Hospital Admission For Heart Failure Research Articles

Comparative effectiveness of second line oral antidiabetic treatments among people with type 2 diabetes mellitus: emulation of a target trial using routinely collected health data

ObjectiveTo compare the effectiveness of three commonly prescribed oral antidiabetic drugs added to metformin for people with type 2 diabetes mellitus requiring second line treatment in routine clinical practice.DesignCohort study...

Lower odds of successful community discharge after medical hospitalization for Veterans with schizophrenia: A retrospective cohort study of national data

Medical comorbidity, particularly cardiovascular diseases, contributes to high rates of hospital admission and early mortality in people with schizophrenia. The 30 days following hospital discharge represents a critical period for mitigating adverse outcomes. This study examined the odds of successful community discharge among Veterans with schizophrenia compared to those with major affective disorders and those without serious mental illness (SMI) after a heart failure hospital admission. Data for Veterans hospitalized for heart failure were obtained from the Veterans Health Administration (VHA) and Centers for Medicare & Medicaid Services between 2011 and 2019. Psychiatric diagnoses and medical comorbidities were assessed in the year prior to hospitalization. Successful community discharge was defined as remaining in the community without hospital readmission, death, or hospice for 30 days after hospital discharge. Logistic regression analyses adjusting for relevant factors were used to examine whether individuals with a schizophrenia diagnosis showed lower odds of successful community discharge versus both comparison groups. Out of 309,750 total Veterans in the sample, 7377 (2.4%) had schizophrenia or schizoaffective disorder and 32,472 (10.5%) had major affective disorders (bipolar disorder or recurrent major depressive disorder). Results from adjusted logistic regression analyses demonstrated significantly lower odds of successful community discharge for Veterans with schizophrenia compared to the non-SMI (Odds Ratio [OR]: 0.63; 95% Confidence Interval [CI]: 0.60, 0.66) and major affective disorders (OR: 0.65, 95%; CI: 0.62, 0.69) groups. Intervention efforts should target the transition from hospital to home in the subgroup of Veterans with schizophrenia.

Timing of previous heart failure hospitalization as a prognostic factor for emergency department heart failure patients.

To investigate whether the timing of a previous hospital admission for acute heart failure (AHF) is a prognostic factor for AHF patients revisiting the emergency department (ED) in the subsequent 12-month follow-up. All ED AHF patients enrolled in the previously described EAHFE registry were stratified by the presence or absence of an AHF hospitalization admission in the prior 12months. The primary outcome was 12-month all-cause mortality postED visit. Secondary end points were hospital admission, prolonged hospitalization (> 7days), mortality during hospitalization and a 90-day post-discharge adverse composite event (ACE) rate, defined as ED revisits due to AHF, hospitalizations due to AHF, or all-cause mortality. Outcomes were adjusted for baseline and AHF episode characteristics.Of 5,757 patients included, the median age was 84years (IQR 77-88); 57% were women, and 3,759 (65.3%) had an AHF hospitalization in the previous 12months. The 12-month mortality was 37% (41.7% vs. 28.3% p < 0.001), hospital admission was 76.1% (78.8% vs. 71.1% p < 0.001) ACE was 60.2% (65.1% vs. 50.5% p < 0.001). In the adjusted analysis, patients with AHF hospitalization in the prior 12months had a higher mortality (HR = 1.41; 95% CI 1.27-1.56), 90-day ACE rate (HR = 1.45: 95% CI 1.32-1.59), and more hospital admissions (OR = 1.32; 95% CI 1.16-1.51), with shorter times since the previous hospitalization being related to the outcomes analyzed. One-year mortality, adverse events at 90days, and readmission rates are increased in ED AHF patients previously admitted within the last 12months.

Exposure-response associations between chronic exposure to fine particulate matter and risks of hospital admission for major cardiovascular diseases: population based cohort study

ObjectiveTo estimate exposure-response associations between chronic exposure to fine particulate matter (PM2.5) and risks of the first hospital admission for major cardiovascular disease (CVD) subtypes.DesignPopulation based cohort study.SettingContiguous US.Participants59 761...

Gender differences in clinical features and outcomes of patients over 75 years presenting with acute heart failure. Results of a nationwide study (2016-2019).

