariable logistic regression models. Results: A total of 258,995 HF hospitalizations from 455 sites were included in the primary analysis of the study. Hospitals in the highest dual eligibility quintile (Q5) tended to care for patients who were younger, more likely female, belong to racial minority groups, or located in rural areas compared with Q1 sites. After multivariable adjustment, hospitals with the highest quintile of dual eligibility (Q5 sites) were associated with lower rates of key process measures including evidence-based beta blocker prescription (aOR: 0.70, 95% CI [0.52,0.94]), measure of left ventricular function (aOR: 0.39, 95% CI [0.21,0.72]), anticoagulation for atrial fibrillation or atrial flutter (aOR: 0.68, 95% CI [0.51,0.91]). Differences in clinical outcomes were seen with higher 30-day all-cause (aOR: 1.24, 95% CI [1.14,1.35]) and HF (aOR: 1.14, 95% CI [1.03,1.27]) readmissions in higher dual eligible Q5 sites compared to Q1 sites. Risk-adjusted in-hospital and 30-day mortality did not significantly differ in Q1 vs Q5 hospitals. Conclusions: Higher dual eligibility quintile sites were associated with lower rates of key HF quality of care process measures and higher 30-day all-cause or HF readmissions compared to lower dual eligibility quintile sites.

Abstract 15829: Temporal Characteristics of Intra-thoracic Impedance Before and After Heart Failure Hospitalizations in a Large Real-world Population of Patients With Cardiovascular Implanted Electronic Devices

Introduction: Intrathoracic impedance (IMP), measured in ICD/CRTD implantable devices, is a measure of intravascular blood volume and have been shown to correlate with intracardiac pressures. We investigated the temporal characteristics of IMP before and after HF events (HFE) in a large real-world cohort of patients (pts) with ICD/CRTD devices. Methods: We linked Optum© deidentified EHR dataset during the period from 2007-2017 to the Medtronic CareLink data warehouse. Pts with ICD/CRTD implants with IMP measurements were included. HFE was defined as an inpatient, ED, or observation unit stay with primary diagnosis of HF and IV diuretics administration. Temporal average of IMP measurement across all pts in the 60 days pre and post HFE were compared for HFE with and without readmission for HF within 60 days and in pts with no HFE. Results: A total of 17,886 pts with 1.8±1.2 years of follow-up met inclusion criteria. The average age was 66.6 ±12.3 years, with 72% being males, and 51% with ICD devices. A total of 1174 pts had 1425 HFE with no readmission and 282 pts had 295 HFE which were followed by readmission. A total of 17,839 pts had no HFE over 86,858 follow-up months. The average IMP during HFE, with and without readmission, and in pts with no HFE are shown in Fig. IMP decreases over a period of time prior to HFE and recovers due to treatment during HFE. The average IMP across all patients was lower on all 60 days pre and post HFE with readmission compared to HFE with no readmission (p&lt;0.001) and both were lower compared to follow-up period with no HFE (p&lt;0.001). The IMP recovers less often after HF events which are followed by readmission within 60 days compared to HF events with no readmission. Conclusions: In a large real-world population of pts with ICD/CRTD devices, on an average IMP reduces prior to and recovers during HFE. IMP was lower before and after HFE with readmission compared to HFE with no readmission. Readmission is more likely in pts with smaller impedance recovery after HF events.

Strauss formula: a great and easy tool to manage congestion in acute heart failure

