Management Of Acute Decompensated Heart Failure Research Articles

Methods for the Assessment of Volume Overload and Congestion in Heart Failure

Acute Decompensated Heart Failure (ADHF) entails a dysregulation of renal and cardiac function, with fluid volume excess or ‘congestion’ being a key component. We provide an overview of methods for its assessment in clinical practice. Evaluation of congestion can be achieved using different methods including plasma biomarkers, measurement of blood volume from the volume of distribution of [131I]-human serum albumin, sonographic modalities, implantable devices, invasive measurements of volume status including right heart catheterization, and impedance methods. Integration into clinical practice of accessible, cost effective, and evidence-based modalities for volume assessment will be pivotal in the management of ADHF.

Abstract 18863: Clinical Assessment of Volume Status in Heart Failure is Inaccurate at Detecting Hypervolemia and Anemia as Quantified by Blood Volume Measurement

Introduction: Blood volume status is a crucial input for care decisions, especially the use of diuretics for decongestion, in acute decompensated heart failure (ADHF). In the absence of direct measurements, total blood volume (TBV) status is typically measured via clinical assessment of external fluid overload (edema, jugular venous distension, etc.), and red blood cell volume (RBCV) is assessed via hematocrit. A recent retrospective analysis showed that direct blood volume assessment (BVA) leads to better outcomes in ADHF. Hypothesis: We hypothesize that BVA-guided ADHF care can be protocolized and integrated into clinical workflow of ADHF management. Methods: The objective of this study is to prospectively compare the efficacy of standard care treatment decisions to those in a BVA-guided fluid management protocol. ADHF patients admitted to a Veterans Affairs Medical Center were randomized to either a control (n=8) or BVA-guided (n=8) arm. TBV, plasma volume (PV) and RBCV were measured at admission and prior to discharge by BVA utilizing an I-131 labeled albumin indicator-dilution technique (Daxor BVA-100). Clinician assessments of volume status were collected for all patients prior to BVA measurement. TBV status was defined relative to patient norms as: Hypovolemic (< -10%), Euvolemic (-10% to +10%), Hypervolemic (> +10%). RBCV status was defined as Anemic (< -10%) Not Anemic (> -10%). Results: Measured volume status at admission was quite heterogeneous, with 62.5% Anemic, and with 37.5% Hypovolemic, 31.25% Euvolemic, and 31.25% Hypervolemic. Clinical assessment at admission was notably inaccurate, with only 56% accuracy (sensitivity 40%, specificity 83%) on the presence of anemia, and only 31% accuracy on the presence of hypervolemia, with 94% of patients assessed by clinicians as hypervolemic. Non-hypervolemic patients in the BVA-Guided group received less diuretic treatment than non-hypervolemic controls. Conclusions: We successfully embedded a BVA guided treatment protocol into the clinical workflow of ADHF management at a large medical center. Clinical assessment of volume status was less accurate that direct BVA. Future studies will address whether BVA guided treatment leads to better outcomes in ADHF.

Furosemide continuous infusion versus repeated injection in the management of acute decompensated heart failure in infants with left to right shunt: a randomized trial

BackgroundFurosemide is the foremost drug used in the management of acute decompensated heart failure (ADHF). By tradition, it was administered as repeated intravenous boluses but fluctuations in intravascular volume and blood pressure were noticed in addition to the possibility of toxicity. Hence, continuous intravenous infusion was thought of as an alternative route of administration. In searching the literature, all previously published data concerning the pediatric age group was for infants and children following cardiac surgery. This study aims to compare the efficacy and safety of furosemide repeated injection versus continuous infusion during the management of ADHF in infants with left to right shunt.MethodsA prospective parallel-design randomized study was conducted on 54 infants with ADHF, Ross class IV, secondary to left to right shunt. Twenty-seven infants received repeated injections of furosemide and 27 infants had furosemide continuous infusion. Patients were followed clinically for weight, urine output, hours required for resolution of failure symptoms, serum creatinine, sodium and potassium, and length of hospital stay.ResultsNon-significant differences were observed between both groups regarding preadmission oral furosemide dose and serum creatinine level. A lower daily dose of furosemide was observed in the continuous infusion arm (3.5 ± 0.6 vs 4.7 ± 1.0, p = 0.001) with less fluctuation in urine output and significantly fewer hours required for resolution of failure symptoms (42.1 ± 9 vs 56 ± 18.5, p = 0.001). At the end of furosemide infusion, serum creatinine was significantly higher in the continuous infusion group (0.39 ± 0.06 vs 0.34 ± 0.1, p = 0.030). However, before hospital discharge, non-significant differences were noticed (0.32 ± 0.05 vs 0.33 ± 0.06, p = 0.584). Non-significant differences between both groups regarding serum sodium and potassium levels at the end of furosemide injection were detected (p = 0.289, 0.890, respectively).ConclusionContinuous infusion of furosemide can be safely administered to infants with ADHF, Ross class IV, secondary to left to right shunt with clinical gradual alleviation of fluid overload symptoms and less hemodynamic instability than repeated injections.Trial registrationThe study was approved by the Mansoura Faculty of Medicine institutional research board (MS/16.02.41) on August 3rd, 2016.