Heart failure (HF) is a major health problem in Western countries, and a leading cause of hospitalizations and death. There is a scarcity of data on the influence of sex on HF outcomes in elderly patients. The aim of the present study was to analyze differences between men and women in clinical characteristics, in-hospital mortality, 30-day HF readmission rates, cardiovascular mortality and HF readmission rates at 1 year after discharge in patients older than 75 years hospitalized for HF in Spain. Retrospective analysis of patients discharged with a main diagnosis of HF from all Spanish public hospitals between 2016 and 2019. Patients aged 75 years or older were selected, and a comparison was made between male and female patients. From 2016 to 2019, a total of 354,786 episodes of HF in this age subgroup were identified, 59.2% being women. The overall mean age was 85.2 ± 5.4 years, being higher in women (85.9 ± 5.5 vs. 84.2 ± 5.3 years, p < 0.001). Risk-adjusted in-hospital mortality was lower in women (odds ratio [OR]: 0.96, 95% confidence interval [CI]: 0.92-0.97; p < 0.001). Female sex also showed a protective effect for 30-day readmissions, with an OR of 1.06 (95% CI: 1.04-1.09; p < 0.001). One-year cardiovascular mortality (24.1% vs. 25.0%; p < 0.001) and one-year HF readmission rates (30.8% vs. 31.6%; p = 0.001) were lower in women. Almost 60% of hospital admissions for HF in people aged 75 years or older between 2016 and 2019 in Spain were female patients. Female sex seems to play a protective role on in-hospital mortality and the rate of admissions and mortality at 1 year after discharge.

Extended septal myectomy for obstructive hypertrophic cardiomyopathy and its impact on mitral valve function.

Septal myectomy is the treatment of choice for hypertrophic obstructive cardiomyopathy (HOCM). Around 30-60% of patients with HOCM have a secondary mitral valve regurgitation due to systolic anterior motion (SAM). We report our experience with extended septal myectomy and its impact on the incidence of concomitant mitral valve procedures. This is a retrospective study on 84 patients who underwent SM from January 2008 to February 2022. Surgical procedure was performed according to the concept of 'extended myectomy' described by Messmer in 1994. Follow-up outcomes in terms of survival, hospital admissions for heart failure or MV disease, cardiac reoperations, and pacemaker (PMK) implantation were recorded. Mean age was 61 ± 15 years. Mitral valve surgery was performed in seven cases (8%); particularly only one patient without degenerative mitral valve disease underwent mitral valve surgery, with a plicature of the posterior leaflet. In-hospital mortality was 5%. Mitral valve regurgitation greater than mild was present in four patients (5%) at discharge. Twelve-year survival was 78 ± 22%. Cumulative incidence of rehospitalization for heart failure and rehospitalization for mitral valve disease was 10 ± 4 and 2.5 ± 2.5%, respectively. PMK implantation was 5% at discharge, with a cumulative incidence of 15 ± 7%. Freedom from cardiac reoperations was 100%. Septal myectomy for HOCM is associated with good outcomes. Although concomitant surgery on the mitral valve to address SAM and associated regurgitation has been advocated, these procedures were needed in our practice only in patients with intrinsic mitral valve disease. Adequate myectomy addresses the underlying pathophysiology in most patients.

Home Hospital Outcomes for Acute Decompensated Heart Failure and Factors Associated With Escalation of Care.

Overall outcomes and the escalation rate for home hospital admissions for heart failure (HF) are not known. We report overall outcomes, predict escalation, and describe care provided after escalation among patients admitted to home hospital for HF. Our retrospective analysis included all patients admitted for HF to 2 home hospital programs in Massachusetts between February 2020 and October 2022. Escalation of care was defined as transfer to an inpatient hospital setting (emergency department, inpatient medical unit) for at least 1 overnight stay. Unexpected mortality was defined as mortality excluding those who desired to pass away at home on admission or transitioned to hospice. We performed the least absolute shrinkage and selection operator logistic regression to predict escalation. We included 437 hospitalizations; patients had a median age of 80 (interquartile range, 69-89) years, 58.1% were women, and 64.8% were White. Of the cohort, 29.2% had reduced ejection fraction, 50.9% had chronic kidney disease, and 60.6% had atrial fibrillation. Median admission Get With The Guidelines HF score was 39 (interquartile range, 35-45; 1%-5% predicted inpatient mortality). Escalation occurred in 10.3% of hospitalizations. Thirty-day readmission occurred in 15.1%, 90-day readmission occurred in 33.8%, and 6-month mortality occurred in 11.5%. There was no unexpected mortality during home hospitalization. Patients who experienced escalation had significantly longer median length of stays (19 versus 7.5 days, P<0.001). The most common reason for escalation was progressive renal dysfunction (36.2%). A low mean arterial pressure at the time of admission to home hospital was the most significant predictor of escalation in the least absolute shrinkage and selection operator regression. About 1 in 10 home hospital patients with HF required escalation; none had unexpected mortality. Patients requiring escalation had longer length of stays. A low mean arterial pressure at the time of admission to home hospital was the most important predictor of escalation of care in the least absolute shrinkage and selection operator logistic regression model.

