Nonfatal Hospitalization Research Articles

Alcohol-Related Deaths and Hospitalizations by Race, Gender, and Age in California

Introduction: Excessive alcohol use is the third leading preventable cause of death in the United States each year and responsible for about 10,000 deaths in California alone. In addition, excessive alcohol use is responsible for many hospitalizations due to injuries and illnesses. Alcohol consumption is known to differ by age, sex, and race/ethnicity and these consumption patterns can lead to differences in alcohol-related outcomes. Methods: Using data from a variety of sources, alcohol-attributable deaths and nonfatal hospitalizations for illnesses and injuries were calculated for California for the year 2006. Results: Excessive alcohol use resulted in over 10,000 deaths and 72,000 nonfatal hospitalizations in California. The majority of consequences (51%) were due to chronic illnesses associated with long-term excessive use of alcohol. Overall, males reported more deaths and nonfatal hospitalizations due to excessive alcohol use than women. Alcohol-attributable deaths and hospitalizations are more likely to occur among individuals aged 50-64 years for illnesses and individuals aged 20-34 years for injuries. Older individuals suffered from more chronic conditions such as alcoholic liver disease, while younger individuals were more likely to suffer from injuries, the most common being motor-vehicle traffic crashes. Significant differences in the rate of deaths and nonfatal hospitalizations by race/ethnicity were more common due to injuries and violence than chronic diseases. Conclusions: This study highlighted key findings of demographic differences in consequences suffered by excessive alcohol use in California. Continued efforts to better evaluate the contribution of alcohol to morbidity and mortality by demographic factors, especially by race and ethnicity, is warranted to prevent and reduce the harm associated with this behavior.

PROGNOSTIC VALUE OF PATHOLOGIC Q-WAVE AND TIME OF ITS APPEARANCE IN PATIENTS WITH MYOCARDIAL INFARCTION: COMPARISON STUDY

Aim. To evaluate short- and long-term prognosis of myocardial infarction (MI) depending on occurrence of pathologic Q-wave on ECG and time of its appearance. Material and methods. 616 patients with initial ST-elevated MI were included into the study — 254 women and 362 men, aged 62.1±11.2. All patients were split up three groups depending on occurrence of pathologic Q-wave on ECG and time of its appearance. First group consisted of 311 patients with early Q-wave (during first 6 hours from onset of MI symptoms). Second group consisted of 120 patients with late Q-wave (from 6 to 24 hours from onset of MI symptoms). Third group consisted of 185 patients with non-Q-wave MI. Results. The hospital lethality in the patients with early Q-wave was significantly higher than this in patients of the second and the third groups. However, we didn’t reveal significant differences between patients with late Q-wave and patients without Q-wave on ECG. The incidences of cardiac death (sudden death and fatal MI), non-fatal MI and hospitalization because of unstable angina was assessed during next two years. During the follow-up period patients of three groups had similar incidences of the non-fatal MI and hospitalization because of unstable angina. However, incidence of cardiac death was significantly higher in early Q-wave group in comparison with non-Q-wave group. Conclusion. Occurrence of pathologic Q-wave on ECG and time of its appearance should be taken into account to assessed short- and long-term prognosis of MI.

Left ventricular hypertrophy increases cardiovascular risk independently of in-office and out-of-office blood pressure values

Previous studies have shown that left ventricular hypertrophy (LVH) represents a cardiovascular risk factor independently of clinic blood pressure (BP). The present study was aimed at determining the impact of LVH on the incidence of cardiovascular morbid and fatal events taking into account not only classical risk factors but also home and ambulatory BP values, which have been shown to have an important independent prognostic impact. In 1716 patients belonging to the 'Pressioni Arteriose Monitorate E Loro Associazioni' population of Monza, we quantified left ventricular mass index and identified LVH by standard cutoff values. We also measured clinic, home and 24-h ambulatory BPs together with serum glucose and lipids. During a follow-up of 148 months, the rate of fatal and nonfatal (hospitalizations) cardiovascular events as well as of all-cause death was markedly greater (four-fold to five-fold) in patients as compared with those without LVH. In LVH individuals, the increased risk remained significant even when data were adjusted for a large number of other confounding factors including home BP, 24-h mean BP and ambulatory BP. Results were similar when left ventricular mass was indexed by height and body surface area. A 10% increase in left ventricular mass index was associated with a significant increase in cardiovascular risk or all-cause deaths. In multivariate analysis, left ventricular mass index was always an independent predictor of cardiovascular events and death for any cause. Our data provide evidence that LVH is an important risk factor even when the contribution of different BPs to risk is fully taken into account.

