Organized Program To Initiate Lifesaving Treatment In Hospitalized Patients With Heart Failure Research Articles

Renin-Angiotensin Inhibition and Outcomes in HFrEF and Advanced Kidney Disease

BackgroundRenin-angiotensin system inhibitors improve outcomes in patients with heart failure with reduced ejection fraction (HFrEF). However, less is known about their effectiveness in patients with HFrEF and advanced kidney disease. MethodsIn the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF), 1582 patients with HFrEF (ejection fraction ≤40%) had advanced kidney disease (estimated glomerular filtration rate <30 mL/min/1.73 m2). Of these, 829 were not receiving angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) prior to admission, of whom 214 were initiated on these drugs prior to discharge. We calculated propensity scores for receipt of these drugs for each of the 829 patients and assembled a matched cohort of 388 patients, balanced on 47 baseline characteristics (mean age 78 years; 52% women; 10% African American; 73% receiving beta-blockers). Hazard ratios (HR) and 95% confidence intervals (CI) were estimated comparing 2-year outcomes in 194 patients initiated on ACE inhibitors or ARBs to 194 patients not initiated on those drugs. ResultsThe combined endpoint of heart failure readmission or all-cause mortality occurred in 79% and 84% of patients initiated and not initiated on ACE inhibitors or ARBs, respectively (HR associated with initiation, 0.79; 95% CI, 0.63-0.98). Respective HRs (95% CI) for the individual endpoints of - Respective HRs (95% CI) for the individual endpoints of all-cause mortality and heart failure readmission were 0.81 (0.63–1.03) and 0.63 (0.47–0.85). ConclusionsThe findings from our study add new information to the body of cumulative evidence that suggest that renin-angiotensin system inhibitors may improve clinical outcomes in patients with HFrEF and advanced kidney disease. These hypothesis-generating findings need to be replicated in contemporary patients.

In-Hospital Weight Loss and Outcomes in Patients With Heart Failure

Acute decompensation of heart failure (HF) is often marked by fluid retention, and weight loss is a marker of successful diuresis. We examined the relationship between in-hospital weight loss and post-discharge outcomes in patients with HF. We conducted a propensity score-matched study of 8830 patients hospitalized for decompensated HF in the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry, in which 4415 patients in the weight-loss group and 4415 patients in the no-weight-loss group were balanced on 75 baseline characteristics. We defined weight loss as an admission-to-discharge weight loss of 1-30 kilograms, and we defined no weight loss as a weight gain or loss of < 1 kilogram. Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with weight loss were estimated. Patients had a mean age of 78 years, 57% were women, and 11% were African American. The median weight loss in the weight-loss group was 3.6 (interquartile range, 2.0-6.0) kilograms. HRs and 95% CIs for 30-day all-cause mortality, all-cause readmission and HF readmission associated with weight loss were 0.75 (0.63-0.90), 0.90 (0.83-0.99) and 0.83 (0.72-0.96), respectively. Respective 60-day HRs (95% CIs) were 0.80 (0.70-0.92), 0.91 (0.85-0.98) and 0.88 (0.79-0.98). These associations were attenuated and lost significance during 6 months of follow-up. Among older patients hospitalized for decompensated HF, in-hospital weight loss was associated with a lower risk of mortality and hospital readmission. These findings suggest that in-hospital weight loss, a marker of successful diuresis and decongestion, is also a marker of improved clinical outcomes.

Use of loop diuretics in chronic heart failure: do we adhere to the Hippocratian principle 'do no harm'?

Use of loop diuretics in chronic heart failure: do we adhere to the Hippocratian principle 'do no harm'?

The utility of the adjusted-OPTIMIZE-HF risk model for predicting in-hospital length of stay in the Chinese population.