Impact of pharmacological treatment for heart failure after myocardial recovery in arrhythmia-induced cardiomyopathy

Abstract Introduction There is scarce evidence regarding the optimal medical treatment of patients with heart failure and recovered LVEF. To date, no study has analyzed the efficacy of maintaining neurohormonal blockade in patients with arrhythmia-induced cardiomyopathy (AiCM) after LVEF normalization. Purpose The aim of this study is to analyze impact of pharmacological treatment for heart failure in preventing heart failure relapse after myocardial recovery in AiCM. Methods We analyze data from a single-center cohort of 200 patients admitted for heart failure and ventricular dysfunction initially attributed to AiCM between 2008 and 2020. Myocardial recovery was defined as an improvement in LVEF up to &amp;gt; = 50% (complete recovery) or an increase of &amp;gt; = 10% up to a value of LVEF &amp;gt;= 40% (partial recovery). Heart failure relapse was defined as a decrease in LVEF to &amp;lt;50% in those with previous complete recovery or a decrease of &amp;gt; = 10% in patients with partial recovery, unplanned Emergency Department (ED) visit or hospital admission for heart failure. As drug prescriptions are not constant over follow up, changes in medication have been recorded and time varying covariates were used for statistical analysis. A Fine and Gray competing-risk multivariate regression was performed, adjusting for initial LVEF at admission, degree of myocardial recovery (complete or partial), presence of underlying cardiomyopathy and age, considering death as competing risk. Results Over a median of 6.14 years, most of the patients had a complete myocardial recovery (n = 164; 82.0%). 24 patients (12%) had partial recovery and 12 patients (6.0%) did not show significant improvement in ventricular function. At the moment of myocardial recovery, ACEI/ARB/ARNI were prescribed in 160 patients (85.11%); beta-blockers in 170 (90.43%); ARB in 112 (59.57%); iSGLT2 in 8 (4.26%); antiarrhythmic drugs in 75 (39.89%) and Digoxin in 40 (21.28). From 188 patients with initial LVEF recovery, 64 (34.04%) had a relapse of systolic dysfunction. 65 patients (34.57%) required unplanned Emergency Department (ED) visits and 40 patients (21.28%) needed hospital admission for heart failure. Maintenance of ACEI/ARB/ARNI and beta-blockers after myocardial recovery was associated with a significant lower risk of HF relapse [sHR 0.43 (95% CI 0.26 - 0.73), p 0.002 for ACEI/ARB/ARNI]; [sHR 0.52 (95% CI 0.29 - 0.92), p 0.025 for beta-blockers]. ARM was associated with a non-significant lower risk of HF relapse [sHR 0.67 (95% CI 0.42 - 1.09), p 0.093]. Treatment with antiarrhythmic drugs [sHR 0.90 (95% CI 0.54 - 1.51), p 0.696] and Digoxin [sHR 0.90 (95% CI 0.54 - 1.51), p 0.696] did not show benefit in this study. Conclusions Maintenance of ACEI/ARB/ARNI and beta-blockers after myocardial recovery was associated with a significant lower risk of HF relapse after myocardial recovery in patients with AiCM.Risk of HF relapse - ACEI ARB ARNIRisk of HF relapse - BetaBlockers

Efficacy of intravenous iron therapy in iron-deficient patients with heart failure: an updated systematic review and meta-analysis

Abstract Background/Introduction Iron deficiency is a common finding in chronic diseases such as heart failure (HF), as well as being a predictor of worse functional class and a higher risk of death in patients with a reduced/moderated reduced left ventricular ejection fraction (HFrEF/HFmrEF). Despite numerous trials evaluating iron supplementation in patients with HF and iron deficiency, the impact on mortality and hospitalisations is not well-established. Purpose The aim of our study was to assess the efficacy of IV iron supplementation on clinical and blood biochemical outcomes in iron-deficient patients with heart failure (HFmrEF and HFrEF). Methods We systematically searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials for randomised controlled trials (RCTs) studying the effects of iron therapy in patients with HF. Statistical analysis was performed using RevMan 5.1.7. Heterogeneity was assessed with I² statistics; p-values inferior to 0.10 and I²&amp;gt;25% were classified with significant heterogeneity. Results Ten RCTs were included comprising a total of 3447 participants, of whom 1810 (52.5%) have received iron infusion. The 6-minute walk distance after 12 weeks of treatment was significantly higher in those who received iron supplementation (MD 54.23; 95% CI 25.41-83.05; p = 0.0002; I² = 64%; Fig. number 1A). Hospital admissions for heart failure were significantly lower in patients randomised to iron therapy when compared with the control group (OR 0.57; 95% CI 0.46-0.70; p &amp;lt;0.001; I² = 17%; Fig. number 1B). There was no statistically significant difference among groups regarding cardiovascular death (OR 0.87; 95% CI 0.71-1.07; p = 0.19; I² = 0%; Fig. number 2A ), all-cause hospitalisations (OR 1.00; 95% CI 0.37-2.73; p = 1.00; I² = 81%; Fig. number 2B), and hospital admissions for cardiovascular causes (OR 0.72; 95% CI 0.4-1.33; p = 0.3; I² = 77%). Ferritin levels have shown a significant increase (MD 212.34; 95% CI 127.05-297.62; I² = 98%). Conclusion(s) This meta-analysis suggests that intravenous iron supplementation in patients with heart failure and iron deficiency was associated with a lower risk of hospital admissions for heart failure and improved exercise capacity, albeit with inconclusive data about the reduction in cardiovascular mortality.Relevant clinical outcomesSecondary relevant clinical outcomes

