Intravenous Diuretics Research Articles

Acute Lymphocyte Myocarditis Associated with Influenza Vaccination

An elderly patient was admitted to our hospital for acute heart failure soon after receiving influenza vaccination. On admission, chest radiography revealed pulmonary edema. An electrocardiogram showed poor R progression, and echocardiography showed diffuse hypokinesis and myocardial edema. The serum troponin level was elevated. A histopathological evaluation indicated active myocarditis with lymphocyte-predominant infiltrates. A drug-induced lymphocyte stimulation test (DLST) was positive. The patient rapidly recovered from heart failure after treatment with conventional heart failure drugs, such as intravenous diuretics and vasodilators. These experimental data and the clinical course suggest that influenza vaccination was responsible for heart failure due to acute lymphocyte myocarditis.

A comprehensive characterization of acute heart failure with preserved versus mildly reduced versus reduced ejection fraction-insights from the ESC-HFA EORP Heart Failure Long-Term Registry.

To perform a comprehensive characterization of acute heart failure (AHF) with preserved (HFpEF), versus mildly reduced (HFmrEF) versus reduced ejection fraction (HFrEF). Of 5951 participants in the ESC HF Long-Term Registry hospitalized for AHF (acute coronary syndromes excluded), 29% had HFpEF, 18% HFmrEF, and 53% HFrEF. Hospitalization reasons were most commonly atrial fibrillation (more in HFmrEF and HFpEF), followed by ischaemia (HFmrEF), infection (HFmrEF and HFpEF), worsening renal function (HFrEF), and uncontrolled hypertension (HFmrEF and HFpEF). Hospitalization characteristics included lower blood pressure, more oedema and higher natriuretic peptides with lower ejection fraction, similar pulmonary congestion, more mitral regurgitation in HFrEF and HFmrEF and more tricuspid regurgitation in HFrEF. In-hospital mortality was 3.4% in HFrEF, 2.1% in HFmrEF and 2.2% in HFpEF. Intravenous diuretic (∼80%) and nitrate (∼15%) use was similar but inotrope use greater in HFrEF (16%, vs. HFmrEF 7.4% vs. HFpEF 5.3%). Weight loss and estimated glomerular filtration rate improvement were greater in HFrEF, whereas reduction in natriuretic peptides was similar. Over 1 year post-discharge, events per 100 patient-years (95% confidence interval) in HFrEF versus HFmrEF versus HFpEF were: all-cause death 22 (20-24) versus 17 (14-20) versus 17 (15-20); cardiovascular (CV) death 12 (10-13) versus 8.6 (6.6-11) versus 8.4 (6.9-10); non-CV death 2.4 (1.8-3.1) versus 3.3 (2.1-4.8) versus 4.5 (3.5-5.9); all-cause hospitalization 48 (45-51) versus 35 (31-40) versus 42 (39-46); HF hospitalization 29 (27-32) versus 19 (16-22) versus 17 (15-20); and non-CV hospitalization 7.7 (6.6-8.9) versus 9.6 (7.5-12) versus 15 (13-17). In AHF, HFrEF is more severe and has greater in-hospital mortality. Post-discharge, HFrEF has greater CV risk, HFpEF greater non-CV risk, and HFmrEF lower overall risk.

Natriuresis‐guided therapy in acute heart failure: rationale and design of the Pragmatic Urinary Sodium‐based treatment algoritHm in Acute Heart Failure (PUSH‐AHF) trial

AimsInsufficient diuretic response frequently occurs in patients admitted for acute heart failure (HF) and is associated with worse clinical outcomes. Recent studies have shown that measuring natriuresis early after hospital admission could reliably identify patients with a poor diuretic response during hospitalization who might require enhanced diuretic treatment. This study will test the hypothesis that natriuresis‐guided therapy in patients with acute HF improves natriuresis and clinical outcomes.MethodsThe Pragmatic Urinary Sodium‐based treatment algoritHm in Acute Heart Failure (PUSH‐AHF) is a pragmatic, single‐centre, randomized, controlled, open‐label study, aiming to recruit 310 acute HF patients requiring treatment with intravenous loop diuretics. Patients will be randomized to natriuresis‐guided therapy or standard of care. Natriuresis will be determined at set time points after initiation of intravenous loop diuretics, and treatment will be adjusted based on the urinary sodium levels in the natriuresis‐guided group using a pre‐specified stepwise approach of increasing doses of loop diuretics and the initiation of combination diuretic therapy. The co‐primary endpoint is 24‐h urinary sodium excretion after start of loop diuretic therapy and a combined endpoint of all‐cause mortality or first HF rehospitalization at 6 months. Secondary endpoints include 48‐ and 72‐h sodium excretion, length of hospital stay, and percentage change in N‐terminal pro brain natriuretic peptide at 48 and 72 h.ConclusionThe PUSH‐AHF study will investigate whether natriuresis‐guided therapy, using a pre‐specified stepwise diuretic treatment approach, improves natriuresis and clinical outcomes in patients with acute HF.