Various risk scores exist for predicting in-hospital mortality in patients with heart failure (HF), including the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) risk model. However, the relations between these risk scores and length of in-hospital stay (LOS) in patients with acute decompensated heart failure (ADHF) has not received much attention. We aim to explore the relationship between the adjusted-OPTIMIZE-HF risk model and LOS in the Chinese population. This was a single-center, retrospective study that enrolled a total of 4,481 patients with ADHF. We investigated the relation between a wide range of patient variables present at hospital admission, including those that comprise the adjusted-OPTIMIZE-HF risk model and LOS (primary outcome). We divided patients into a short LOS (n=2,177, LOS <6 days) and a long LOS (n=2,304, LOS ≥6 days) group. We then explored the relations between the adjusted-OPTIMIZE-HF risk score and LOS using logistic regression, receiver operating characteristic (ROC) curves, and subgroup analyses. A total of 4,481 people [61.6% male, median age 71 years (interquartile range, 16 years)] were included in this study. In univariate regression analyses, numerous variables were significantly different between the long and short LOS groups. Multivariate logistic regression showed that the adjustedOPTIMIZE-HF risk score had a significant predictive ability for LOS (OR 1.248, 95% CI: 1.094-1.424), P=0.001). The results of the ROC curve analysis [area under the curve (AUC) 0.583, 95% CI: 0.567-0.600] demonstrated the potential value of the risk score for predicting LOS. Finally, subgroup analyses showed that the risk score was not only predictive of LOS in the overall population, but also in subgroups of patients defined by gender, history of smoking, history of drinking, presence of hypertension, and diabetes. The adjusted-OPTIMIZE-HF risk model performed well in predicting LOS greater than 6 days in the Chinese patients with ADHF. Moreover, the model proved to be stable across subgroup analyses.

Loop Diuretic Prescription and 30-Day Outcomes in Older Patients With Heart Failure

BackgroundHeart failure (HF) is a major source of morbidity and mortality. Fluid retention and shortness of breath are its cardinal manifestations for which loop diuretics are used. Although their usefulness is well accepted, less is known about their role in improving clinical outcomes. ObjectivesThe purpose of this study was to determine the relationship between loop diuretics and clinical outcomes in patients with HF. MethodsOf the 25,345 older patients hospitalized for HF in the Medicare-linked OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry, 9,866 (39%) received no pre-admission diuretics. The study excluded 1,083 patients receiving dialysis and 847 discharged on thiazide diuretics. Of the remaining 7,936 patients, 5,568 (70%) were prescribed loop diuretics at discharge. Using propensity scores for receipt of loop diuretics estimated for each of the 7,936 patients, a matched cohort of 2,191 pairs of patients was assembled balanced on 74 baseline characteristics. Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes were estimated in the matched cohort. ResultsMatched patients (n = 4,382) had a mean age of 78 years, 54% were women, and 11% were African American. The 30-day all-cause mortality occurred in 4.9% (107 of 2,191) and 6.6% (144 of 2,191) of patients in the loop diuretic and no loop diuretic groups, respectively (HR when the use of loop diuretics was compared with nonuse: 0.73; 95% CI: 0.57 to 0.94; p = 0.016). Patients in the loop diuretic group had a significantly lower risk of 30-day HF readmission (HR: 0.79; 95% CI: 0.63 to 0.99; p = 0.037) but not of 30-day all-cause readmission (HR: 0.89; 95% CI: 0.79 to 1.01; p = 0.081). None of the associations was statistically significant during 60 days of follow-up. ConclusionsHospitalized older patients not taking diuretics prior to hospitalization for HF decompensation who received a discharge prescription for loop diuretics had significantly better 30-day clinical outcomes than those not discharged on loop diuretics. These findings provide new information about short-term clinical benefits associated with loop diuretic use in HF.

Digoxin Initiation and Outcomes in Patients with Heart Failure (HFrEF and HFpEF) and Atrial Fibrillation