Efficacy and safety of intermittent preventive treatment with sulfadoxine-pyrimethamine for malaria in African infants: a pooled analysis of six randomised, placebo-controlled trials

Intermittent preventive treatment (IPT) is a promising strategy for malaria control in infants. We undertook a pooled analysis of the safety and efficacy of IPT in infants (IPTi) with sulfadoxine-pyrimethamine in Africa. We pooled data from six double-blind, randomised, placebo-controlled trials (undertaken one each in Tanzania, Mozambique, and Gabon, and three in Ghana) that assessed the efficacy of IPTi with sulfadoxine-pyrimethamine. In all trials, IPTi or placebo was given to infants at the time of routine vaccinations delivered by WHO's Expanded Program on Immunization. Data from the trials for incidence of clinical malaria, risk of anaemia (packed-cell volume <25% or haemoglobin <80 g/L), and incidence of hospital admissions and adverse events in infants up to 12 months of age were reanalysed by use of standard outcome definitions and time periods. Analysis was by modified intention to treat, including all infants who received at least one dose of IPTi or placebo. The six trials provided data for 7930 infants (IPTi, n=3958; placebo, n=3972). IPTi had a protective efficacy of 30.3% (95% CI 19.8-39.4, p<0.0001) against clinical malaria, 21.3% (8.2-32.5, p=0.002) against the risk of anaemia, 38.1% (12.5-56.2, p=0.007) against hospital admissions associated with malaria parasitaemia, and 22.9% (10.0-34.0, p=0.001) against all-cause hospital admissions. There were 56 deaths in the IPTi group compared with 53 in the placebo group (rate ratio 1.05, 95% CI 0.72-1.54, p=0.79). One death, judged as possibly related to IPTi because it occurred 19 days after a treatment dose, was subsequently attributed to probable sepsis. Four of 676 non-fatal hospital admissions in the IPTi group were deemed related to study treatment compared with five of 860 in the placebo group. None of three serious dermatological adverse events in the IPTi group were judged related to study treatment compared with one of 13 in the placebo group. IPTi with sulfadoxine-pyrimethamine was safe and efficacious across a range of malaria transmission settings, suggesting that this intervention is a useful contribution to malaria control. Bill & Melinda Gates Foundation.

Air Quality and Cardiovascular Health

Ambient particulate matter has been associated consistently with an increased risk for mortality largely due to cardiovascular diseases.1 Although the relative risk estimates from epidemiological studies are small, they apply to almost the entire population of the United States. Consequently, exposure to ambient particles produces considerable burden of disease, and its mitigation offers the benefit of improving life expectancy.2 Articles see pp 941 and 949 Over the past decade, research has substantiated the understanding of the pathophysiological mechanisms linking ambient particles to the cardiovascular system3,4 once it was noted that ambient air pollution elicits systemic inflammatory responses in the general population.5 An update of the American Heart Association statement on air pollution and cardiovascular disease3 is under way. Mechanisms considered for active and secondhand smoke as well as ambient air pollution are strikingly similar.4,6,7 They include progression of atherosclerotic plaques to vulnerable forms, prothrombotic states, endothelial dysfunction, and altered autonomic nervous system control (Figure). Increased systemic oxidative stress is considered the key mechanism responsible for most of these pathophysiological changes. Increased risks for cardiovascular disease in general and coronary artery disease in particular have been documented for active and secondhand smoke as well as ambient particulate matter. Deep venous thrombosis has been added to this list recently.8 Figure. Overview on pathomechanism linking ambient air pollution,4 secondhand smoke,7 and active smoking to acute coronary syndromes. Nevertheless, the public health relevance of particulate matter in the light of the smoking literature remains hotly debated. Smokers are exposed to considerably higher cumulative doses of particulate matter than the general nonsmoking population. Mortality due to low doses of ambient particles may be considered counterintuitive compared with doses of particles tolerated by smoking individuals. A systematic assessment of the exposure-response function ranging from low doses of inhaled particles …