Validation of the GRACE 3.0 score and redefinition of the risk threshold for early invasive treatment in non-ST-segment elevation acute coronary syndromes: a modelling study from five countries

Abstract Background Clinical use of the GRACE scoring system is recommended across international guidelines to guide early treatment stratification in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). Recently, the machine learning-based GRACE 3.0 score was derived from patients with NSTE-ACS undergoing contemporary treatment approaches. External validation studies and the reassessment of clinical risk categories are lacking. Purpose We aimed to evaluate the predictive performance of the GRACE 3.0 score and to explore clinically meaningful risk groups in contemporary patients with NSTE-ACS. Methods We studied the GRACE 3.0 score in 8070 patients with NSTE-ACS in contemporary ACS cohorts from Denmark (VERDICT, n=2147), Germany (Heidelberg-ACS, n=2034), Italy and Spain (CORALYS, n=1650), and Switzerland (SPUM-ACS, n=2239). Heterogeneity in the treatment effect of very early invasive management (within 12 hours) or standard invasive management (within 48 to 72 hours) on the primary composite outcome of all-cause death, nonfatal recurrent myocardial infarction, hospital admission for refractory myocardial ischemia, or hospital admission for heart failure in relation to baseline mortality risk was assessed in 2147 patients enrolled in the VERDICT trial who were randomized to different timing of invasive treatment. Results The GRACE 3.0 score showed excellent discriminatory properties with an area under the receiver operating characteristic curve (AUC) for in-hospital death of 0.89 (95% CI, 0.85–0.93) in the total study cohort. Similar results were observed in Denmark (AUC 0.93, 95% CI, 0.88–0.98), Germany (AUC 0.90, 95% CI, 0.85–0.94), and Italy and Spain (AUC 0.85, 95% CI, 0.77–0.94), and Switzerland (AUC 0.93, 95% CI, 0.86–1.00). Early invasive treatment reduced the composite endpoint (absolute risk reduction: 0.12, 95% CI, 0.03–0.21, P=0.011) in patients at high risk (≥1.7%), but not in those with lower risk profiles (P interaction=0.033). Based on this new high-risk threshold, GRACE 3.0 stratified 475 (42.2%) more patients into the high-risk group, as compared to traditional GRACE risk categories (P&amp;lt;0.001). Conclusion GRACE 3.0 shows unprecedented predictive performance in patients with NSTE-ACS. In the context of a comprehensive clinical evaluation, GRACE 3.0 can support clinical decision making for the timing of invasive treatment. The high-risk group of patients with NSTE-ACS who benefit from early invasive treatment is substantially larger than previously described.ROC curve and risk groupsRestratfication towards high risk group

A universal electronic consultation programme at the cardiology department after general practitioner referrals improves healthcare outcomes in patients with health failure

Abstract Background Electronic consultation (e-Consult) is an emerging health care innovation developed to address excess wait times for specialist care by enabling primary care physicians (PCPs) to obtain a specialist consultant’s expert opinion in a timely manner 1. A recent wait time report in England showed that in the first 7 months of 2017, 89.4% of patients waited up to 18 weeks to see a specialist. This result failed to meet their standard of 92% of patients waiting no more than 18 weeks for their consult 2. e-Consult services were shown to be effective in terms of providing faster access to specialist’s advice, with short response times (from 1 to 6 days) of the participating specialists and resulting in substantial avoidance of face-to-face referral visits 3. The recent ESC HF guideline made a "may be considered" recommendation for the use of home-based telemonitoring, according on a meta-analysis published in 2017 4,5. Nevertheless, never has been evaluated the impact on access to care and clinical outcomes of a clinician-to-clinician e-consult program as a first step for all the PCPs referrals to cardiologist in heart failure patients. Purpose We aimed to assess in patients with heart failure (HF) the clinical impact of the implementation of an outpatient care model that includes an initial e-consultation (from 2013 to 2021) and to compare it with a one-time in-person consultation model (from 2010 to 2012) for all the primary care physicians’ referrals to a cardiology department. Methods We selected 6,859 HF patients who visited the cardiology service at least once between 2010 and 2021: 4,851 were attended in e-consultation and 2,008 in one-time in-person consultations. Using an interrupted time series regression model, we analysed the impact of incorporating e-consultation into the health care model (started in 2013), and evaluated the elapsed time to cardiology care, cardiovascular (CV) and HF hospital admissions, and HF, CV and all-cause mortality. Results The interrupted time series regression model showed that the introduction of e-consultation substantially decreased waiting times to cardiology care (8.6 [8.7] vs 55.4 [79.9] days, p&amp;lt;0.001). and a reduction in the need for visits to the emergency department 1-year after e-consultation compared with the previous period (HR [IC95%]: 0.07 [0.05-0.08]). After e-consultation implantation, hospital admissions were reduced (RRi [IC95%]: 0,867 [0,875-0,838] for HF, 0,838 [0,825-0,856] for CV and 0,639 [0,635-0,651] all-cause), figure 1; and lower mortality (RRi [IC95%]: 0,981 [0,977-0,983] due to HF, 0,977 [0,970-0,980] for CV and 0,985 [0,984-0,985] for all-cause), figure 2. These results were maintained during the COVID-19 pandemic. Conclusion In HF patients, an outpatient care program that includes an e-consultation significantly reduced waiting times to cardiology care and was safe, with a lower rate of hospital admissions and mortality in the first year.Figure 1Figure 2