Serum and Urine Osmolality as Predictors of Adequate Diuresis in Acute Decompensated Heart Failure: A Prospective Cohort Study

Background: Determination of adequacy of decongestion remains a significant challenge in the management of acute heart failure (AHF). Methods: This is a prospective single center cohort study of patients (>18 years old) admitted for AHF on intravenous diuretics, with BNP >100 pg/mL or echocardiographic findings of reduced ejection fraction or diastolic dysfunction, and at least 1 clinical sign of volume overload. Patients with eGFR ≤45 mL/min or on dialysis, and with exposure to contrast dye or nephrotoxins were excluded. Serum and spot urine osmolality were obtained in the early morning simultaneously daily for 5 days or until discharge. Receiver operating characteristic curves were used to analyze the optimal cutoffs for the osmolality values in the prediction of heart failure (HF) readmissions Results: Of the total 100 patients, 62% were male and 59% were Black American. The mean age was 64.41 ± 12.53 and 34% had preserved ejection fraction. Patients with 30-day readmission had higher serum osmolality (mOsm/kg) on admission (305 [299–310] vs. 298 [294–303]; p = 0.044) and had higher drop in serum osmolality between admission and discharge (−7.5 [−9.0, −1.25] vs. −1.0 [−4.0, 4.0]; p = 0.044). Serum osmolality on admission of >299 mOsm/kg (sensitivity: 83%, specificity: 61%) and drop in serum osmolality between admission and discharge of >2 mOsm/kg (sensitivity: 83%, specificity: 65%) was associated with 30-day HF readmissions. No patients discharged with urine osmolality more than 500 mOsm/kg had 30-day readmissions, but this was not statistically significant, p = 0.334. Conclusion: Measurement of serum osmolality and urine osmolality may have some utility in AHF, but interpretation should consider baseline values and dynamic changes to account for individual differences in sodium and water handling.

Peritoneal Dialysis for Refractory Heart Failure from a Congenitally Corrected Transposition of the Great Arteries who has not Undergone Definitive Surgery: A Case Report

Heart failure (HF) is a major cause of significant morbidity, mortality, and hospitalization worldwide including the Philippines. Congenitally corrected transposition of the great arteries (C-TGA) occurs when the right atrium enters the morphological left ventricle which gives rise to the pulmonary artery and the left atrium communicates with the right ventricle which gives rise to the aorta. Heart failure can occur in C-TGA especially if associated with other heart defects. Ideal management is anatomic correction via surgery to prevent or address heart failure. Peritoneal dialysis has been used as a therapeutic intervention for patients with refractory heart failure and kidney injury with or without kidney failure due to its gentler fluid removal compared to conventional ultrafiltration resulting in less myocardial stunning and neurohormonal activation. We present the case of a patient with heart failure who started on peritoneal dialysis (PD) as an adjunct therapy for fluid management after failing to satisfactorily achieve volume control with diuretics. The patient is a 56-year-old man with C-TGA admitted for decompensated heart failure. He was initially treated with intravenous diuretics on the first admission but was readmitted after 3 months for decompensation this time with borderline low blood pressure making diuresis difficult. The patient was given loop diuretics, tolvaptan, and angiotensin receptor neprilysin inhibitor (ARNI) but still with decreasing trends in urine output and inadequate symptom control. PD was initiated before discharge with subsequent improvement in heart failure symptoms. The patient was on regular follow-up for PD maintenance and titration of heart failure medication. In this case report, we have shown how PD can be an effective adjunct to guideline-directed medical therapy in patients with severely symptomatic heart failure who have an unstable hemodynamic status and for which volume management cannot be satisfactorily achieved with diuretics.