BackgroundDigoxin reduces the risk of heart failure hospitalization but has no effect on mortality in patients with heart failure without atrial fibrillation in the randomized controlled trial setting. Observational studies of digoxin use in patients with atrial fibrillation have suggested a higher risk for poor outcomes. Less is known about this association in patients with heart failure and atrial fibrillation, the examination of which was the objective of the current study. MethodsWe conducted an observational propensity score-matched study of predischarge digoxin initiation in 1768 hospitalized patients with heart failure and atrial fibrillation in the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry, balanced on 56 baseline characteristics (mean age, 79 years; 55% women; 7% African American). Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes were estimated for the 884 patients initiated on digoxin compared with 884 not initiated on digoxin. ResultsHRs (95% CIs) for 30-day, 2-year, and 4-year all-cause mortality were 0.80 (0.55-1.18; P = .261), 0.94 (0.87-1.16; P = .936), and 1.01 (0.90-1.14; P = .729), respectively. Respective HRs (95% CIs) for heart failure readmission were 0.67 (0.49-0.92; P = .014), 0.81 (0.69-0.94; P = .005), and 0.85 (0.74-0.97; P = .022), and those for all-cause readmission were 0.78 (0.64-0.96; P = .016), 0.90 (0.81-1.00; P = .057), and 0.91 (0.83-1.01; P = .603). These associations were homogeneous between patients with left ventricular ejection fraction ≤45% vs >45%. ConclusionsAmong hospitalized older patients with heart failure (HFrEF and HFpEF) and atrial fibrillation, initiation of digoxin was associated with a lower risk of heart failure readmission but had no association with mortality.

Predictive Value of the Get With The Guidelines Heart Failure Risk Score in Unselected Cardiac Intensive Care Unit Patients.

BackgroundThe cardiac intensive care unit (CICU) population is no longer composed of only patients with acute coronary syndromes, and includes those with acute heart failure and multiple comorbidities. We hypothesized that the GWTG‐HF (Get With The Guidelines–Heart Failure) risk score that predicts inpatient mortality in hospitalized patients with heart failure would predict mortality in CICU patients.Methods and ResultsWe retrospectively analyzed CICU patients at a tertiary care hospital from 2007 to 2015. The GWTG‐HF risk score was calculated at CICU admission. As a secondary analysis, the EFFECT (Enhanced Feedback for Effective Cardiac Treatment), OPTIMIZE‐HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure), and ADHERE (Acute Decompensated Heart Failure National Registry) risk scores were calculated. Kaplan–Meier survival analysis and the area under the receiver operating characteristic curve value were determined for inpatient and 1‐year mortality. The GWTG‐HF risk score was calculated in 9532 (95%) patients, with a median value of 40 (interquartile range, 35–47). Inpatient mortality occurred in 824 (8.6%) patients, and 2075 (21.8%) patients died by 1 year. Patients who died in hospital had a significantly higher mean GWTG‐HF score (47.7 versus 40.2; P<0.001). Inpatient and 1‐year mortality increased in each GWTG‐HF risk score quartile (P<0.0001). Discrimination of the GWTG‐HF, EFFECT, OPTIMIZE‐HF, and ADHERE risk scores was assessed using area under the receiver operating characteristic curve values for hospital mortality, and were similar for all risk scores (0.72–0.74; P>0.05). The Hosmer–Lemeshow statistic suggested poor calibration for hospital mortality by the GWTG‐HF risk score (P<0.001).ConclusionsThe GWTG‐HF risk score and other heart failure prediction tools demonstrate good discrimination for inpatient and 1‐year mortality in a heterogeneous cohort of CICU patients. Our study emphasizes that prognostic variables overlap in cardiac patients, regardless of the admission diagnosis.

Digoxin Discontinuation and Outcomes in Patients With Heart Failure With Reduced Ejection Fraction