Long-Term Prognostic Value of 13N-Ammonia Myocardial Perfusion Positron Emission Tomography: Added Value of Coronary Flow Reserve

The goal of this study was to assess the predictive value of myocardial perfusion imaging with (13)N-ammonia positron emission tomography (PET) and coronary flow reserve (CFR) on long-term prognosis in patients with suspected myocardial ischemia. No prognostic data exist on the predictive value of CFR and (13)N-ammonia PET. Perfusion and CFR were assessed in 256 patients using (13)N-ammonia PET, and follow-up was obtained in 245 (96%) patients. Sixteen early revascularized patients were excluded and 229 were assigned to normal versus abnormal perfusion or normal versus abnormal CFR (<2.0). Major adverse cardiac events (MACE) (cardiac death, nonfatal myocardial infarction, late revascularization, or hospitalization for cardiac reasons) were assessed using the Kaplan-Meier method. Cox proportional hazard regression was used to identify independent predictors for cardiac events. During follow-up (5.4 +/- 2.2 years), 78 patients had at least 1 cardiac event, including 29 cardiac deaths. Abnormal perfusion (n = 126) was associated with a higher incidence of MACE (p < 0.001) and cardiac death (p < 0.05). In patients with normal perfusion, abnormal CFR was independently associated with a higher annual event rate over 3 years compared with normal CFR for MACE (1.4% vs. 6.3%; p < 0.05) and cardiac death (0.5% vs. 3.1%; p < 0.05). In abnormal perfusion, CFR remained predictive throughout the 10-year follow-up (p < 0.001). Perfusion findings in (13)N-ammonia PET and CFR are strong outcome predictors. CFR allows further risk stratification, suggesting a "warranty" period of 3 years if normal CFR is associated with normal perfusion. Conversely, in patients with abnormal perfusion, an impaired CFR has added value for predicting adverse outcomes.

Pioglitazone does not enhance the effectiveness of lifestyle modification in preventing conversion of impaired glucose tolerance to diabetes in Asian Indians: results of the Indian Diabetes Prevention Programme-2 (IDPP-2)

The objective of this prevention programme was to study whether combining pioglitazone with lifestyle modification would enhance the efficacy of lifestyle modification in preventing type 2 diabetes in Asian Indians with impaired glucose tolerance. In a community-based, placebo-controlled 3 year prospective study, 407 participants with impaired glucose tolerance (mean age 45.3 +/- 6.2 years, mean BMI 25.9 +/- 3.3 kg/m(2)) were sequentially grouped to receive either: lifestyle modification plus pioglitazone, 30 mg (n = 204) or lifestyle modification plus placebo (n = 203). The participants and investigators were blinded to the assignment. The primary outcome was development of diabetes. At baseline, both groups had similar demographic, anthropometric and biochemical characteristics. At year 3, the response rate was 90.2%. The cumulative incidence of diabetes was 29.8% with pioglitazone and 31.6% with placebo (unadjusted HR 1.084 [95% CI 0.753-1.560], p = 0.665). Normoglycaemia was achieved in 40.9% and 32.3% of participants receiving pioglitazone and placebo, respectively (p = 0.109). In pioglitazone group, two deaths and two non-fatal hospitalisations occurred due to cardiac problems; in the placebo group there were two occurrences of cardiac disease. Despite good adherence to lifestyle modification and drug therapy, no additional effect of pioglitazone was seen above that achieved with placebo. The effectiveness of the intervention in both groups was comparable with that of lifestyle modification alone, as reported from the Indian Diabetes Prevention Programme-1. The results are at variance with studies that showed significant relative risk reduction in conversion to diabetes with pioglitazone in Americans with IGT. An ethnicity-related difference in the action of pioglitazone in non-diabetic participants may be one explanation. ClinicalTrials.gov NCT00276497 FUNDING: This study was funded by the India Diabetes Research Foundation.