The Utility of Systemic Immune-Inflammation Index for Predicting Contrast-Induced Nephropathy in Patients with ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Objective: The systemic immune-inflammation index (SII), derived from counts of neutrophils, platelets, and lymphocytes, has been developed to predict clinical outcomes in several cancers and cardiovascular diseases. The aim of this study was to evaluate the utility of SII to predict contrast-induced nephropathy (CIN) in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI). Methods: A total of 632 patients with STEMI who underwent primary PCI were retrospectively included. The patients were divided into two groups based on the presence or absence of CIN. Baseline demographic, laboratory, and clinic characteristics were evaluated between the two groups. Logistic regression analysis was used to identify independent predictors of CIN. Results: The receiver operating characteristic curve analysis demonstrated that the optimal cutoff value of SII for predicting CIN was 1,282 with a sensitivity of 76.1% and specificity of 86.7% (AUC: 0.834; 95% CI: 0.803–0.863; p < 0.001). Multivariate analysis performed in two models (SII; as separate continuous and categorical variables) showed age, estimated glomerular filtration rate (eGFR), diabetes, left ventricular ejection fraction (LVEF), Killip class ≥2, use of an intravenous diuretic, troponin I, and SII as independent predictors of CIN in model 1. In model 2, age, eGFR, diabetes, LVEF, Killip class ≥2, use of an intravenous diuretic, troponin I, and a value of SII >1,282 (p < 0.001, OR 6.205, 95% CI: 2.301–12.552) remained as independent predictors of CIN. Conclusion: SII may be a useful and reliable indicator to predict the development of CIN in patients with STEMI undergoing primary PCI than NLR and PLR.

Benefits of Early Diuretic Administration in Emergency Department Presentations of Acute Heart Failure

Early intravenous diuretic administration in acute heart failure (AHF) presentations to the emergency department (ED) is associated with improved patient outcomes. Yet limited data exist on the timeliness of diuretics and associated outcomes of AHF in Australia. We present our experience from a quaternary referral centre.

Medication Trajectory and Treatment Patterns in Medicare Patients With Heart Failure and Reduced Ejection Fraction

Although a worsening heart failure event (WHFE) is associated with poor outcomes in patients with heart failure with reduced ejection fraction (HFrEF), it is unclear how guideline-directed medical therapy (GDMT) is used in this population compared to those without WHFEs. This study evaluated treatment patterns in patients with HFrEF, both with and without WHFEs. A retrospective study using 100% Medicare Fee-For-Service claims identified beneficiaries with HFrEF, stratified by those with and without WHFEs (defined as hospitalization due to HF or outpatient intravenous diuretic use). The use of GDMT for HFrEF before and after WHFEs and adherence were assessed in patients who were prescribed and initiated GDMT. Logistic regression identified patients' characteristics associated with medication nonadherence. Of 353,642 patients with HFrEF, 31.4% had a WHFE. Although there was no overall change in the treatment trajectory of patients without WHFEs, GDMT use in patients with WHFEs intensified within the first 3 months of a WHFE, but the intensification was not sustained in subsequent months. From 0-3 months pre-WHFE to 0-3 months post-WHFE, the proportion of patients receiving dual (41%-48%) and triple-therapy (4%-12%) increased, followed by a decline to pre-WHFE rates. The 1-year adherence rates for those with and without WHFEs were 67.9% vs 73.3% for beta-blockers; 59.1% vs 70.9% for angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor-neprilysin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists; 53.9% vs 61.3% for angiotensin receptor-neprilysin inhibitors; and 49.2% vs 59.3% for mineralocorticoid receptor antagonists. WHFE, age < 65 years, Black race, asthma, chronic kidney disease, and depression were associated with nonadherence to medications. Asians and Hispanics were less adherent to some medication classes. This study demonstrated underuse of GDMT for patients with HFrEF with or without WHFEs. Although there was a treatment escalation within 3 months following WHFE, it was not sustained thereafter.

N-terminal pro-B-type natriuretic peptide testing patterns in patients with heart failure with reduced ejection fraction.