BackgroundThe deleterious effects of discontinuation of digoxin on outcomes in ambulatory patients with chronic heart failure (HF) with reduced ejection fraction (HFrEF) receiving angiotensin-converting enzyme inhibitors are well-documented. ObjectivesThe authors sought to determine the relationship between digoxin discontinuation and outcomes in hospitalized patients with HFrEF receiving more contemporary guideline-directed medical therapies including beta-blockers and mineralocorticoid receptor antagonists. MethodsOf the 11,900 hospitalized patients with HFrEF (EF ≤45%) in the Medicare-linked OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry, 3,499 received pre-admission digoxin, which was discontinued in 721 patients. Using propensity scores for digoxin discontinuation, estimated for each of the 3,499 patients, a matched cohort of 698 pairs of patients, balanced on 50 baseline characteristics (mean age 76 years; mean EF 28%; 41% women; 13% African American; 65% on beta-blockers) was assembled. ResultsFour-year post-discharge, digoxin discontinuation was associated with significantly higher risks of HF readmission (hazard ratio [HR]: 1.21; 95% confidence interval [CI]: 1.05 to 1.39; p = 0.007), all-cause readmission (HR: 1.16; 95% CI: 1.04 to 1.31; p = 0.010), and the combined endpoint of HF readmission or all-cause mortality (HR: 1.20; 95% CI: 1.07 to 1.34; p = 0.002), but not all-cause mortality (HR: 1.09; 95% CI: 0.97 to 1.24; p = 0.163). Discontinuation of digoxin was associated with a significantly higher risk of all 4 outcomes at 6 months and 1 year post-discharge. At 30 days, digoxin discontinuation was associated with higher risks of all-cause mortality (HR: 1.80; 95% CI: 1.26 to 2.57; p = 0.001) and the combined endpoint (HR: 1.36; 95% CI: 1.09 to 1.71; p = 0.007), but not of HF readmission (HR: 1.19; 95% CI: 0.90 to 1.59; p = 0.226) or all-cause readmission (HR: 1.03; 95% CI: 0.84 to 1.26; p = 0.778). ConclusionsAmong hospitalized older patients with HFrEF on more contemporary guideline-directed medical therapies, discontinuation of pre-admission digoxin therapy was associated with poor outcomes.

Role of High-Dose Beta-Blockers in Patients with Heart Failure with Preserved Ejection Fraction and Elevated Heart Rate

BackgroundBeta-blockers in high target doses are recommended for heart failure with reduced ejection fraction (HFrEF) but not for preserved ejection fraction (HFpEF). Treatment benefits are often more pronounced in high-risk subgroups, and patients with HFpEF with heart rate ≥70 beats per minute have emerged as such a high-risk subgroup. We examined the associations of high-dose beta-blocker use with outcomes in these patients. MethodsOf the 8462 hospitalized patients with heart failure with ejection fraction ≥50% in the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry, 5422 had a discharge heart rate ≥70 beats per minute. Of these, 4537 had no contraindications to beta-blocker use, of which 2797 (2592 with dose data) received prescriptions for beta-blockers. Of the 2592, 730 received high-dose beta-blockers, defined as atenolol ≥100 mg/day, carvedilol ≥50 mg/day, metoprolol tartrate or succinate ≥200 mg/day, or bisoprolol ≥10 mg/day, and 1740 received no beta-blockers. Using propensity scores for the receipt of high-dose beta-blockers, we assembled a matched cohort of 1280 patients, balanced on 58 characteristics. ResultsAll-cause mortality occurred in 63% and 68% of matched patients receiving high-dose beta-blocker vs no beta-blocker, respectively, during 6 years (median, 2.8) of follow-up (hazard ratio, 0.86; 95% confidence interval, 0.75-0.98; P = .027). The hazard ratios (95% confidence intervals) for all-cause readmission and the combined endpoint of all-cause readmission or all-cause mortality associated with high-dose beta-blocker use were 0.90 (0.81-1.02) and 0.89 (0.80-1.00), respectively. ConclusionsIn patients with HFpEF and heart rate ≥70 beats per minute, high-dose beta-blocker use was associated with a significantly lower risk of death. Future randomized controlled trials are needed to examine this association.

Performance of existing risk scores around heart transplantation: validation study in a 4-year cohort.