Myocardial performance index improves prediction of major adverse cardiovascular events and heart failure in type 1 and type 2 diabetes without known heart disease: Thousand&amp;1 and Thousand&amp;2 study

Abstract Background Cardiovascular disease (CVD) is the leading cause of mortality and morbidity in type 1 (T1D) and type 2 diabetes (T2D). Despite myocardial involvement in diabetes, current risk prediction models do not include parameters of the myocardial function. Myocardial performance index (MPI) reflects left ventricular systolic and diastolic function. The prognostic value of MPI has not been evaluated in larger-scale diabetes populations. Purpose To assess the prognostic value of MPI in a larger-scale diabetes population. Methods We evaluated two prospective cohort studies: The Thousand&amp;1 Study (1093 individuals with T1D) and The Thousand&amp;2 Study (1030 individuals with T2D). Clinical data, including echocardiography, were collected at baseline. We excluded 480 individuals with heart disease. We collected follow-up data from national registries. We defined major adverse cardiovascular events (MACE) as the first incident of all-cause death, hospital admission for acute coronary syndrome, heart failure, or stroke. Results For included individuals (56% male, 54±15 years, MPI 0.51±0.1, 63% T1D), follow-up was 100% after a median of 5.3 years (interquartile range: 4.8 to 6.3). MPI was significantly associated with MACE (Hazard ratio 1.2, 95% confidence interval 1.0-1.3, p=0.012, per 0.10-unit increase) and heart failure (Hazard ratio 1.3, 95% confidence interval 1.1-1.6, p=0.005, per 0.10-unit increase) after adjusting for clinical and echocardiographic variables. MPI predicted MACE better in T1D than in T2D (p=0.031 for interaction). MPI added discriminatory power to the Steno T1D Risk Engine (1,2) in predicting heart failure, but not MACE. Conclusions MPI is an independent predictor of MACE and heart failure in T1D and T2D, with the strongest prediction in T1D. Echocardiographic assessment in diabetes may enhance risk prediction.

A systematic review and meta-analysis of cardiac resynchronization therapy in inotrope-dependent heart failure: an update