AimsThe N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) is a commonly used biomarker in heart failure for diagnosis and prognostication. We aimed to determine the prevalence of NT‐proBNP testing, distribution of NT‐proBNP concentrations, and factors associated with receiving an NT‐proBNP test in patients with heart failure with reduced ejection fraction (HFrEF), including the subset with a worsening heart failure event (WHFE).Methods and resultsThis was a retrospective cohort study using two US databases: (i) the de‐identified Humana Research Database between January 2015 and December 2018 and (ii) the Veradigm PINNACLE Registry® between July 2013 and September 2017. We included adult patients with a confirmed diagnosis of HFrEF. In each data source, a subgroup of patients with a WHFE was identified, where a WHFE was defined as a heart failure‐related hospitalization or receipt of intravenous diuretics. Bivariate and multivariate analyses were conducted to assess factors associated with receiving NT‐proBNP testing. In Cohort 1 (n = 249 238), 9.2% of patients with HFrEF and 10.8% of patients with a WHFE received NT‐proBNP testing. When restricted to patients with at least one laboratory claim, 11.3% of patients with HFrEF and 13.2% of those with a WHFE received NT‐proBNP testing. In Cohort 2 (n = 91 444), 2.3% of patients with HFrEF were tested. Median (inter‐quartile range) NT‐proBNP concentrations among patients with HFrEF were 1399 (423–4087) pg/mL in Cohort 1 and 394 (142–688) pg/mL in Cohort 2. Median (inter‐quartile range) NT‐proBNP concentrations in the subset of patients with a WHFE in each cohort were 2209 (740–5894) and 464 (174–783) pg/mL, respectively. In Cohort 1, 13.4% of all HFrEF patients receiving NT‐proBNP testing and 18.9% of patients with a WHFE had NT‐proBNP values >8000 pg/mL; in Cohort 2, these percentages were 1.0% and 2.5%, respectively.ConclusionsIn US clinical practice, NT‐proBNP testing was not frequently performed in patients with HFrEF. NT‐proBNP concentrations varied across data sources and subpopulations within HFrEF.

675 A rare case of tako-tsubo syndrome in a patient with hypertrophic cardiomyopathy

Abstract Aims We know that basal septal hypertrophy is a rare and unique anatomical finding associated with hypertrophic cardiomyopathy (HCM). Tako-Tsubo cardiomyopathy (TTC) is a transient left ventricular systolic dysfunction induced by high physical or emotional stress. Its occurrence with HCM is unusual. However, this presentation occurs more often with the classic asymmetrical septal hypertrophy compared with the apical variant. This case demonstrates that the coexistence of TTC with septal HCM in an elderly patient may lead to a severe haemodynamic instability picture. Methods and results A 81-year-old female presented to the emergency department (ED) complaining of dyspnoea and chest pain lasting for 1 day. She had hypertension and dyslipidemia associated with a familial history of sudden death. On physical exam, we found a severe hypotension (systolic blood pressure of 80 mmHg) associated with bilateral rales at chest auscultation. Cardiac auscultation revealed a harsh systolic murmur, best heard over the left sternal border. Heart rate was 60 b.p.m. in sinus rhythm. Labs were significant for HS-I troponin of 6.035 ng/L (NV: ≤ 12) and NT-proBNP of 7.640 pg/ml (NV: ≤1800). A 12-leads electrocardiogram (ECG) at admission revealed a STEMI-like ST segment elevation from V2 to V6 (Figure 1A). For this reason she was urgently taken to the cath-lab where she was found to have tortuous but normal coronary arteries. After coronary angiography, a trans-thoracic echocardiogram (TTE) revealed a pathological LV hypertrophy with a septal diastolic thickness of 19 mm, depressed LV ejection fraction (LVEF) due to a severe apical ballooning. At continuous wave (CW)-Doppler there was a dynamic obstruction across the LV outflow tract (LVOT), with a late peak velocity of 4.9 m/s and an estimated peak gradient of 98 mmHg. The gradient was increased by a systolic anterior motion (SAM) of anterior mitral leaflet causing a moderate mitral regurgitation (MR). All these findings were consistent with obstructive septal HCM associated with Takotsubo cardiomyopathy. After treatment with intravenous diuretics and metoprolol (5 + 5 mg i.v. bolus followed by oral dose of 100 mg daily), her clinical condition markedly improved. One week later, ECG demonstrated deeply inverted T waves on antero-lateral leads and QT prolongation (501 ms). Three weeks later, after a complete resolution of the LV apical dyskinesia, LVEF normalized. LVOT gradient decreased to 20 mmHg, with a dynamic increase to 70 mmHg during Valsalva manoeuvre. Conclusions It is well known that TTC may be complicated by a reversible LVOT obstruction by itself but the combination with obstructive HCM can lead to low cardiac output and acute heart failure. This combination has been found to be not common and the correct treatment of this unusual type of cardiogenic shock is still unclear. Careful initial evaluation and continuous monitoring must be warranted in such rare cases. Supportive care afterward with beta blockers, along with echocardiogram surveillance, are the mainstay of management. Cardiologists, intensivisits, and clinicians alike need to recognize and comprehend the pathophysiology behind this unique clinical manifestation so that they may adjust their management and treatment accordingly.

Intravenous diuretic administration in the home environment.

Chronic heart failure is a condition associated with ageing, affecting 1-2% of the adult population, raising to 70% of the adult population over 70 years of age. Diuretics are often the first-line treatment for patients with symptomatic heart failure, not just oedema. Traditionally, intravenous (IV) diuretic therapy has been administered only in hospitals. In 2012, the British Heart Foundation ran a pilot study investigating the effectiveness of IV diuretic administration within the home. Since then, there has been an increase in these services. This article examines the advantages and disadvantages of this service, whether community nurses are best placed to deliver this, and what the benefits to the patient might be.