Several risk scores exist to help identify best candidate recipients for heart transplantation (HTx). This study describes the performance of five heart failure risk scores and two post-HTx mortality risk scores in a French single-centre cohort. All patients listed for HTx through a 4-year period were included. Waiting-list risk scores [Heart Failure Survival Score (HFSS), Seattle Heart Failure Model (SHFM), Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC), Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) and Get With The Guidelines-Heart Failure (GWTG-HF)] and post-HTx scores Index for Mortality Prediction After Cardiac Transplantation (IMPACT and CARRS) were computed. Main outcomes were 1-year mortality on waiting list and after HTx. Performance was assessed using receiver operator characteristic (ROC), calibration and goodness-of-fit analyses. The cohort included 414 patients. Waiting-list mortality was 14.0%, and post-HTx mortality was 16.3% at 1-year follow-up. Heart failure risk scores had adequate discrimination regarding waiting-list mortality (ROC AUC for HFSS=0.68, SHFM=0.74, OPTIMIZE-HF=0.72, MAGGIC= 0.70 and GWTG=0.77; all P-values <0.05). On the contrary, post-HTx risk scores did not discriminate post-HTx mortality (AUC for IMPACT=0.58, and CARRS=0.48, both P-values >0.50). Subgroup analysis on patients undergoing HTx after ventricular assistance device (VAD) implantation (i.e. bridge-to-transplantation) (n=36) showed an IMPACT AUC=0.72 (P<0.001). In this single-centre cohort, existing heart failure risk scores were adequate to predict waiting-list mortality. Post-HTx mortality risk scores were not, except in the VAD subgroup.

Systolic Blood Pressure and Outcomes in Patients With Heart Failure With Preserved Ejection Fraction

Lower systolic blood pressure (SBP) levels are associated with poor outcomes in patients with heart failure. Less is known about this association in heart failure with preserved ejection fraction (HFpEF). To determine the associations of SBP levels with mortality and other outcomes in HFpEF. A propensity score-matched observational study of the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry included 25 354 patients who were discharged alive; 8873 (35.0%) had an ejection fraction of at least 50%, and of these, 3915 (44.1%) had stable SBP levels (≤20 mm Hg admission to discharge variation). Data were collected from 259 hospitals in 48 states between March 1, 2003, and December 31, 2004. Data were analyzed from March 1, 2003, to December 31, 2008. Discharge SBP levels less than 120 mm Hg. A total of 1076 of 3915 (27.5%) had SBP levels less than 120 mm Hg, of whom 901 (83.7%) were matched by propensity scores with 901 patients with SBP levels of 120 mm Hg or greater who were balanced on 58 baseline characteristics. Thirty-day, 1-year, and overall all-cause mortality and heart failure readmission through December 31, 2008. The 1802 matched patients had a mean (SD) age of 79 (10) years; 1147 (63.7%) were women, and 134 (7.4%) were African American. Thirty-day all-cause mortality occurred in 91 (10%) and 45 (5%) of matched patients with discharge SBP of less than 120 mm Hg vs 120 mm Hg or greater, respectively (hazard ratio [HR], 2.07; 95% CI, 1.45-2.95; P < .001). Systolic blood pressure level less than 120 mm Hg was also associated with a higher risk of mortality at 1 year (39% vs 31%; HR, 1.36; 95% CI, 1.16-1.59; P < .001) and during a median follow-up of 2.1 (overall 6) years (HR, 1.17; 95% CI, 1.05-1.30; P = .005). Systolic blood pressure level less than 120 mm Hg was associated with a higher risk of heart failure readmission at 30 days (HR, 1.47; 95% CI, 1.08-2.01; P = .02) but not at 1 or 6 years. Hazard ratios for the combined end point of heart failure readmission or all-cause mortality associated with SBP level less than 120 mm at 30 days, 1 year, and overall were 1.71 (95% CI, 1.34-2.18; P < .001), 1.21 (95% CI, 1.07-1.38; P = .004), and 1.12 (95% CI, 1.01-1.24; P = .03), respectively. Among hospitalized patients with HFpEF, an SBP level less than 120 mm Hg is significantly associated with poor outcomes. Future studies need to prospectively evaluate optimal SBP treatment goals in patients with HFpEF.