Abstract Background Inotrope-dependent heart failure (HF) carries a poor prognosis. Advanced mechanical supports have been viewed as primary treatment modalities for these patients, but cardiac resynchronization therapy (CRT) is an emerging alternative. Whether CRT is viable in HF patients who require inotropic support is uncertain. Purpose To assess outcomes of CRT in end-stage inotrope-dependent HF. Methods Following PRISMA guidelines, we searched Medline, EMBASE, Scopus, and Cochrane Library until December 31st 2022, with the following terms: "end-stage heart failure," "catecholamine-dependent overt heart failure," "inotrope-dependent heart failure," "advanced heart failure," "New York Heart Association class IV," "NYHA class IV." These terms were combined with "cardiac resynchronization therapy" OR "CRT" OR "biventricular device". Studies were included if: 1) HF patients required on inotropic support at CRT implantation; 2) patients were at least 18 years old; and 3) provided a clear definition of "inotrope dependence" or "inability to wean." A meta-analysis with random effects was performed in R (Version 3.5.1) with data presented as mean ± standard error. Results 19 studies comprised of 386 inotrope-dependent HF patients (mean age 64.4 ± 1.2 years, 76.9% male, 54.6% non-ischemic cardiomyopathy, mean QRS duration 168.0 ± 4.6 ms, mean follow-up 778 ± 110.7 days) were included for meta-analysis. A large majority of patients survived until discharge at 90% (95% CI: 81.0%-96.8%, I2=51%, p=0.04, Figure 1A), 88.6% were weaned off inotropes (95% CI: 77.5%-96.8%, I2=64%, p&amp;lt;0.01), and mean time to discharge post-CRT was 7.8 days (95% CI: 3.9-11.7, I2= 84%, p&amp;lt;0.01). After one year of follow-up 69.5% survived (95% CI: 59.2%-78.9%, I2=53%, p=0.02, Figure 1B) and 59.1% (95% CI: 50.1%-67.8%, I2=58%, p&amp;lt;0.01, Figure 1C) were alive at the end of follow-up. During follow-up the mean number of hospital admission for HF was reduced by 1.87 (95% CI: 2.70-1.04, I2=77%, p=0.04). Post-CRT mean QRS duration was reduced by 29.0 ms (95% CI: 41.33-16.68, I2=69%, p=0.006, Fig) and mean left ventricular ejection fraction increased by 4.83% (95% CI: 3.09%-6.57%, I2=16%, p=0.31, Fig). The mean NYHA class post-CRT was 2.7 (95% CI: 2.5-3.0, I2=56%, p=0.03, Figure 2A), 39.6% (95% CI: 18,.7%-62.3%, I2=83%, p&amp;lt;0.01, Figure 2C) improved to NYHA class III and 34.6% (95% CI: 16.4%-55.2%, I2=79%, p&amp;lt;0.01, Figure 2D) improved to NYHA class II. Responders to CRT tended be male (85.7% vs. 40%, p=0.015), have a history of left bundle branch block (71.4% vs. 30%, p=0.036) or an increased left ventricular end-diastolic volume (274.3 mL vs. 225.9 mL, p=0.038). Conclusion(s) Our results suggest that CRT is an alternative option for end-stage inotrope-dependent HF, improving survival, NYHA status, and HF readmission. CRT responders appear to be male with evidence of preserved diastolic function or a history of a left bundle branch block.

Home hospital heart failure admissions are an opportunity to initiate goal directed medical therapy - a retrospective analysis

Abstract Background There is growing recognition of the importance of goal directed medical therapy (GDMT) initiation for heart failure (HF) during hospitalization. Home hospital provides traditional inpatient hospital care in the patient’s home. Data describing GDMT initiation in home hospital is lacking. Purpose We described the rate of GDMT prescription on admission to and on discharge from home hospital for HF exacerbations, and compared the rate of sodium/glucose cotransporter-2 inhibitors (SGLT2i) prescription before and after home hospitalization. Methods This retrospective cohort is derived from all HF hospitalizations in two home hospital programs in the US between February 2020 and October 2022. Patients with heart failure with reduced ejection fraction (HFrEF; EF &amp;lt;50%) and patients with heart failure with preserved ejection fraction (HFpEF) who were hospitalized after February 2022 (when the FDA approved SGLT2i for HFpEF) were included. Exclusion criteria were if care was escalated to the traditional hospital setting, if patient goals of care were comfort care only, or if patients were receiving palliative inotropes. We report the rate of GDMT prescription immediately prior to home hospital admission and at discharge. GDMT for HFrEF was defined as beta-blocker, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB), angiotensin receptor-neprilysin inhibitor (ARNI), mineralocorticoid receptor antagonists (MRA), and SGLT2i; for HFpEF, only SGLT2i were considered. For the entire cohort, McNemar’s chi-squared test was performed to compare the rate of SGLT2i prescription before and after admission. Other GDMT therapies were not compared due to insufficient power. Reasons for not initiating GDMT are reported. Data were collected through manual chart review. Results We studied 173 hospitalizations; 95 patients had HFrEF and 78 had HFpEF. Mean age was 77.3 years; 65% had atrial fibrillation, 57% had diabetes mellitus, and 51% had chronic kidney disease. For patients with HFrEF, rates of beta-blocker, ACEi/ARB, ARNI, MRA, and SGLT2i prescription on admission were 88%, 56%, 16%, 34%, and 14% and on discharge were 85%, 49%, 17%, 35%, and 23% respectively; Figure 1. For the entire cohort – patients with HFrEF or HFpEF, the difference between the rate of SGLT2i prescription before and after the admission was statistically significant (12.1% vs 20.8%, p-value &amp;lt; 0.001); Figure 2. In 89% of hospitalizations GDMT was not initiated; the three most common reasons were no reason cited (68%), deferral to outpatient follow-up (14%), and kidney dysfunction (10%). Conclusion Home hospital admission for HF represents a feasible opportunity to initiate GDMT. Patients admitted to home hospital for HF had a statistically significant increase in the rate of SGLT2i prescription, although the overall rate remained low. Future study will investigate if GDMT prescription rates are improved with cardiology e-consultation in home hospitalizations.GDMT Prescription Rate - Reduced EFSGLT2i Prescription Rate

30- and 60-Day Readmission Rates for Children With Heart Failure in the United States