Congenital nephrotic syndrome.

Congenital nephrotic syndrome (CNS), a challenging form of nephrotic syndrome, is characterized by massive proteinuria, hypoalbuminemia, and edema. Extensive leakage of plasma proteins is the main feature of CNS. Patients can be diagnosed in utero or during the first few weeks of life, usually before three months. The etiology of CNS can be related to either genetic or nongenetic etiologies. Pathogenic variants in NPHS1, NPHS2, LAMB2, WT1, and PLCE1 genes have been implicated in this disease. The clinical course is complicated by significant edema, infections, thrombosis, hypothyroidism, failure to thrive, and others. Obtaining vascular access, frequent intravenous albumin infusions, diuretic use, infection prevention, and nutritional support are the mainstay management during their first month of life. The best therapy for these patients is kidney transplantation. CNS diagnosis and treatment continue to be a challenge for clinicians. This review increases the awareness about the pathogenesis, diagnosis, and management of CNS patients.

A Natural Language Processing–Based Approach for Identifying Hospitalizations for Worsening Heart Failure Within an Integrated Health Care Delivery System

The current understanding of epidemiological mechanisms and temporal trends in hospitalizations for worsening heart failure (WHF) is based on claims and national reporting databases. However, these data sources are inherently limited by the accuracy and completeness of diagnostic coding and/or voluntary reporting. To assess the overall burden of and temporal trends in the rate of hospitalizations for WHF. This cohort study, performed from January 1, 2010, to December 31, 2019, used electronic health record (EHR) data from a large integrated health care delivery system. Calendar year trends. Hospitalizations for WHF (ie, excluding observation stays) were defined as 1 symptom or more, 2 objective findings or more including 1 sign or more, and 2 doses or more of intravenous loop diuretics and/or new hemodialysis or continuous kidney replacement therapy. Symptoms and signs were identified using natural language processing (NLP) algorithms applied to EHR data. The study population was composed of 118 002 eligible patients experiencing 287 992 unique hospitalizations (mean [SD] age, 75.6 [13.1] years; 147 203 [51.1%] male; 1655 [0.6%] American Indian or Alaska Native, 28 451 [9.9%] Asian or Pacific Islander, 34 903 [12.1%] Black, 23 452 [8.1%] multiracial, 175 840 [61.1%] White, and 23 691 [8.2%] unknown), including 65 357 with a principal discharge diagnosis and 222 635 with a secondary discharge diagnosis of HF. The study population included 59 868 patients (20.8%) with HF with a reduced ejection fraction (HFrEF) (<40%), 33 361 (11.6%) with HF with a midrange EF (HFmrEF) (40%-49%), 142 347 (49.4%) with HF with a preserved EF (HFpEF) (≥50%), and 52 416 (18.2%) with unknown EF. A total of 58 042 admissions (88.8%) with a primary discharge diagnosis of HF and 62 764 admissions (28.2%) with a secondary discharge diagnosis of HF met the prespecified diagnostic criteria for WHF. Overall, hospitalizations for WHF identified on NLP-based algorithms increased from 5.2 to 7.6 per 100 hospitalizations per year during the study period. Subgroup analyses found an increase in hospitalizations for WHF based on NLP from 1.5 to 1.9 per 100 hospitalizations for HFrEF, from 0.6 to 1.0 per 100 hospitalizations for HFmrEF, and from 2.6 to 3.9 per 100 hospitalizations for HFpEF. The findings of this cohort study suggest that the burden of hospitalizations for WHF may be more than double that previously estimated using only principal discharge diagnosis. There has been a gradual increase in the rate of hospitalizations for WHF with a more noticeable increase observed for HFpEF.