BEAUTIfUL-Studie – Analyse der Studienergebnisse

The results of the BEAUTIfUL-Study presented at the ESC meeting in Munich last year showed the following:

Hormone Replacement Therapy and Cardiovascular Health in the United States

Hormone replacement therapy (HRT) was widely used among postmenopausal women until 2002 because observational studies suggested that HRT reduced cardiovascular risk. The Women's Health Initiative randomized trial reported opposite results in 2002, which caused HRT use to drop sharply. We examine the relationship between HRT use and cardiovascular outcomes (deaths and nonfatal hospitalizations) in the entire US population, which has not been studied in prior clinical trials or observational studies. We use an instrumental variables regression design to analyze the relationship between medication use, cardiovascular risk factors, and acute stroke and myocardial infarction event rates in women aged 40 to 79 years. The natural experiment of the 2002 decline in HRT usage mitigates confounding factors. We use US death records, hospital discharge data obtained from the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, and nationally representative surveys of medication usage, and behavioral risk factors. Decreases in HRT use were not associated with statistically significant changes in hospitalizations or deaths due to acute stroke (0.000002, P = 0.999, 95% CI: -0.0027 to 0.0027). Decreased HRT use was associated with a decrease in the incidence of acute myocardial infarction (-0.0025 or -25 events/10,000 person-years, P = 0.021, 95% CI: -0.0047 to -0.0004). The results were similar in a sensitivity analysis using alternate data sources. Decreased HRT use was not associated with reduced acute stroke rate but was associated with a decreased acute myocardial infarction rate among women. Our results suggest that observational data can provide correct inferences on clinical outcomes in the overall population if a suitable natural experiment is identified.

Leapfrogging Data

Properly designed and conducted randomized controlled clinical trials (RCTs) are the premier tool for both testing mechanistic hypotheses and critically ascertaining the risks and benefits of a therapy or strategy for clinical care. The sample size of a trial is mainly a function of the rates of its primary objectives and the presumed influence of the intervention. Trials focusing on a primary outcome variable that can be readily quantified in each subject, such as blood pressure or plasma cholesterol levels, require substantially fewer participants and shorter durations to determine whether their predefined measurement is altered compared with a morbidity and mortality trial. Trials designed to determine whether clinical prognosis is altered by an intervention depend on the proportion of patients experiencing the predefined adverse clinical event(s) and often require 100s-fold–greater patient-time exposures to test their primary hypothesis and provide even modest information about safety. These resource-intense morbidity and mortality trials are generally only performed when information from observational studies as well as smaller mechanistic and surrogate- outcomes RCTs are so highly supportive of a favorable outcome that they justify the effort. Despite this understandable stacking of the cards with the best available information, many of the morbidity and mortality trials conducted to test for a potential favorable impact of an intervention conclude by not supporting the prestudy hypothesis-generating data.1 The lessons in humility offered by these neutral or negative outcomes trials underscore the importance of obtaining crucial risk–benefit data before widespread adoption of even an apparently favorable therapy.2 Articles pp 2506 and 2515 For rational therapeutic decision making, we would ideally like to have both a framework of reliable mechanistic information and robust clinical outcomes and safety data. Sometimes major clinical outcomes trials are designed with a complement of embedded ancillary trials to generate a more complete picture …