IV Diuresis in Alternative Treatment Settings for the Management of Heart Failure: Implications for Mortality, Hospitalizations and Cost

Recent advances in heart failure (HF) care have sought to shift management from inpatient to outpatient and observation settings. We evaluated the association among HF treatment in the (1) inpatient; (2) observation; (3) emergency department (ED); and (4) outpatient settings with 30-day mortality, hospitalizations and cost. Using 100% Medicare inpatient, outpatient and Part B files from 2011-2018, 1,534,708 unique patient encounters in which intravenous (IV) diuretics were received for a primary diagnosis of HF were identified. Encounters were sorted into mutually exclusive settings: (1) inpatient; (2) observation; (3) ED; or (4) outpatient IV diuretic clinic. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 30-day hospitalization and total 30-day costs. Multivariable logistic and linear regression were used to examine the association between treatment location and the primary and secondary outcomes. Patients treated in observation and outpatient settings had lower 30-day mortality rates (observation OR 0.67, 95% CI 0.66-0.69; P < 0.001; outpatient OR 0.53, 95% CI 0.51-0.55; P < 0.001) compared to those treated in inpatient settings. Observation and outpatient treatment were also associated with decreased 30-day total cost compared to inpatient treatment. Observation relative cost -$5528.77, 95% CI -$5613.63 to -$5443.92; outpatient relative cost -$7005.95; 95% CI -$7103.94 to -$6907.96). Patients treated in the emergency department and discharged had increased mortality rates (OR 1.15, 95% CI 1.13-1.17; P < 0.001) and increased rates of hospitalization (OR 1.72, 95% CI 1.70-1.73; P < 0.001) compared to patients treated as inpatients. Medicare beneficiaries who received IV diuresis for acute HF in the outpatient and observation settings had lower mortality rates and decreased costs of care compared to patients treated as inpatients. Outpatient and observation management of acute decompensated HF, when available, is a safe and cost-effective strategy in certain populations of patients with HF.

Decongestion strategies in patients presenting with acutely decompensated heart failure: A worldwide survey among physicians.

Decongestion strategies for acute decompensated heart failure (ADHF) characterized by volume overload differ widely. The aim of this independent international academic web-based survey was to capture the therapeutic strategies that physicians use to treat ADHF and to assess differences in therapeutic approaches between cardiologists versus non-cardiologists. Physicians were invited to complete a web-based questionnaire, capturing anonymized data on physicians' characteristics and treatment preferences based on a hypothetical clinical scenario of a patient hospitalized with ADHF. A total of 641 physicians from 60 countries participated. A wide variation in the management of the patient was observed. There was conservative use of diuretics, i.e. only 7% started intravenous furosemide at a dose ≥2 times the baseline oral dose, and infrequent use of ultrasound in assessing congestion (20.4%). Spot urinary sodium was infrequently or never measured by ≥85% of physicians. A third considered a patient with ongoing oedema as being stabilized. There were significant differences between cardiologists and non-cardiologists in the management of ADHF, the targets for daily body weight loss and urine output, diuretic escalation strategies (66.3% vs. 40.7% would escalate diuresis by adding a thiazide) and assessment of response to treatment (27.0% vs. 52.9% considered patients with minimal congestion as stabilized). There is substantial variability amongst physicians and between cardiologists and non-cardiologists in the management of patients with ADHF, with regard to clinical parameters used to tailor treatment, treatment goals, diuretic dosing and escalation strategies.