Abstract Background Approaching the congestive patient is a complex task that requires the combination of different assessment methods. The Strauss formula uses variations in haemoglobin and haematocrit to estimate plasma volume variations (PVV) and haemoconcentration. However, this formula was only validated in outpatients followed with chronic heart failure. We aimed to assess the applicability of this formula to hospitalized patients for acute heart failure (AHF). Methods We conducted a single-centre, retrospective, observational study of 302 patients who were admitted to our hospital for AHF during 2016 and were discharged alive. Baseline clinical, laboratory and demographic characteristics were evaluated at admission and the Strauss formula was applied, as PVV (%) = 100 x [(Hb A / Hb D) x (1 − Hct D) / (1 − Hct A)] − 100), where A = admission and D = discharge. At discharge, we considered that a positive change (≥0%) in PV regarding the admission was linked to an increase in PV (haemodilution); a negative change (&amp;lt;0%) correlated to a decrease in the PV (haemoconcentration). The primary endpoint was a composite of cardiovascular death (CV-death) and HF readmission at 3-months. Results Mean age was 76±11 years and 57% were male. At baseline, 92% were on clinical-haemodynamic profile B, with a median NT-proBNP of 2157 (IQR 1161–4242) pg/dL, a mean of glomerular filtration rate (GFR) of 63±57 mL/min/m2, a mean haemoglobin of 12±2 g/dL and a mean haematocrit of 38±6%. At discharge, the median plasma volume variation was −1.1% (IQR – 9.6 to 7.8) and the distribution of PVV values in the histogram reveals that a large proportion of patients (44%) increased or maintained plasma volume (PVV ≥0% – haemodilution). The group of patients who decreased plasma volume at discharge was slightly younger (75 vs 78 years, p=0.044), showing higher numerical decreases in NT-proBNP, gamma-glutamyl transferase (gGT) and bilirubin at discharge. A positive change in PV (PVV &amp;gt;0%) during admission almost doubled the risk for readmission and CV-death at 3-months [OR 1.9 (95% CI: 1.1 to 3.1, p=0.026], after adjusting for age and sex. Conclusions In this work, we demonstrate that PVV, as calculated by the Strauss formula, increases or is unchanged in 44% of patients admitted with AHF and is strongly associated with a composite of 3-months CV death and HF readmission. Tools to guide the management of residual congestion are of great importance to assess the optimal discharge timing. Funding Acknowledgement Type of funding source: None

Prognostic value of integrated cardiopulmonary ultrasound in inpatients with acute heart failure with preserved and reduced ejection fraction and without heart failure

Abstract Objective To assess the prognostic value of B-lines integrated with echocardiography in patients admitted to a Cardiology Department, with and without acute heart failure (AHF). Background Lung-ultrasound (LUS) B-lines are sonographic signs of pulmonary congestion and can be used in the differential diagnosis of dyspnea to rule in or rule out AHF. Their prognostic value at admission is less established, as well as the different role in AHF with reduced and preserved ejection fraction (HFrEF and HFpEF), or patients admitted for cardiac conditions but without overt signs and symptoms of AHF. Methods A total of 1021 consecutive in-patients (69±12 years) admitted for various cardiac conditions were enrolled. Patients were classified into three groups: 1) acute HFrEF; 2) acute HFpEF; 3) no AHF. All patients underwent on the admission an echocardiogram coupled with LUS, according to standardised protocols. Results Patients were followed-up for a median of 14.4 months (interquartile range: 4.6–24.3) for death and HF readmission (composite endpoint). During the follow-up, 126 events occurred. Kaplan-Meier survival analyses showed admission B-lines &amp;gt;30 identified patients with worse outcome at follow-up in the overall population and each of the three groups (Figure). At multivariable analysis (Table), admission B-lines &amp;gt;30, EF &amp;lt;50%, tricuspid regurgitation velocity &amp;gt;2.8 m/s and tricuspid annular plane systolic excursion (TAPSE) &amp;lt;17 mm resulted in independent predictors of the composite endpoint. B-lines &amp;gt;30 had a strong predictive value in HFpEF and non-AHF, but not in HFrEF. Conclusions Ultrasound B-lines can detect subclinical pulmonary interstitial edema in patients thought to be free of congestion, and provide useful information not only for the diagnosis but also for the prognosis in different cardiac conditions. Their added prognostic value among standard echocardiographic parameters is stronger in patients with HFpEF compared to HFrEF. Figure 1 Funding Acknowledgement Type of funding source: None

Remote TELEmonitoring and Health Coaching for patients with acute heart failure: results of the TELE-HC randomized trial