Trends in Hospitalizations Associated With Pediatric Traumatic Brain Injuries

The goals were to describe trends in pediatric traumatic brain injury hospitalizations in the United States and to provide national benchmarks for state and regional comparisons. Analysis of existing data (1991-2005) from the Nationwide Inpatient Sample, the largest longitudinal, all-payer, inpatient care database in the United States, was performed. Children 0 to 19 years of age were included. Annual rates of traumatic brain injury-related hospitalizations, stratified according to age, gender, severity of traumatic brain injury, and outcome, were determined. From 1991 to 2005, the estimated annual incidence rate of pediatric hospitalizations associated with traumatic brain injury decreased 39%, from 119.4 to 72.7 hospitalizations per 100,000. The rates decreased for all age groups and for both boys and girls, although the rate for boys remained consistently higher at each time point. Fatal hospitalization rates decreased from 3.5 deaths per 100,000 in 1991-1993 to 2.8 deaths per 100,000 in 2003-2005. The rate of mild traumatic brain injury hospitalizations accounted for most of the overall decrease, whereas nonfatal hospitalization rates for moderate and severe traumatic brain injuries remained relatively unchanged. Although pediatric hospitalization rates for mild traumatic brain injuries have decreased over the past 15 years, rates for moderate and severe traumatic brain injuries are relatively unchanged. Our study provides national estimates of pediatric traumatic brain injury hospitalizations that can be used as benchmarks to increase injury prevention effectiveness through targeting of effective strategies.

Letter by Höglund and Nilsson Regarding Article, “Influence of Nonfatal Hospitalization for Heart Failure on Subsequent Mortality in Patients With Chronic Heart Failure”

To the Editor: We read with great interest the article by Solomon et al1 concerning the influence of nonfatal hospitalizations for heart failure on subsequent mortality rates. However, we are intrigued by the design of this investigation and by the statistical approach chosen. Three clinical trials were merged into 1 observational study; a minor problem is determining what population the study actually represents. Our major concern is that the study is indeed observational and that the findings are probably due to the clinical courses of HF patients being variable, as noted in another publication from the Candesartan in Heart failure: Assessment of Reduction in Mortality …

Response to Letter Regarding Article, “Influence of Nonfatal Hospitalization for Heart Failure on Subsequent Mortality in Patients With Chronic Heart Failure”

We appreciate the insights provided by Drs Hoglund and Nilsson regarding our recent publication on the risk associated with heart failure hospitalization.1 Although in principle their request that models should also adjust for time-updated covariates is of interest, in practice it is liable to be unrealistic in most follow-up studies of this kind. When a clinical event such as a hospitalization for heart failure …

Hospitalisations for sport-related concussions in US children aged 5 to 18 years during 2000–2004

Objectives:To describe patient and hospital characteristics associated with hospitalisation for a diagnosis of non-fatal sport-related concussion, and to determine factors associated with these hospitalisations.Methods:Children aged 5–18 years with a primary...

Traffic-Related Air Pollution in Relation to Incidence and Prognosis of Coronary Heart Disease

Long-term air pollution exposure is associated with increased mortality, but the association with incidence of fatal and nonfatal coronary heart disease is less certain. Moreover, it is unknown how chronic exposure to air pollution affects prognosis among survivors of a first coronary event. This study evaluated the association between long-term traffic-related air pollution exposure and incidence of nonfatal and fatal coronary events, as well as subsequent hospital readmission and mortality among myocardial infarction survivors. The study population comprised all residents of Rome aged 35-84 years during the period 1998-2000. Residential nitrogen dioxide (NO2) exposure as a marker of traffic pollution was assessed by a land-use regression model in 1995-1996 (R = 0.69). A total of 11,167 incident coronary events were observed (4654 fatal, including 3598 out-of-hospital coronary deaths, and 6513 nonfatal). The cohort of 6513 survivors was followed 4.0-7.5 years for readmission or mortality, starting 28 days from the date of first event. Relative risks per 10 mug/m of NO2 exposure, adjusted for age, sex, and socioeconomic status, were calculated by Poisson regression (population-based incidence) and Cox regression (cohort analysis). The relative risk for incidence in coronary events per 10 mug/m of NO2 was 1.03 (95% confidence interval = 1.00-1.07). Stronger associations were found for fatal cases (1.07; 1.02-1.12) and out-of-hospital deaths (1.08; 1.02-1.13). Using NO2 exposure at the time of the first event, there was no association of air pollution exposure with either subsequent hospital readmission or mortality among survivors of the first coronary event. Long-term air pollution exposure increases the risk of coronary heart disease, particularly fatal events. Hospital readmission or subsequent mortality among survivors was not associated with traffic air pollution.