Mitral regurgitation severity dynamic during acute decompensated heart failure treatment

Acute decompensated heart failure (ADHF) treatment leads to significant hemodynamic changes. The aim of our study was to quantitatively analyze the dynamics of mitral regurgitation (MR) severity (evaluated by transthoracic echocardiography) which occur during the treatment of ADHF and to correlate these changes with the clinical condition of patients as well as heart failure biochemical markers. The study included 27 consecutive adult patients (40.7% females, mean age 71.19 ± 11.2 years) who required hospitalization due to signs of acute HF. Echocardiographic assessment was performed upon admission and discharge together with clinical and laboratory evaluation. Significant reduction in dyspnea intensity [0–100 scale] (81.48 ± 9.07 vs. 45.00 ± 11.04 pts, p < 0.001), body weight (84.98 ± 18.52 vs. 79.77 ± 17.49 kg, p < 0.001), and NT-proBNP level (7520.56 ± 5288.62 vs. 4949.88 ± 3687.86 pg/ml, p = 0.001) was found. The severity of MR parameters decreased significantly (MR volume 44.92 ± 22.83 vs. 30.88 ± 18.77 ml, p < 0.001; EROA 0.37 ± 0.17 vs. 0.25 ± 0.16 cm2, p < 0.001; VC 6.21 ± 1.48 vs. 5.26 ± 1.61 mm, p < 0.001). Left atrial area (35.86 ± 9.11 vs. 32.47 ± 9.37, p < 0.001) and mitral annular diameter (42.33 ± 6.63 vs. 39.72 ± 5.05. p < 0.001) also underwent statistically significant reductions. An increase in LVEF was observed (34.73 ± 13.88 vs. 40.24 ± 13.19%, p < 0.001). In 40.7% of patients, a change in MR severity class (transition from a higher class to a lower one) was observed: 6/8 (75%) patients transitioned from severe to moderate and 6/18 (33.3%) patients transitioned from moderate to mild class. Treatment of ADHF leads to a significant reduction in MR severity, together with significant reductions in left atrial and mitral annular dimensions. Quantitative measurement of MR dynamics offer valuable assistance for ADHF management.

Sodium-based osmotherapy for hyponatremia in acute decompensated heart failure.

Acute decompensated heart failure (ADHF) accounts for more than 1 million hospital admissions annually and is associated with high morbidity and mortality. Decongestion with removal of increased total body sodium and total body water are goals of treatment. Acute kidney injury (AKI) or chronic kidney disease (CKD) is present in two-thirds of patients with ADHF. The pathophysiology of ADHF and AKI is bidirectional and synergistic. AKI and CKD complicate the management of ADHF by decreasing diuretic efficiency and excretion of sodium and water. Among patients hospitalized with ADHF, hyponatremia is the most common electrolyte abnormality and is classically encountered with volume overload. ADHF represents an additional therapeutic challenge particularly when oligoanuria is present. Predilution continuous venovenous hemofiltration with sodium-based osmotherapy can safely increase plasma sodium concentration without deleteriously increasing total body sodium. We present a detailed methodology that addresses the issue of hypervolemic hyponatremia in patients with ADHF and AKI.

Temporal changes of cardiac acoustic biomarkers and cardiac function in acute decompensated heart failure.

AimsRelationships between cardiac acoustic biomarkers (CABs) measured by acoustic cardiography and clinical outcomes have been reported in heart failure (HF) patients. However, no studies have investigated the temporal change of CABs and the corresponding changes in HF status. The purpose of this study was to assess whether the temporal changes of CABs in patients with acute decompensated heart failure (ADHF) reflect changes in cardiac function and status.Methods and resultsSixty ADHF patients were enrolled prospectively. CABs and echocardiography data were collected at admission, before discharge, and at the first clinic visit. CABs included electromechanical activation time (EMAT); the time interval from Q wave onset on electrocardiography to the first heart sound (S1), QoS2; the time interval from Q wave onset on electrocardiography to the second heart sound (S2); and third heart sound (S3) and fourth heart sound (S4) intensities, defined as the peak‐to‐peak amplitudes of S3 and S4. EMATc (EMAT/RR) (P = 0.001), S3 intensity (P < 0.001), and S4 intensity (P < 0.001) were significantly decreased, and QoS2 (P = 0.005) was significantly increased from admission to discharge. The change in S3 intensity was significantly correlated with that of E/A (ρ = 0.571, P < 0.001), and the extended QoS2 was also significantly correlated with the increase in the stroke volume index (ρ = 0.383, P = 0.004).ConclusionsSome CABs in ADHF patients changed significantly in the normal direction throughout the treatment course and could be useful biomarkers in ADHF management.