Abstract Introduction Patients discharged after acute decompensated heart failure (ADHF) have elevated risk for readmission due to multiple factors including suboptimal behavioral and social support. Telemonitoring interventions have shown inconsistent effectiveness in reducing HF readmissions. Patient-centered health coaching, when combined with telemonitoring, may be a viable model to engage patients in self-care behaviors and enhance patient experiences following acute hospitalization. Purpose This multicenter randomized trial evaluates whether remote telemonitoring combined with health coaching decreases 60 day readmission rates for patients with ADHF when compared to standard of care. Methods Patients with primary or secondary diagnosis of ADHF were consented and randomized prior to hospital discharge to either standard care or intervention of remote telemonitoring and health coaching. Within 2 days of hospital dismissal, intervention patients were onboarded to the remote monitoring platform, which links personal health sensors which collect on-body physiologic measures (ECG, heart rate, respiration rate, and activity via 3-axis accelerometer) with providers through secure mobile communication. A registered nurse was designated as the primary health coach focusing on disease management - including symptom recognition, adherence to treatment strategies, care coordination, medication matters, and problem solving. A social worker and nutritionist were also assigned. The primary outcome was all-cause mortality or readmission within 60 days of hospital dismissal. Statistical analysis included stratified log-rank tests and stratified Cochran-Mantel-Haenszel Chi-square test to account for site-stratified randomization. Results The study was halted due to low rate of subject accrual. Of planned 304 subjects, 143 were randomized between 2015 and 2019 at 6 sites in the United States. Dropout and withdrawal after randomization of 32 subjects (22%) left 112 analyzable for the primary endpoint. Many subject withdrawals after unblinded disclosure of arm allocation were related to treatment assignment. Immediate withdrawal without follow up in these subjects precluded an intention-to-treat analysis. Mean age was 69 years and subjects were more often male (56%) and non-Hispanic white (70%). In per-protocol analysis, using subjects adherent to protocol specified visits (n=112), we observe no difference in the primary outcome (26% among intervention vs 28% among standard care, Figure, p=0.77). There were also no differences among secondary outcomes of overall mortality (2% vs 7%, p=0.20) or composite emergency department visit, hospital admission, or death (35% vs 34%, p=0.85). Conclusions Among patients with heart failure, an intervention of remote telemonitoring and health coaching did not reduce all-cause readmission or mortality. Significant withdrawal rates suggest future studies may need to improve screening and study retention. Figure 1 Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institutes of Health, National Institute on Aging

Impact of Physical Function and Exercise Capacity on the Outcomes In Hospitalized Elderly Patients with Acute Heart Failure

Background Functional decline due to skeletal muscle abnormalities or frailty in elderly patients with heart failure, demonstrates poor outcomes. The Short Physical Performance Battery (SPPB) is a comprehensive measure of physical performance. Objectives The aim of this study was to examine the prognostic significance of SPPB in comparison with that of the 6-minute walking distance (6MWD) test, in elderly patients hospitalized for acute decompensated heart failure (ADHF). Methods This is a post-hoc analysis from a prospective, observational, multicenter cohort study, that enrolled consecutive elderly ADHF patients. Results were analyzed for 1,192 patients, in whom the SPPB and 6MWD were measured during the hospitalization. Primary outcome measure was defined as a composite of all-cause death and HF readmission till one year after discharge. Results The median age was 81 years, 57.2 % were male and the median left ventricular ejection fraction was 45%. During follow-up, there were 138 deaths and 322 HF readmissions. Patients with lower SPPB scores (0 to 6, n=373) had significantly poorer outcomes than those with higher SPPB scores (7 to 12, n=819) even after adjustment for multivariable factors (adjusted HR: 1.28, 95% CI: 1.01 to 1.61, p=0.049), similar to those with shorter 6MWD ( Conclusions Impaired physical function, assessed by SPPB, was associated with poorer outcomes. Thus, the evaluation of muscular functional capacity is important in the management of elderly patients with ADHF.