Heart Rate and Outcomes in Hospitalized Patients With Heart Failure With Preserved Ejection Fraction

BackgroundA lower heart rate is associated with better outcomes in patients with heart failure (HF) with reduced ejection fraction (EF). Less is known about this association in patients with HF with preserved ejection fraction (HFpEF). ObjectivesThe aims of this study were to examine associations of discharge heart rate with outcomes in hospitalized patients with HFpEF. MethodsOf the 8,873 hospitalized patients with HFpEF (EF ≥50%) in the Medicare-linked OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry, 6,286 had a stable heart rate, defined as ≤20 beats/min variation between admission and discharge. Of these, 2,369 (38%) had a discharge heart rate of <70 beats/min. Propensity scores for discharge heart rate <70 beats/min, estimated for each of the 6,286 patients, were used to assemble a cohort of 2,031 pairs of patients with heart rate <70 versus ≥70 beats/min, balanced on 58 baseline characteristics. ResultsThe 4,062 matched patients had a mean age of 79 ± 10 years, 66% were women, and 10% were African American. During 6 years (median 2.8 years) of follow-up, all-cause mortality was 65% versus 70% for matched patients with a discharge heart rate <70 versus ≥70 beats/min, respectively (hazard ratio [HR]: 0.86; 95% confidence interval [CI]: 0.80 to 0.93; p < 0.001). A heart rate <70 beats/min was also associated with a lower risk for the combined endpoint of HF readmission or all-cause mortality (HR: 0.90; 95% CI: 0.84 to 0.96; p = 0.002), but not with HF readmission (HR: 0.93; 95% CI: 0.85 to 1.01) or all-cause readmission (HR: 1.01; 95% CI: 0.95 to 1.08). Similar associations were observed regardless of heart rhythm or receipt of beta-blockers. ConclusionsAmong hospitalized patients with HFpEF, a lower discharge heart rate was independently associated with a lower risk of all-cause mortality, but not readmission.

Gulf CARE: Heart failure in the Middle East.

[first paragraph of article] Despite striking improvement in the prognosis and survival in patients with coronary artery disease (CAD), hypertension, and congenital heart disease, the prevalence of heart failure (HF) is still growing. 1–3 HF is the most common cause of hospitalization after normal delivery - approximately 1 million patients are hospitalized annually for HF in the United States. 4 Moreover, the prognosis of HF is relatively poor, with 25% mortality at 1 year and 50% mortality at 5 years (stage D HF: 80% mortality at 5 years) - worse than that of many cancers. 1,2 The clinical profile, and outcome of HF in western population is well demonstrated after the release of several large registries such as Acute Decompensated Heart Failure National Registry (ADHERE) and the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). 5–7 Based on data from ADHERE registry, lower systolic blood pressure (BP), elevated serum BUN and creatinine, hyponatremia, older age, presence of dyspnea at rest, and absence of chronic beta-blocker were identified as independent predictors of mortality. 5,6

Abstract 257: Discharge Heart Rate and Beta-blocker Dose in Patients Hospitalized with Acute Heart Failure

Background: The SHIFT study (Systolic Heart failure treatment with the I f inhibitor ivabradine Trial) demonstrated the importance of elevated heart rate (defined as &gt; 70 beats per minute [bpm]) despite beta-blocker use as a treatment target in patients with heart failure with reduced ejection fraction (HFrEF). Limited data are available that describe the proportion of HFrEF patients that have an elevated heart rate despite beta-blocker therapy. Methods: We analyzed data from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) to describe discharge heart rate as a function of beta-blocker use and dose. We included adult patients with a left ventricular ejection fraction &lt;40% and excluded those with a history of a pacemaker or cardiac resynchronization therapy. For beta-blockers, we considered the 3 evidence-based beta-blockers as well as atenolol and described the dose at discharge as a percentage of the target daily dose (categories included no beta-blocker, &lt;25%, 25-49%, &gt; 50%). Results: Among 14,186 patients hospitalized with acute HFrEF between January 2003 and December 2004, the median discharge heart rate was 76 bpm (25 th -75 th percentile, 68-86). Of these, 10,264 (72%) were discharged on a beta-blocker. For patients not on a beta-blocker, the median discharge heart rate was 80 bpm (70-88), compared to 77 bpm (68-87) on &lt;25% target dose, 75 bpm (66-84) on 25-49% target dose, and 74 bpm (66-83) on &gt; 50% target dose (P&lt;0.001) (Figure). For patients on &gt; 50% target dose of a beta-blocker, 1397(65%) had a heart rate &gt; 70 bpm. Conclusion: Despite treatment with beta-blockers, a substantial proportion of HFrEF patients have an elevated heart rate at hospital discharge.