Pathophysiology and Therapeutic Approaches to Acute Decompensated Heart Failure.

Acute decompensated heart failure (ADHF) is one of the leading admission diagnoses worldwide, yet it is an entity with incompletely understood pathophysiology and limited therapeutic options. Patients admitted for ADHF have high in-hospital morbidity and mortality, as well as frequent rehospitalizations and subsequent cardiovascular death. This devastating clinical course is partly due to suboptimal medical management of ADHF with persistent congestion upon hospital discharge and inadequate predischarge initiation of life-saving guideline-directed therapies. While new drugs for the treatment of chronic HF continue to be approved, there has been no new therapy approved for ADHF in decades. This review will focus on the current limited understanding of ADHF pathophysiology, possible therapeutic targets, and current limitations in expanding available therapies in light of the unmet need among these high-risk patients.

Optimal diuretic strategies in heart failure.

Heart failure (HF) is one of the major causes of morbidity and mortality in the world. According to a 2019 American Heart Association report, about 6.2 million American adults had HF between 2013 and 2016, being responsible for almost 1 million admissions. As the population ages, the prevalence of HF is anticipated to increase, with 8 million Americans projected to have HF by 2030, posing a significant public health and financial burden. Acute decompensated HF (ADHF) is a syndrome characterized by volume overload and inadequate cardiac output associated with symptoms including some combination of exertional shortness of breath, orthopnea, paroxysmal nocturnal dyspnea (PND), fatigue, tissue congestion (e.g., peripheral edema) and decreased mentation. The pathology is characterized by hemodynamic abnormalities that result in autonomic imbalance with an increase in sympathetic activity, withdrawal of vagal activity and neurohormonal activation (NA) resulting in increased plasma volume in the setting of decreased sodium excretion, increased water retention and in turn an elevation of filling pressures. These neurohormonal changes are adaptive mechanisms which in the short term are associated with increased contractility of the left ventricular (LV) and improvement in cardiac output. But chronically, the failing heart is unable to overcome the excessive pressure and volume leading to worsening HF. The primary symptomatic management of ADHF includes intravenous (IV) diuresis to help with decongestion and return to euvolemic status. Even though diuretics have not been shown to provide any mortality benefit, they have been clinically proven to be of significant benefit in the acute decompensated phase, as well as in chronic management of HF. Loop diuretics remain the mainstay of therapy for symptomatic management of HF with use of thiazide diuretics for synergistic effect in the setting of diuretic resistance. Poor diuretic efficacy has been linked with higher mortality and increased rehospitalizations.

Medical management of decompensated heart failure in adult patients: Part 1: Definition and medical management

Acute decompensated heart failure (ADHF) is the leading cause of hospitalization in patients older than 65 years. It continues to increase in prevalence and is associated with significant mortality and morbidity including frequent hospitalizations. The American Heart Association is predicting that more than 8 million Americans will have heart failure by 2030 and that the total direct costs associated with the disease will rise from $21 billion in 2012 to $70 billion in 2030. The definition of ADHF has important limitations, and its management differs significantly from that of chronic heart failure. Although many large, randomized, controlled clinical trials have been conducted in patients with chronic heart failure, it was not until recently that more studies began to address the management of ADHF. The mainstay of ADHF management involves identification of precipitating factors, oxygen supplementation, sodium and fluid restriction, and diuresis. The phenomenon of diuretic resistance is a significant obstacle to relief of congestion and is a field of active investigation. Other important adjuncts to treatment include noninvasive ventilation, inotropes, vasopressors, nitrates, opiates, and vasopressin receptor antagonists. In this review, we will discuss the terminology and classification of ADHF, and review the multiple modalities and strategies available for the management of this disorder.&#x0D; Keywords: heart failure, medical management, complications, devices, palliative care

Acute Heart Failure Advanced Life Support: Guideline-Based Interactive Training for Providers