Neighborhood Matters For Transitional Care and Heart Failure Hospital Readmission

Introduction The social and economic conditions of where people live has been associated with HF hospital readmission. Multidisciplinary transitional care is effective to decrease HF readmission, but the impact of neighborhood disadvantage on transitional care is unknown. Early provider follow-up and nursing care coordination have unique contributions to transitional care and HF outcomes. The purposes of this study were to examine the relationship between early provider follow-up, nursing care coordination, and hospital readmission in a population of older adults with HF, and determine if an interaction exists with neighborhood disadvantage. Hypothesis There is a direct relationship between early provider follow-up and decreased HF readmission and an indirect relationship through nursing care coordination intensity that is moderated by neighborhood disadvantage. Methods A retrospective, correlational design utilized existing data. Data were from medical records and billing databases. Home addresses from index admissions were geocoded to census block groups and linked to the 2015 Area Deprivation Index database. Logistic regression was used to compare patients by readmission and early provider follow-up status. Moderated mediation analysis included ordinary least squares regression, logistic regression, and bootstrap confidence intervals to test the hypothesis. Results Of 1280 subjects, mean (SD) age was 79 (8.66) years, 50.7% were female, and 25.9% were non-white. In multivariable analysis, early provider follow up decreased the odds of readmission (OR 0.70 [CI, 0.50, 0.97], p=.032) and having 2 care coordination contacts increased the odds of readmission (OR 1.67 [1.07, 2.60], p=.024). Neighborhood disadvantage decreased the odds of having an early provider visit (OR 0.67 [0.49, 0.93], p=.015) and having a care coordination contact within 3 days of hospital discharge increased the odds of a provider visit two-fold (OR 2.13 [1.67, 2.72], p Conclusions Neighborhood disadvantage influences participation in transitional care interventions for the elderly HF population. An interventional study that examines the combined effect of care coordination and provider follow-up on HF readmission, using innovative processes to reach the most disadvantaged populations is needed.

Inspire - HF Manifesto Reduces Readmissions And Improves Outcomes In Chronic Heart Failure

Introduction Multiple co-morbidity is common in patients with HF increasing their risk for poor health outcomes. In the US, approximately 40% of Medicare beneficiaries with HF have >5 non-cardiac conditions and this group accounts for >80% of the total inpatient HF-related hospital days in the US. Annual total costs for HF is more than $ 40 B and the majority (61%) of hospital readmissions are attributable to multimorbidity and occur within 15-days of discharge. Most of these HF admissions and readmissions are preventable. A proactive management strategies are needed to address all comorbidities such as hypertension, diabetes, dyslipidemia, metabolic derangement, worsening renal function, and repetitive hospitalizations that ultimately lead to loss of psychosocial and financial independence, anxiety, depression, poor coping skills, falls, sarcopenia and death. Hypothesis Use of a novel framework such as INSPIRE -HF will address multiple comorbidities and improve outcomes Methods A comprehensive, multidisciplinary, nurse-directed, physician guided heart failure management program including those with CKD was started in 2017. The goal of the Cardiorenal center is to reduce 30-day hHF, 90-day hHF, optimize GDMT, improve QOL, prevent CKD progression, and enhance survival .The program consists of intensive face to face weekly or bimonthly encounters in patients enrolled at this clinic within a week after discharge from the hospital for CHF. The multicomponent program consists of the INSPIRE HF framework: 1) Identify individualized priorities and nature of multimorbidity, 2) Nutrition intervention including management of diabetes, obesity, hypertension, dyslipidemia and poor functional capacity, 3) Stabilize fluid status 4) Psychosocial motivational empowerment and financial assistance as needed, 5) Initiate GDMT 6) Revisit comorbidities with biomarker assessments and 7) Education and exercise programs including EECP therapy for those who qualify. A total of 162 patients discharged from the hospital enrolled within a week at the clinic were followed for 30 months on a weekly or bimonthly basis. Results A total of 162 patients (Men 66 %, Systolic HF 69%, Ischemic etiology 55%, 35 % with diabetes, 27 % hypertensive and 58 % with CKD) were started on the INSPIRE Strategy driven protocol. Total of 27 patients (16 %) were admitted during the 30-month period of which 8 patients (5%) were readmitted within 30 days and 19 patients (11%) were readmitted in the subsequent 180 days. Twenty-seven patients have died (16.7%) during this period. Fifty-nine patients received IV diuretics at some point during their visits and averted readmission (37%). More than 90% improved by at least 1 NYHA functional class. Conclusion A comprehensive multiple comorbidity management strategy in a nurse directed physician guided outpatient cardiometabolic renal center using the INSPIRE HF manifesto improves HF outcomes.