Aldosterone Antagonists and Outcomes in Real-World Older Patients With Heart Failure and Preserved Ejection Fraction

The purpose of this study was to examine the clinical effectiveness of aldosterone antagonists in older patients with heart failure and preserved ejection fraction (HF-PEF). Aldosterone antagonists improve outcomes in HF and reduced EF. However, their role in HF-PEF remains unclear. Of the 10,570 hospitalized older (65 years of age) HF-PEF (EF 40%) patients in the Medicare-linked OPTIMIZE-HF(Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) trial, 8,013 patients had no prior aldosterone antagonist use and no current contraindications; 492 (6% of these 8,013) patients received new prescriptions for aldosterone antagonists. We assembled a matched cohort of 487 pairs of patients receiving and not receiving aldosterone antagonists, who had a similar propensity to receive these drugs and were balanced on 116 baseline characteristics. Patients had a mean age of 80 years old, a mean EF of 54%, 59% were women, and 8% were African American. During 2.4 year of mean follow-up (through December 2008), the primary composite endpoint of all-cause mortality or HF hospitalization occurred in 392 (81%) and 393 (81%) patients receiving and not receiving aldosterone antagonists, respectively (hazard ratio [HR]: 0.97; 95% confidence interval [CI]: 0.84 to 1.11; p = 0.628). Aldosterone antagonists had no association with all-cause mortality (HR: 1.03; 95% CI: 0.89 to 1.20; p = 0.693) or HF hospitalization (HR: 0.88; 95% CI: 0.73 to 1.07; p = 0.188). Among 8013 prematched patients, multivariable-adjusted HR for the primary composite endpoint associated with aldosterone antagonist use was 0.93 (95% CI: 0.83 to 1.03; p = 0.144). In older HF-PEF patients, aldosterone antagonists had no association with clinical outcomes. Findings from the ongoing randomized controlled TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) trial will provide further insights into their effect in HF-PEF.

Association of Beta-Blocker Use and Selectivity With Outcomes in Patients With Heart Failure and Chronic Obstructive Pulmonary Disease (from OPTIMIZE-HF)

In patients with heart failure (HF) with chronic obstructive pulmonary disease (COPD), concerns exist regarding β blockers, particularly noncardioselective β blockers, precipitating bronchospasm or attenuating the benefit of inhaled β(2) agonists. The aim of this study was to test the hypothesis that noncardioselective β blockers would not be associated with worse outcomes compared with cardioselective β blockers in patients with concomitant COPD in a large HF registry. A retrospective analysis of patients from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF) who had systolic dysfunction, documentation of β-blocker status, and follow-up information available after index hospitalization (n= 2,670) was performed. The associations between cardioselective and noncardioselective β blockers and the end points of 60- to 90-day mortality and mortality or rehospitalization in patients with (n= 722) and without (n=1,948) COPD were analyzed using regression modeling. The models were adjusted for covariate predictors of β-blocker use at discharge and clinical predictors of outcomes. Noncardioselective and cardioselective β blockers were associated with lower risk-adjusted mortality in patients with and without COPD. There was no evidence that β-blocker selectivity was associated with a difference in outcomes between patients with and those without COPD (p for interaction >0.10 for both outcomes). In conclusion, despite concerns regarding β blockers in patients with HF with COPD, there was no evidence that β-blocker selectivity was associated with differences in outcomes for patients with HF with COPD versus those without.