Introduction There are over one million hospitalizations per year in the United States (US) for acute decompensated heart failure (ADHF). Unfortunately, there is often a delay in initiating guideline directed medical therapy (GDMT) and other interventions resulting in prolonged length of stay, increased readmission rate, and higher mortality. To date, no formal program has been established on education to streamline heart failure GDMT for US providers. Our center implemented Acute Heart Failure Advanced Life Support (AHFALS), a novel international educational training course to address this deficit. AHFALS, developed by Sociedade de Cardiologia do Estado de San Paulo, has been successfully implemented throughout Brazil and Portugal. This four hour course provides a standardized, algorithmic approach integrating current GDMT for management of ADHF utilizing interactive patient simulation with manikins similar to Advanced Cardiac Life (ACLS). The course teaches appropriate management across the continuum of care; from the emergency department to inpatient care with transition to outpatient care. Hypothesis Course participants will have improved knowledge of ADHF management, improvement in post-test course scores compared with pre-test course scores, and a high level of participant satisfaction upon course completion. Methods Participants received course materials via email and completed a pre-test online. Upon completion of a half-day course taught by trained instructors, the post-test was administered in written form and scored. A score of 70% or greater was considered passing, resulting in course certification. Participants were given a satisfaction survey, with a follow-up survey 6 months post-course completion. Results 115 internal medicine, emergency medicine, hospitalists, cardiology fellows, and advanced practice providers participated in the course and completed the pre/post-test and participant satisfaction survey. There was a statistically significant difference between pre (Avg 55.47%, STD 16.09) and post-test (Avg 73%, STD 11.21) exam scores with a p-value of Conclusions Preliminary data show high provider satisfaction, improvement in knowledge base and level of comfort in management of ADHF across the continuum of care. We anticipate more providers completing AHFALS within our institution and throughout local hospitals. Our hope is to expand the AHFALS course statewide and eventually nationwide and utilize it to train house staff, cardiology fellows and other providers managing ADHF. AHFALS will likely become recognized as an educational tool with credentialing similar to ACLS. Data collection is ongoing along with course expansion to determine the impact on patient outcomes.

Predictive Value of Spot Urine Sodium during the Treatment of Acute Decompensated Heart Failure

Background A mainstay of treatment for acute decompensated heart failure is decongestion by diuresis commonly monitored with urine output. The aim of this study was to examine whether a spot urine sodium (UNa) measurement can predict diuretic response as well as in-hospital outcomes. Methods A total of 613 consecutive patients (age: 77±12 years, male: 60%) who were admitted to our institution due to acute decompensated heart failure (ADHF), were retrospectively reviewed. Spot urine samples were obtained within 24 hours after hospitalization. Patients were divided into two groups according to the value of UNa: UNa ≥50 mEq/L (high-UNa) and UNa Results The UNa level was 107.9 ±1.5 mEq/L in high-UNa (n=484) and 30.9 ±2.8 mEq/L in low-UNa (n=129). Although there were no significant differences between the two groups regarding age, gender, Left ventricular ejection fraction, diuretics use before admission and total dose of intravenous furosemide within 24 hours (high-UNa vs low-UNa, 65 ±3 vs 74 ±7 mg, P=0.24), high-UNa was associated with higher sodium level (138.4 ±0.2 vs 135.7 ±0.4 mEq/L, P Conclusion Higher urine sodium excretion was associated with larger amount of urine output, lower incidence of WRF and lower in-hospital mortality. Spot urine sodium measurement may be useful in the management of ADHF.

Therapeutic Advances in the Management of Acute Decompensated Heart Failure.

Acute decompensated heart failure (ADHF) is the most common presenting phenotype of acute heart failure (AHF). The main goal of this article was to review the contemporary management strategies in these patients and to describe how future clinical trials may address unmet clinical needs. The current pathophysiologic understanding of AHF is incomplete. The guideline recommendations for the management of ADHF are based only on algorithms provided by expert consensus guided by blood pressure and/or clinical signs of congestion or hypoperfusion. The lack of adequately conducted trials to address the unmet need for evidence therapy in AHF has not yet been surpassed, and at this time, there is no evidence-based strategy for targeted decongestive therapy to improve outcomes. The precise time point for initiation of guideline-directed medical therapies (GDMTs), as respect to moment of decompensation, is also unknown. The available data informing current management of patients with ADHF are based on randomized controlled trials, observational studies, and administrative databases. A major step-forward in the management of ADHF patients is recognizing congestion, either clinical or hemodynamic, as a major trigger for heart failure (HF) hospitalization and most important target for therapy. However, a strategy based exclusively on congestion is not sufficient, and at present, comprehensive assessment during hospitalization of cardiac and noncardiovascular substrate with identification of potential therapeutic targets represents "the corner-stone" of ADHF management. In the last years, substantial data have emerged to support the continuation of GDMTs during hospitalization for HF decompensation. Recently, several clinical trials raised hypothesis of "moving to the left" concept that argues for very early implementation of GDMTs as potential strategy to improve outcomes. The management of ADHF is still based on expert consensus documents. Further research is required to identify novel therapeutic targets, to establish the precise time point to initiate GDMTs, and to identify patients at risk of recurrent hospitalization.