Independent and cumulative association of clinical and morphological heart failure with long-term outcome after percutaneous coronary intervention

BackgroundHeart failure (HF) is a risk factor for adverse post-procedural outcome after revascularization; however, it is unclear how left ventricular systolic dysfunction (LVSD) and clinical HF symptoms affect percutaneous coronary intervention (PCI) outcomes. We investigated the characteristics and long-term outcomes of patients with clinical HF or LVSD after PCI. MethodsThis was a Japanese multicenter registry study of adult patients receiving PCI. Among 4689 consecutive patients who underwent PCI at 15 hospitals from January 2009 to December 2012, we analyzed 2634 (56.2%) with documented left ventricular ejection fraction (LVEF). They were divided into four groups based on clinical HF (symptoms or HF hospitalization) and LVEF [≥35% and <35% (HF due to LVSD)]. The primary outcome was major adverse cardiovascular events (MACE), comprising all-cause death, acute coronary syndrome, HF hospitalization, performance of coronary artery bypass grafting, and stroke within 2 years after the initial PCI. ResultsOur findings revealed 354 patients (13.4%) with HF (clinical HF, n = 173, 48.9%; LVSD, n = 132, 37.3%; both, n = 49; 13.8%). The incidence of MACE was higher in patients with clinical HF or LVSD, and was largely due to higher non-cardiac death and HF hospitalization. After adjustment, clinical HF (hazard ratio 2.16, 95% confidence interval; 1.49−3.14) and lower LVEF (per 10%, hazard ratio 0.89, 95% confidence interval; 0.81−0.99) were independently associated with higher MACE risk. ConclusionsClinical HF and LVSD were independently associated with adverse long-term clinical outcomes, particularly with non-cardiac death and HF readmission, in patients treated with PCI.

Illuminating Hospital Disparities in Readmissions for Patients with Social Risk Factors: Comparing Hospital Performance Using Two Different Approaches

Research ObjectiveSocioeconomic disparities in hospital readmissions for Medicare patients are well established. Medicare currently provides hospitals with within‐hospital disparities in readmission using dual eligibility status as a social risk factor. Community‐based social risk factors, such as the AHRQ SES Index (ASI), may allow capture of different types of information regarding social risk, as compared to income and assets, which are principally used for establishing dual eligibility. This study examines concordance of within‐hospital disparities in 30‐day readmission rates for Medicare patients that arise from dual eligibility status and ASI, and how this concordance varies across patients admitted for three common clinical conditions (AMI, HF, and pneumonia).Study DesignWe conducted a retrospective cohort study of hospitalized Medicare fee‐for‐service (FFS) patients meeting the inclusion criteria for the 30‐day AMI, HF, and PN hospital readmission measures used by Medicare. We used Medicare Part A and B Standard Analytic Files and Enrollment Files to identify the study cohort, clinical risk factors for adjustment, and enrollment information. We calculated the within‐hospital disparity score, for each hospital, using dual eligibility (defined as full‐benefit Medicaid enrollment at time of discharge) and the ASI score for beneficiary 9‐digit ZIP code of residence. Using the method currently used by CMS for estimating within‐hospital disparities, we calculated the hospital‐specific disparity effect for each hospital and each social risk factor for each of the three conditions. Disparity effects are reported as hospital‐specific odds ratios (ORs) and absolute risk differences; we calculated the Spearman rank‐order correlations between the two disparity effects for each condition.Population StudiedHospitalized U.S. Medicare FFS patients aged 65 years and older admitted to U.S. acute care, critical access, and Veterans Affairs hospitals from July 1, 2015, to June 30, 2018.Principal FindingsThe final sample included 3,126,185 Medicare FFS admissions to 4,730 U.S. hospitals. Both dual eligibility (mean ORs for three conditions ranging from 1.04 to 1.08) and AHRQ SES Index (mean ORs ranging 1.03‐1.05) were associated with higher adjusted odds of 30‐day readmission. However, hospital‐specific disparity effects for the two risk factors were uncorrelated for AMI (Spearman’s correlation □ = ‐0.017, P = .28), weakly correlated for HF (□ = 0.10, P &lt; .001), and moderately correlated for PN (□ = 0.49, P &lt; .001). Results were similar for absolute risk differences.ConclusionsDisparities in 30‐day readmission rates for hospitalized Medicare patients may differ across different dimensions of social risk, depending on the reason for admission. Within‐hospital disparities related to different social risks may capture distinct effects, according to patient condition.Implications for Policy or PracticeEfforts to illuminate socioeconomic disparities in hospital outcomes will benefit from examination of different social risk factors; a single social risk factor may not fully capture the impact of disparities in outcomes.Primary Funding SourceThe study was funded by the Centers for Medicare and Medicaid Services.