Abstract 13415: Initial Diuretic Dosing and Length of Stay in Patients Hospitalized for Congestive Heart Failure

Background: Among patients hospitalized for heart failure, a prior randomized trial suggests the initial dose of diuretics may have implications on time to decongestion and length of hospital stay. Little is known about the dosing of intravenous loop diuretics in routine clinical practice and the association between diuretic dosing and hospital length of stay. Methods: We identified 12,209 patients admitted with heart failure at 12 Allina Health hospitals in central Minnesota and western Wisconsin between January 1, 2017 and December 31, 2020. We excluded patients on observational status, no or unknown home loop diuretic dosing, no intravenous loop diuretic within 24 hours of admission, and patients who received inotropes or dialysis within 24 hours of admission. Initial diuretic dose was compared to home dose in furosemide equivalents using the Diuretic Strategies in Patients with Acute Decompensated Heart Failure trial logic and categorized into below home dose, equivalent to home dose, or above home dose. We describe patient characteristics and length of stay by category of initial diuretic dose. Results: Among 3,580 admitted for heart failure, initial diuretic dose was below home dose in 555 (15%) patients, equivalent to home dose in 756 (21%) patients, and above home dose in 2269 (64%) patients. Baseline characteristics by category of initial diuretic dose are presented in the Table. Mean length of stay was longest in patients receiving a diuretic dose that was below home dose (6.4 days) and shortest in patients receiving a dose above home equivalent (5.0 days) (Table). Conclusions: In a cohort of patients admitted for heart failure, more than 1 in 3 patients received an initial dose of intravenous loop diuretics that was equivalent to or below their home diuretic dose and this was associated with a longer length of hospital stay. These findings may represent a quality improvement opportunity in the care of patients hospitalized for heart failure.

Abstract 14004: Long Term Outcomes of Ambulatory Outpatient Management of Acute Decompensated Heart Failure in a Heart Failure Specialist Nurse Delivered Consultant Led Unit versus Inpatient Management

Introduction: Acutely decompensated heart failure (ADHF) usually results in hospitalisation for intravenous diuretics. The safety and efficacy of ambulatory or outpatient management of ADHF by heart failure specialist nurses has not been described before. Methods: This retrospective analysis compared 2 cohorts of consecutive ADHF patients - hospitalised in-patients (IP) versus outpatients (OP) who were treated with bolus intravenous diuretics in a specialist heart failure nurse delivered consultant led OP HF unit (Ambulatory HF Unit -AHFU) with input from various specialties (renal, diabetes, elderly care, chest, pharmacy, palliative, ascitic, pleural teams) from 2016 to 2020. Mean follow-up duration was similar for both groups (IP=46±8.1 months; OP=45.5± 7 months, p=0.1). We compared clinical risk scores using the Get With the Guidelines (GWTG) score, comorbidities using the Charlson Comorbidity Index (CCI) and frailty using the Rockwood Clinical Frailty Index (CFI). Results were expressed as mean±SD, analysed using the Student’s T test and Chi-squared test. Results: 1012 patients were treated in our specialist outpatient AHFU and 1889 patients were hospitalised. Mean number of visits per ambulatory spell was 5.1±-2.2 days and the median dose of furosemide was 220 mg (range 80-480). Average hospital stay for IP was 12.1±5 days. CCI (IP=6.5±2; OP=6.4±1.9; p=0.19) and mean GWTG scores were similar (IP=40.4±7.9; OP=39.9±7.1; p=0.09) between the 2 groups but mean Frailty Index was higher amongst the IP group (IP 5.1±1.2; OP 4.9±1; p=0&lt;0.001). 30 day hospitalisation and mortality (30 day,1 year and overall mortality) were lower in the OP cohorts. Conclusions: Ambulatory management of ADHF using bolus IV diuretics in a heart failure specialist nurse delivered consultant led multidisciplinary unit offers an effective alternative to hospitalisation and also leads to improved outcomes. Frailty Index can help assess suitability for outpatient management of ADHF.

Abstract 9408: Serum and Urine Osmolality as Predictors of Adequate Diuresis in Acute Decompensated Heart Failure: A Prospective Cohort Study

Introduction: The utility of serum and urine osmolality in evaluating decongestion and outcomes in heart failure (HF) remain understudied. Methods: This is a prospective cohort single center study of patients with acute HF on intravenous diuretics &gt; 18 years old, with BNP &gt; 100 pg/mL or echocardiographic finding of reduced ejection fraction or diastolic dysfunction, and at least 1 symptom of volume overload. Patients with eGFR≤45mL/minute or on dialysis, and with exposure to contrast dye or nephrotoxins were excluded. Serum and urine osmolality were obtained daily for 5 days or until discharge. Wilcoxon signed-rank test was used to check for differences in serum and urine osmolality on admission and on discharge. Mann Whitney U test compared osmolality values between those with and without readmissions. ROC curve and Youden’s index were used to analyze the optimal cut-offs for the osmolality values in the prediction of readmissions. Results: A total of 100 hospitalized patients were included. Majority were males (62%) and African American (59%). The mean age was 64.41±12.53 with co-morbidities of hypertension (86%), diabetes (43%), coronary artery disease (39%), and heart failure with preserved ejection fraction (34%). The inpatient mortality rate was 3%, with 6% and 16% 30-day and 60-day readmission rates respectively. Patients with 30-day readmission had higher serum osmolality on admission (305 [299-310] vs 298 [294-303] p=0.044) and had higher drop in serum osmolality between admission and discharge (-7.5 [-9.0 - -1.25] vs -1.0 [-4.0 - 4.0]) [p=0.044]. Serum osmolality on admission of &gt;299 mOsm/kg (sensitivity: 83%, specificity: 61%) and drop in serum osmolality between admission and discharge of &gt;2 mOsm/kg (sensitivity: 83%, specificity: 65%) was associated with 30-day readmissions. Conclusions: Measurement of serum osmolality and urine osmolality may have some utility in the management of acute heart failure.