Fall-related traumatic brain injury deaths and hospitalizations among older adults — United States, 2005

Problem Among older adults, both unintentional falls and traumatic brain injuries (TBI) result in significant morbidity and mortality; however, only limited national data on fall-related TBI are available. Method: To examine the relationship between older adult falls and TBI deaths and hospitalizations, CDC analyzed 2005 data from the National Center for Health Statistics' National Vital Statistics System and the Agency for Healthcare Research and Quality's Nationwide Inpatient Sample. Results: In 2005, among adults ≥ 65 years, there were 7946 fall-related TBI deaths and an estimated 56,423 hospitalizations for nonfatal fall-related TBI in the United States. Fall-related TBI accounted for 50.3% of unintentional fall deaths and 8.0% of nonfatal fall-related hospitalizations. Summary: These findings underscore the need for greater dissemination and implementation of evidence-based fall prevention interventions.

Effects of Torcetrapib in Patients at High Risk for Coronary Events

Inhibition of cholesteryl ester transfer protein (CETP) has been shown to have a substantial effect on plasma lipoprotein levels. We investigated whether torcetrapib, a potent CETP inhibitor, might reduce major cardiovascular events. The trial was terminated prematurely because of an increased risk of death and cardiac events in patients receiving torcetrapib. We conducted a randomized, double-blind study involving 15,067 patients at high cardiovascular risk. The patients received either torcetrapib plus atorvastatin or atorvastatin alone. The primary outcome was the time to the first major cardiovascular event, which was defined as death from coronary heart disease, nonfatal myocardial infarction, stroke, or hospitalization for unstable angina. At 12 months in patients who received torcetrapib, there was an increase of 72.1% in high-density lipoprotein cholesterol and a decrease of 24.9% in low-density lipoprotein cholesterol, as compared with baseline (P<0.001 for both comparisons), in addition to an increase of 5.4 mm Hg in systolic blood pressure, a decrease in serum potassium, and increases in serum sodium, bicarbonate, and aldosterone (P<0.001 for all comparisons). There was also an increased risk of cardiovascular events (hazard ratio, 1.25; 95% confidence interval [CI], 1.09 to 1.44; P=0.001) and death from any cause (hazard ratio, 1.58; 95% CI, 1.14 to 2.19; P=0.006). Post hoc analyses showed an increased risk of death in patients treated with torcetrapib whose reduction in potassium or increase in bicarbonate was greater than the median change. Torcetrapib therapy resulted in an increased risk of mortality and morbidity of unknown mechanism. Although there was evidence of an off-target effect of torcetrapib, we cannot rule out adverse effects related to CETP inhibition. (ClinicalTrials.gov number, NCT00134264 [ClinicalTrials.gov].).