Novel Data Domains and Machine Learning Modestly Improved Performance of Risk Calculators for Heart Failure Readmission

Research ObjectiveHeart failure (HF)–related hospitalizations are a growing public health burden, especially among older adults. Risk calculators for HF readmissions identify patients at high risk for readmissions who may benefit from outpatient interventions to improve outcomes and prevent readmissions. We hypothesized that incorporating additional variables and using machine learning approaches would improve the performance of these existing 30‐day readmission risk calculators.Study DesignWe evaluated the performance of several published risk calculators for predicting 30‐day readmission after heart failure hospitalizations: 1) using updating the coefficients based on data from a new, ethnically diverse HF population; 2) developing a new model that incorporates additional variables in addition to updated coefficients; and 3) developing new models with all variables using machine learning approaches. We used an 80%/20% split sampling for development and validation testing. The risk calculators tested included the LACE+ Index and Yale CORE, which included traditional clinical variables such as comorbidities, laboratory values, prior utilization, and vital signs. For the model with additional variables, we included all variables used in the original models with the addition of Comorbidity Point Score (COPS), Laboratory‐based Acute Physiology Score (LAPS), cardiovascular medications, discharge status, and socioeconomic status. We evaluated the original model and the original plus model, the additional variables using logistic regression. For the machine learning approaches, we used lasso penalized regression and gradient boosting with k‐fold cross‐validation to avoid overfitting. We assessed model performance using area under the curve (AUC) and calibration plots.Population StudiedWe identified 38,234 adults hospitalized for HF between 2012 and 2017 within Kaiser Permanente Northern California, an integrated health care delivery system covering over 4.4 million members.Principal FindingsDiscrimination (AUC) was poor using original models, LACE+ [0.60 (0.59‐0.62)] and Yale CORE [0.57 (0.56‐0.59)]. Including the additional variables resulted in a small improvement in AUC: LACE+ [0.62 (0.60‐0.64)] and Yale CORE [0.62 (0.60‐0.64)]. The lasso model [0.67 (0.65, 0.68) and gradient boosting model [0.67 (0.65‐0.68)] resulted in greater improvement. Calibration plots showed generally good calibration across all models with modest improvements after adding the additional data domains and using the machine learning approaches.ConclusionsIncorporating additional data domains led to small, statistically significant improvements in model discrimination while maintaining good calibration for published models to predict readmission. Machine learning approaches resulted in even greater improvement and overall moderate discrimination.Implications for Policy or PracticeWe were able to increase the utility of these published risk calculators for readmission after discharge from a HF hospitalization by including additional data domains and using machine learning approaches. Health systems attempting to adapt published risk calculators for readmissions should consider including these data domains and using machine learning approaches to improve performance.Primary Funding SourceThe Permanente Medical Group Delivery Science Research Program.