Abstract 9964: Influence of Worsening Heart Failure During Hospitalization on the Prognosis in Patients with Acute Decompensated Heart Failure

Introduction: Worsening heart failure (WHF) during hospitalization has been used as the one of endpoint in assessing treatments for acute decompensated heart failure (ADHF). However, there are few data on WHF and long-term prognosis, especially in Japanese population. Hypothesis: WHF during hospitalization can influence the long-term prognosis in patients with ADHF. Methods and Results: The Kyoto Congestive Heart Failure registry is a prospective multicenter cohort study enrolling 4056 consecutive patients hospitalized for ADHF in Japan. WHF was defined as additional intravenous inotropes, diuretics, respiratory management (noninvasive positive pressure ventilation or intubation), or extracorporeal ultrafiltration after 24 hours from admission. Among 4056 patients, 775 (19.4%) patients developed WHF during hospitalization. Inotropes use in emergency room was significantly higher (8.0% vs 2.7%, p&lt;0.001), whereas diuretics use was significantly lower (45.6% vs 51.7%, p=0.002) in patients with WHF than those without WHF. In-hospital mortality was significantly higher in patients with WHF than in those without WHF (16.3% vs 4.0%, p&lt;0.001). A composite of all-cause death and HF hospitalization at 1-year were compared in 3728 patients who were alive at discharge with available data. Patients with WHF (N=644, 18.3%) were younger (79 [70-85] vs 81 [7-85], p&lt;0.001), more likely to be men (61.7 % vs 53.6%, p&lt;0.001), and more likely to have diabetes (44.7% vs 35.2% p&lt;0.001), chronic kidney disease (57.9% vs 41.3%, p&lt;0.001), and ischemic etiology (41.6% vs 30.7%, p&lt;0.001) than those without WHF (N=3084, 87.4%). After adjusting for confounders, the risk for primary outcome of WHF group remained significant (OR: 1.27, 95%CI: 1.02-1.58, p=0.03). Conclusions: The WHF during hospitalization was associated with worse 1-year clinical outcomes as well as in-hospital mortality in patients with ADHF.

Abstract 11494: Patient Characteristics, Management and Outcomes of Acute Heart Failure Hospitalizations in Japan

Introduction: In Japan, the prevalence of heart failure (HF) was approximately 0.8% in 2005 and is projected to increase. Yet, studies of real-world HF patients are limited. Thus, using a large multi-institutional database, we described in-hospital management and outcome of acute HF hospitalizations. Methods: We conducted a retrospective cohort study of adult patients (age ≥18) using the Medical Data Vision (MDV) database in Japan. MDV consists of ~ 35million medical records from &gt; 400 hospitals across all regions in Japan providing data on diagnosis, procedures, pharmacy claims, and laboratory data. Acute HF hospitalizations were defined as primary HF diagnoses + use of intravenous diuretics within 48 hours. We described patient characteristics, in-hospital management, length of stay (LOS), in-hospital death, and 30-day all-cause readmissions. We included published results from AHA’s Get With The Guidelines (GWTG)-HF for benchmarking. Results: Table includes results from 120,921 hospitalizations in Japan and GWTG-HF publications. Mean age was higher but weight and BMI were lower in Japan. Laboratory values were similar but Hemoglobin A1c, B-type natriuretic peptide, and creatinine levels were lower in Japan. Mean LOS was 24 in Japan vs.4 in the US but 44% had cardiac rehab during hospitalization. In-hospital mortality was &gt; 3 times higher but the 30-day readmission rate was lower in Japan. Conclusion: In a large multi-institutional real-world data of acute HF hospitalizations, compared to published US GWTG-HF data, Japanese patients were older but had less comorbidities. They had longer LOS and lower readmission rates. While hospital death was higher in Japan, this is not directly comparable to the US data due to the large LOS difference. Further studies to understand the reasons for the population and practice differences may generate hypotheses for potential interventions to improve HF outcomes.