BackgroundStudies on readmission for pediatric heart failure (HF) patients is sparse. ObjectivesThis study evaluated 30- and 60-day readmission rates in pediatric HF patients from 2010 to 2019. MethodsThe authors used data from the Nationwide Readmission Database to evaluate trends in 30- and 60-day hospital readmissions among pediatric patients with HF and compare them with adults with HF. Readmissions were also stratified by sex, diagnosis, neighborhood income, and hospital volume. ResultsThere were 84,731 hospital admissions for HF. Compared with children without HF, those with HF were older, had Medicare/Medicaid insurance, and resided in micropolitan areas and low-income neighborhoods. The 30- (19.5% vs 3.1%) and 60-day (27.5% vs 4.3%) all-cause readmission rates were higher for children with HF compared with those without HF. Compared with children without HF, lengths of stay, deaths, and costs related to their readmission were higher for children readmitted with HF (P < 0.05 for all). There was no significant decline in pediatric HF-related 30- or 60- day readmissions during the study period overall, or for those with congenital heart disease (P > 0.05), unlike adult HF readmissions (P < 0.01). Infants were at highest risk, and readmission rates for teenagers are rising. ConclusionsThe 30- and 60-day readmission rates for pediatric patients with HF in the current era is high (∼20% and 30%, respectively). Unlike adult HF, pediatric HF readmission rates have not declined. Pediatric HF patients readmitted to the hospital have higher death rates and greater resource utilization than patients without HF. National measures to decrease readmissions for pediatric patients with HF is warranted.

Abstract 16203: A Case for Cardiomems Use in Cardiac Amyloidosis to Prevent Hospitalization

Background: Patients with cardiac amyloidosis (CA) have recurrent hospital admissions for heart failure (CHF). However, CardioMEMS placement is still considered ‘investigational’ by various insurance payers, requiring peer-to-peer review for approval. Landmark CardioMEMS trials did not identify CA patients in their cohort, so the benefit is unclear. Results and Discussion: Three patients with symptomatic CA (2 with light-chain, one with transthyretin CA) are presented. All the patients had chronic kidney disease stage 3, worsening orthostatic symptoms with heart failure medical therapy and a history of ≥ 2 hospitalizations/year for CHF with acute kidney injury. To prevent further hospitalizations, CardioMEMS was planned but denied by their respective insurance companies as ‘investigational use’, which required a rigorous appeal process to overturn. One year prior to CardioMEMS, there were 8 hospitalizations due to CHF between all three candidates. After implantation, there was only 1 CHF-related hospitalization. This represents a 88% decrease in hospital admissions for CHF, saving a potential 7 CHF hospitalizations in the succeeding year and potentially adding one quality-adjusted life-year (QALY)/patient. Decompensated CHF adversely affects the quality of life of CA patients. CardioMEMs costs $20,000/device on average and $100/month of monitoring cost. The average cost of heart failure hospitalization is $14,000. Amongst the 3 patients, there was a total expenditure of $112,000 in hospitalizations prior to CardioMEMS placement. With an 88% reduction in hospitalization and correcting for the cost of device placement and monitoring, there was a $11,653/patient/year decrease in spending with CardioMEMS placement. Additionally, the cost of adding 1 QALY/patient was only $21,200 with CardioMEMS. The Institute for Clinical and Economic Review values one QALY at $50,000 to $150,000 as an acceptable cost and the expenditure with CardioMEMS comes significantly lower. Conclusion: CardioMEMs has been shown to decrease the number of hospitalizations in patients with HF and has a similar benefit in patients with CA. The CardioMEMs device has the capability to improve patient quality of life and decrease the cost of medical care of CA patients.

Impact of a clinician-to-clinician electronic consultation in heart failure patients with previous hospital admissions.

To evaluate the impact of an outpatient care management programme that includes a clinician-to-clinician e-consultation on delay time in care, hospital admissions, and mortality in a high-risk group of patients with heart failure (HF) and previous episodes of HF hospitalization (HFH). We selected 6444 HF patients who visited the cardiology service at least once between 2010 and 2021. Of these, 4851 were attended in e-consult, and 2230 had previous HFH. Using an interrupted time series regression model, we analysed the impact of incorporating e-consult into the healthcare model in the group of patients with HFH and evaluated the elapsed time to cardiology care, HF, cardiovascular (CV), and all-cause hospital admissions and mortality, calculating the incidence relative risk (iRR). In the group of patients with HFH, the introduction of e-consult substantially decreased waiting times to cardiology care (8.6 [8.7] vs. 55.4 [79.9] days, P < 0.001). In that group of patients, after e-consult implantation, hospital admissions for HF were reduced (iRR [95%CI]: 0.837 [0.840-0.833]), 0.900 [0.862-0.949] for CV and 0.699 [0.678-0.726] for all-cause hospitalizations. There was also lower mortality (iRR [95%CI]: 0.715 [0.657-0.798] due to HF, 0.737 [0.764-0.706] for CV and 0.687 [0.652-0.718] for all-cause). The improved outcomes after e-consultation implementation were significantly higher in the group of patients with previous HFH. In patients with HFH, an outpatient care programme that includes an e-consult significantly reduced waiting times to cardiology care and was safe, with a lower rate of hospital admissions and mortality in the first year.