Subcutaneous furosemide for the treatment of heart failure: a state-of-the art review.

The prevalence of heart failure (HF) is on the rise. By 2030, over eight million Americans (46% increase from current prevalence) will have heart failure. In the USA, approximately 30 billion dollars is spent annually on heart failure and this number will likely double in 2030. Thus, HF represents a significant economic burden. Acute decompensated heart failure (ADHF) is a clinical spectrum, which refers to increasing symptoms and signs of heart failure prompting an emergency room visit or hospitalization. In ADHF, inpatient administration of intravenous diuretic is the standard of care due to the variability in the absorption of oral diuretics. Within 30days, 25-30% of these patients are readmitted with recurrent ADHF. Recent efforts have focused in reducing HF readmission, and thereby decreasing costs; hence, innovative outpatient treatment options have emerged. Subcutaneous furosemide use will potentially overcome the need to place intravenous lines, reduce associated expenses, and enable management of ADHF at home. This review presents data on the pharmacodynamics and pharmacokinetics of subcutaneous furosemide, scientific evidence on the use of this therapy in the palliative and hospice population, and its experimental use as an outpatient therapy and/or as a bridge from inpatient to home.

1866. Adverse Outcomes Associated with Potentially Inappropriate Antibiotic Use in Heart Failure Admissions

BackgroundHospital admissions due to acute decompensated heart failure (ADHF) are common, and the clinical presentation can be confused with other conditions such as pneumonia. Hospitalized ADHF patients often receive antibiotic therapy even when the clinical suspicion for pneumonia is low, and intravenous (IV) antibiotics are commonly used. We hypothesized the additional fluid and sodium content of potentially unnecessary antibiotic therapy could worsen outcomes and complicate management of ADHF patients.MethodsWe conducted a retrospective cohort analysis of adult patients with a diagnosis of ADHF. Patients were excluded if chest radiography suggested pneumonia, if they were continuing a prior antibiotic regimen, if they were diagnosed with a proven infection during admission, or if serum BNP level was not elevated. Patients who received antibiotics were compared with those who did not with respect to diuretic requirements, length of stay, sodium and fluid load attributable to antibiotic treatment, and readmission rate.ResultsThree hundred thirty-seven patients were screened for inclusion of which 153 were enrolled, 89 in the nonantibiotic arm compared with 64 in the antibiotic arm. Median length of stay in the antibiotic arm was 6.5 days as opposed to 3.25 days in the nonantibiotic arm (P < 0.001). The antibiotic group received a median dosage of 1,000 mg of furosemide compared with 400 mg in the nonantibiotic arm (P < 0.001). Patients who received antibiotics were 2.51 times more likely to be readmitted compared with patients who did not receive antibiotics (P = 0.04). On average, each patient in the antibiotic arm received approximately 970 mg of sodium daily and 1.6 L of volume attributed to antibiotic infusions.ConclusionPatients who received IV antibiotics during treatment for ADHF without evidence of infection had significantly longer lengths of stay, received significantly higher doses of furosemide, and were more likely to be readmitted compared with patients with the same diagnosis who were not exposed to intravenous antibiotics. Additional studies are needed to determine factors contributing to potential overprescribing in this population, and ADHF patients are a promising target of antibiotic stewardship interventions.Disclosures All authors: No reported disclosures.