Out-of-pocket payments for part d covered medications by medicare fee-for-service beneficiaries with heart failure with reduced ejection fraction

Out-of-pocket (OOP) drug costs for MedicareFee-for-Service (FFS) beneficiaries with heart failure withreduced ejection fraction (HFrEF) are not well characterized.This study evaluated Part D OOP spending by Medicare beneficiaries with chronic HFrEF, stratified by thosewithand withouta worsening HF event (WHFE). Medicare FFS 100% Part D claims were used to identify HFrEF patients with 12 months of continuous Part D enrollment in 2018. HFrEF was defined as 1 inpatient or 2 outpatient claims of systolic HF or 1 systolic HF plus 1 HF outpatient claim. WHFE was defined as having a HF hospitalization or intravenous diuretic use within 12 months of HFrEF index date. OOP costs by Medicare Part D coverage phase for all covered drugs were calculated for HFrEF patients, and those with and without WHFE. Of 305,373 Medicare patients with HFrEF, 26% had a WHFE. Total mean (SD) OOP drug costs among all HFrEF patients was $1,166 (1,205)/year. Patients with WHFE and patients without WHFE had respectively a mean (SD) annual OOP costs of $1,302 (1,273) and $1,117 (1,176). Over 39% of HFrEF patients entered the "donut hole" (44% and 37% of patients with WHFE and without WHFE, respectively), while 11% of HFrEF patients entered the catastrophic phase (13% and 10% of patients with and without WHFE, respectively). More than 1 in 10 patients with heart failure entered the catastrophic phase within Medicare-Fee-For-Service, whereas in 2018 only 10% of costs were attributable to heart failure medication and 90% to comorbidities.

Dose of furosemide before admission predicts diuretic efficiency and long-term prognosis in acute heart failure.

AimsThe outpatient diuretic dose is a marker of diuretic resistance and prognosis in chronic heart failure (HF). Still, the impact of the preadmission dose on diuretic efficiency (DE) and prognosis in acute HF is not fully known.Methods and resultsWe conducted an observational and prospective study. All patients admitted for acute HF treated with intravenous diuretic and at least one criterion of congestion on admission were evaluated. Decongestion [physical examination, hemoconcentration, N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) change, and lung ultrasound], DE (weight loss and urine output per unit of 40 mg furosemide), and urinary sodium were monitored on the fifth day of admission. DE was dichotomized into high–low based on the median value. A multivariate Cox regression analysis was conducted to find predictors of HF readmission or mortality. A total of 105 patients were included between July 2017 and July 2019. Mean age was 74.5 ± 12.0 years, 64.8% were male, 33.3% had de novo HF, and mean left ventricular ejection fraction was 46 ± 17%. Median follow‐up was 26 [15–35] months. Low DE based on weight loss was associated with a higher previous dose of furosemide (odds ratio [OR] 1.01 [1.00–1.02]), thiazide treatment before admission (OR 9.37 [2.19–40.14]), and lower diastolic blood pressure (OR 0.95 [0.91–0.98]) in the multivariate regression model. Only previous dose of furosemide (OR 1.01 [1.00–1.02]) and haemoglobin at admission (OR 0.76 [0.58–0.99]) were associated with low DE based on urine output in the multivariate analysis. The correlation between the previous dose of furosemide and DE based on weight loss was poor (r = −0.12; P = 0.209) and with DE based on urine output was weak to moderate (r = −0.33; P < 0.001). Low DE based on weight loss and urine output was associated with lesser decongestion measured by NT‐proBNP (P = 0.011; P = 0.007), hemoconcentration (P = 0.006; P = 0.044), and lung ultrasound (P = 0.034; P = 0.029), but not by physical examination (P = 0.506; P = 0.560). Survival and event‐free survival in acute decompensated HF (ADHF) were lower than in de novo HF; a preadmission dose of furosemide > 80 mg in ADHF identified patients with particularly poor prognosis (log‐rank < 0.001). In ADHF, the preadmission dose of furosemide (hazard ratio [HR] 1.34 [1.08–1.67] per 40 mg) and NT‐proBNP at admission (HR 1.03 [1.01–1.06] per 1000 pg/mL) were independently associated with mortality or HF readmission in the multivariate Cox regression analysis.ConclusionsThe outpatient dose of furosemide before acute HF admission predicts DE and must be taken into account when deciding on the initial diuretic dose. In ADHF, the outpatient dose of furosemide can predict long‐term prognosis better than DE during hospitalization.