Chest Pain on Exercise Treadmill Test Predicts Future Cardiac Hospitalizations

Patients often have chest pain during exercise treadmill testing (ETT). However, the evidence supporting chest pain as an independent adverse prognostic factor during ETT has been inconsistent. The objective of this study was to determine the importance of chest pain during ETT in predicting future nonfatal cardiac hospitalizations. This was a prospective cohort study of all patients undergoing ETT between July 2001 and June 2004 in a large managed care organization. The primary outcome of interest was nonfatal cardiac hospitalizations including myocardial infarction and unstable angina. Multivariable Cox proportional hazards regression assessed the independent association between chest pain during ETT and subsequent nonfatal cardiac hospitalizations, adjusting patient, clinical and other treadmill variables. Of the 8,459 patients undergoing ETT, 697 (8.2%) patients had chest pain during the test. Patients with chest pain during ETT had more nonfatal cardiac hospitalizations compared to patients without chest pain (11.9% vs. 2.6%; p < 0.0001). In multivariable Cox regression analysis, patients with chest pain during ETT remained at significantly increased risk of nonfatal cardiac hospitalizations (HR 3.44; 95% CI 2.60-4.56). The association between chest pain and adverse outcomes was consistent among prespecified subgroups including patients without ST-segment changes and with good functional capacity on ETT. Chest pain during ETT, even without ECG changes, predicts subsequent cardiac hospitalizations. Future studies should evaluate whether aggressive management of such patients can prevent subsequent hospitalizations.

Should beta‐blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET

It is unclear whether beta-blocker therapy should be reduced or withdrawn in patients who develop acute decompensated heart failure (HF). We studied the relationship between changes in beta-blocker dose and outcome in patients surviving a HF hospitalisation in COMET. Patients hospitalised for HF were subdivided on the basis of the beta-blocker dose administered at the visit following hospitalisation, compared to that administered before. In COMET, 752/3029 patients (25%, 361 carvedilol and 391 metoprolol) had a non-fatal HF hospitalisation while on study treatment. Of these, 61 patients (8%) had beta-blocker treatment withdrawn, 162 (22%) had a dose reduction and 529 (70%) were maintained on the same dose. One-and two-year cumulative mortality rates were 28.7% and 44.6% for patients withdrawn from study medication, 37.4% and 51.4% for those with a reduced dosage (n.s.) and 19.1% and 32.5% for those maintained on the same dose (HR,1.59; 95%CI, 1.28-1.98; p<0.001, compared to the others). The result remained significant in a multivariable model: (HR, 1.30; 95%CI, 1.02-1.66; p=0.0318). No interaction with the beneficial effects of carvedilol, compared to metoprolol, on outcome was observed (p=0.8436). HF hospitalisations are associated with a high subsequent mortality. The risk of death is higher in patients who discontinue beta-blocker therapy or have their dose reduced. The increase in mortality is only partially explained by the worse prognostic profile of these patients.

Influence of Nonfatal Hospitalization for Heart Failure on Subsequent Mortality in Patients With Chronic Heart Failure

Patients with chronic heart failure (HF) are at increased risk of both fatal and nonfatal major adverse cardiovascular events. We used data from the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) trials to assess the influence of nonfatal hospitalizations for HF on subsequent mortality rates in a broad spectrum of HF patients. In the present study, 7599 patients with New York Heart Association class II to IV HF and reduced or preserved left ventricular ejection fraction were randomized to placebo or candesartan. We assessed the risk of death after discharge from a first hospitalization for HF using time-updated Cox proportional-hazards models on 7572 patients for whom discharge data were available. Of 7572 patients, 1455 (19%) had at least 1 HF hospitalization, and 586 of 1819 deaths occurred after discharge from an HF hospitalization. The mortality rate was increased after HF hospitalizations, even after adjustment for baseline predictors of death (hazard ratio, 3.15; 95% confidence interval, 2.83 to 3.50). Longer duration of HF hospitalization enhanced the risk of dying, as did repeat HF hospitalizations. Moreover, risk of death was highest within a month of discharge and then declined progressively over time, particularly for death resulting from HF progression and for sudden cardiac death. We observed a similar pattern of risk associated with all-cause hospitalization, although the magnitude was less than that with HF hospitalization. In patients with chronic HF, the risk of death is greatest in the early period after discharge after a hospitalization for HF and is directly related to the duration and frequency of HF hospitalizations. These findings suggest a role for increased surveillance in the early postdischarge period of greatest vulnerability after an HF admission.