213 - Discharge Readiness Assessment and 6-month Readmission Risk in Acute Decompensated Heart Failure

Background: Attention has been paid recently to the short-term effects of discharging patients admitted for acute decompensated heart failure (ADHF) prior to achieving euvolemia, but long-term effects remain unknown. This study evaluated the influence of the discharge volume status assessment on readmissions over 6 months. Methods: This was a retrospective cohort study of 100 consecutive adult patients discharged from a single academic hospital admission for management of ADHF from May, 2014 to June, 2015. Exclusion criteria included characteristics of the patient (ESRD on HD, congenital heart disease, or LVAD in place) and the hospitalization (discharge within 6 months of index admission or surgery/death during hospitalization). Baseline characteristics were obtained from the admission H&P and primary data reports. Discharge characteristics were obtained solely from the discharge summary (DS). Co-primary outcomes were 6-month readmission for all-cause and HF as primary diagnosis, assessed by chart review. Comparisons were made by chi-square testing for categorical variables and independent samples t-testing or Kruskal-Wallis testing for continuous variables. Results: Mean age was 62.1 years (SD 15.3), 44% were women, and the average BMI was 33.9 kg/m2 (SD 11.6). Hypertension (87%), history of tobacco use (68%), hyperlipidemia (59%), coronary artery disease (44%), and diabetes (42%) were common. Ejection fraction was preserved (>40%) in 46%. All-cause 6-month readmission occurred in 51% and HF-related 6-month readmissions occurred in 38%. In the DS physical exam, traditional markers of volume status were documented at similar rates in those who were and were not readmitted, except for absence of edema, which was more commonly documented in those not readmitted (82.6 vs. 56.3%, P = .04). A clear discussion in the DS that the patient had achieved euvolemia was similarly documented between those readmitted and those not (17.6 vs. 18.4%, P = .93). In the DS assessment section, no markers of volume status to justify discharge reached statistical significance except dyspnea resolution, which was more commonly cited in those not readmitted (40.8 vs. 23.5%, P = .06). These differences remained significant if HF was the primary readmission diagnosis. Conclusions: The presence or absence of clinical euvolemia as measured by DS physical exam and heart failure assessment was not associated with readmission rate. This long-term outcome possibly reflects long-term disease severity rather than the management practices during a singular admission.

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

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

Use of Biomarkers to Predict Readmission for Congestive Heart Failure

Acute decompensated heart failure (ADHF) is a major reason for repeated hospitalizations. Identifying those patients with ADHF at risk for readmission is critical so that preventive interventions can be implemented. Biomarkers such as B-type natriuretic peptide (BNP), high-sensitivity troponin I, and galectin-3 (Gal-3) assessed at discharge may be useful, although their role in predicting short-term readmission is not well defined in the literature. We enrolled and had follow-up data for 101 participants admitted to our facility from April 2013 to March 2015 with a primary diagnosis of ADHF. Gal-3, high-sensitivity troponin I, and BNP were obtained within 48hours before hospital discharge after management of ADHF. Gal-3 was assessed using 2 commercially available assays. We compared subjects who were and were not readmitted. Discharge BNP was found to be a significant predictor of 30- and 60-day readmission (area under the curve [AUC] 0.69 [p= 0.046], AUC 0.7 [p= 0.005], respectively). The addition of Gal-3 to discharge BNP provided significantly improved prediction of 60-day readmission. Gal-3 alone was found to be a significant predictor of 60-day readmission in patients with preserved ejection fraction (AUC 0.85, p <0.001). The net reclassification improvement was 55.2 (p= 0.037). Using multivariate analysis, for every 100 pg/L BNP increase, the probability of readmission increased by approximately 10%, and for every 1-ng/ml Gal-3 increase, the probability further increased 8%. A statistically significant net reclassification improvement was not found on examination of 30-day readmission. In conclusion, measurement of both Gal-3 and BNP at hospital discharge provides significant prediction of hospital readmission within 60days. When combined, the prediction of readmission is significantly improved.

Acute Decompensated Heart Failure

Heart failure (HF) is a societal burden due to its high prevalence, frequent admissions for acute decompensated heart failure (ADHF), and the economic impact of direct and indirect costs associated with HF and ADHF. Common etiologies of ADHF include medication and diet noncompliance, arrhythmias, deterioration in renal function, poorly controlled hypertension, myocardial infarction, and infections. Appropriate medical management of ADHF in patients is guided by the identification of signs and symptoms of fluid overload or low cardiac output and utilization of evidence-based practices. In patients with fluid overload, various strategies for diuresis or ultrafiltration may be considered. Depending on hemodynamics and patient characteristics, vasodilator, inotropic, or vasopressor therapies may be of benefit. Upon ADHF resolution, patients should be medically optimized, have lifestyle modifications discussed and implemented, and medication concierge service considered. After discharge, a multidisciplinary HF team should follow up with the patient to ensure a safe transition of care. This review article evaluates the management options and considerations when treating a patient with ADHF.