New Challenges in Heart Failure with Reduced Ejection Fraction: Managing Worsening Events.

Patients with an established diagnosis of heart failure (HF) with reduced ejection fraction (HFrEF) are prone to experience episodes of worsening symptoms and signs despite continued therapy, termed "worsening heart failure" (WHF). Despite guideline-directed medical therapy, worsening of chronic heart failure accounts for almost 50% of all hospital admissions for HF, and patients experiencing WHF carry a substantially higher risk of death and hospitalization than patients with "stable" HF. New drugs are emerging as arrows in the quiver for clinicians to address the residual risk of HF hospitalization and cardiovascular deaths in patients with WHF. This question-and-answer-based review will discuss the emerging definition of WHF in light of the recent clinical consensus released by the Heart Failure Association (HFA) of the European Society of Cardiology (ESC), the new therapeutic approaches to treat WHF and then move on to their timing and safety concerns (i.e., renal profile).

Novel Nebulized Milrinone Formulation for the Treatment of Acute Heart Failure Requiring Inotropic Therapy: A Phase 1 Study

Nonintravenous inotropic-delivery options are needed for patients with inotropic-dependent heart failure (HF) to reduce the costs, infections and thrombotic risks associated with chronic central venous catheters and home infusion services. We developed a novel, concentrated formulation of nebulized milrinone for inhalation and evaluated the feasibility, safety and pharmacokinetic profile in a prospective, single-arm, phase I clinical trial. We enrolled 10 patients with stage D HF requiring inotropic therapy during a hospital admission for acute HF. Milrinone 60 mg/4 mL was inhaled via nebulization 3 times daily for 48 hours. The coprimary outcomes were adverse events and pharmacokinetic profiles of inhaled milrinone. Acute changes in hemodynamic parameters were secondary outcomes. A concentrated nebulized milrinone formulation was well tolerated, without hypotensive events, arrhythmias or inhalation-related adverse events requiring discontinuation. Nebulized milrinone produced serum concentrations in the goal therapeutic range with a median plasma milrinone trough concentration of 39 (17-66) ng/mL and a median peak concentration of 207 (134-293) ng/mL. There were no serious adverse events. From baseline to 24 hours, mean pulmonary artery saturation increased (60% ± 7%-65 ± 5%; P = 0.001), and mean cardiac index increased (2.0 ± 0.5 mL/min/1.73m2-2.5 ± 0.1 mL/min/1.73m2; P = 0.001) with nebulized milrinone. In a proof-of-concept study, a concentrated, nebulized milrinone formulation for inhalation was safe and produced therapeutic serum milrinone concentrations. Nebulized milrinone was associated with improved hemodynamic parameters of cardiac output in a population with advanced HF. These promising results require further investigation in a longer-term trial in patients with inotrope-dependent advanced HF.

Association of Vascular Aging With Cardiovascular Disease in Middle-Aged Chinese People: A Prospective Cohort Study

BackgroundWhether middle-aged individuals with a greater difference between chronological age and vascular age show a lower cardiovascular disease risk remains to be clarified. ObjectivesThis study sought to examine whether individuals with supernormal vascular aging (VA) have a lower cardiovascular disease risk than do individuals with normal VA. MethodsThis prospective cohort study included 20,917 middle-aged (40-60 years) participants from the Kailuan Study. VA was defined as the predicted age in a multivariate regression model, including classic cardiovascular risk factors and pulsed wave velocity. The chronological age minus the VA was defined as the Δ-age, and the 10th and 90th percentiles of the Δ-age were used as cutoffs to define early VA and supernormal VA, respectively. The outcome was a composite of myocardial infarction, hospital admission for heart failure, and stroke. The study used Cox proportional hazards regression to examine the association between the VA categories and the incident cardiovascular outcome. ResultsDuring the median 4.6-year follow-up period, 584 endpoint events were observed. After adjusting for potential variables, when compared with the normal VA group, the supernormal VA group had a decreased rate of cardiovascular events (HR: 0.47; 95% CI: 0.35-0.64), and the early VA group had an increased rate (HR: 1.90; 95% CI: 1.22-2.95) of cardiovascular events. ConclusionsIndividuals with supernormal VA are at a lower risk of cardiovascular events, and individuals with early VA are at a higher risk of cardiovascular events than individuals with normal VA. Further characterization may provide novel insight into future preventive strategies against cardiovascular disease.