Defining hyponatraemia: a call for action

Defining hyponatraemia: a call for action

Clinical characteristics and outcomes of hospitalized heart failure patients with systolic dysfunction and chronic obstructive pulmonary disease: findings from OPTIMIZE‐HF

Chronic obstructive pulmonary disease (COPD) is common in heart failure (HF) patients, yet the population is poorly characterized and associated with conflicting outcomes data. We aimed to evaluate the clinical characteristics and outcomes of HF patients with systolic dysfunction and COPD in a large acute HF registry. OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) was a performance-improvement registry of patients hospitalized with HF (n =48 612), which included a pre-specified subgroup of patients (n =5,701) with 60- to 90-day follow-up. We performed a retrospective analysis of the clinical characteristics and outcomes (length of stay, and in-hospital and 60-day mortality) of patients with systolic dysfunction according to baseline COPD status. COPD was present in 25% of the patients. These patients had more co-morbidities compared with patients without COPD. They were less likely to receive a beta-blocker or angiotensin-converting enzyme inhibitor during hospitalization and at discharge (P < 0.001). COPD was associated with an increased median length of stay [5 days (interquartile range 3-8) vs. 4 days (interquartile range 3-7), P < 0.0001] and increased in-hospital all-cause and non-cardiovascular (CV) mortality, with rates of 4.5% vs. 3.7% (P =0.01) and 1.0% vs. 0.6% (P =0.01), respectively, for the two endpoints, but similar 60-day mortality (6.2% vs. 6.0%, P =0.28). After risk adjustment, the in-hospital non-CV mortality remained increased (odds ratio 1.65, 95% confidence interval 1.12-2.41; P =0.01). The presence of COPD in HF patients with systolic dysfunction is associated with an increased burden of co-morbidities, lower use of evidence-based HF medications, longer hospitalizations, and increased in-hospital non-CV mortality, but similar post-discharge mortality.

Design and rationale of studies of neurohormonal blockade and outcomes in diastolic heart failure using OPTIMIZE-HF registry linked to Medicare data

BackgroundHeart failure (HF) is the leading cause of hospitalization for Medicare beneficiaries. Nearly half of all HF patients have diastolic HF or HF with preserved ejection fraction (HF–PEF). Because these patients were excluded from major randomized clinical trials of neurohormonal blockade in HF there is little evidence about their role in HF–PEF. MethodsThe aims of the American Recovery & Reinvestment Act-funded National Heart, Lung, and Blood Institute-sponsored “Neurohormonal Blockade and Outcomes in Diastolic Heart Failure” are to study the long-term effects of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and aldosterone antagonists in four separate propensity-matched populations of HF–PEF patients in the OPTIMIZE-HF (Organized Program to Initiate Life-Saving Treatment in Hospitalized Patients with Heart Failure) registry. Of the 48,612 OPTIMIZE-HF hospitalizations occurring during 2003–2004 in 259 U.S. hospitals, 20,839 were due to HF–PEF (EF ≥40%). For mortality and hospitalization we used Medicare national claims data through December 31, 2008. ResultsUsing a two-step (hospital-level and hospitalization-level) probabilistic linking approach, we assembled a cohort of 11,997 HF–PEF patients from 238 OPTIMIZE-HF hospitals. These patients had a mean age of 75years, mean EF of 55%, were 62% women, 15% African American, and were comparable with community-based HF–PEF cohorts in key baseline characteristics. ConclusionsThe assembled Medicare-linked OPTIMIZE-HF cohort of Medicare beneficiaries with HF–PEF with long-term outcomes data will provide unique opportunities to study clinical effectivenss of various neurohormonal antagonists with outcomes in HF–PEF using propensity-matched designs that allow outcome-blinded assembly of balanced cohorts, a key feature of randomized clinical trials.

Abstract 8493: Lack of Association between Discharge Prescription of Aldosterone Antagonists and Outcomes in Medicare Beneficiaries with Heart Failure and Preserved Ejection Fraction: A Propensity-Matched Study of the OPTIMIZE-HF

Background: Aldosterone antagonists reduce mortality in systolic heart failure (HF). However, their effect in HF patients with preserved ejection fraction (HF-PEF) remains unclear. Propensity-matched studies can assemble balanced cohorts while remaining blinded to outcomes, and are suitable when RCTs are difficult or unethical. We examined the association of aldosterone antagonist with outcomes in a propensity-matched cohort of older HF-PEF patients. Methods: Of the 26,376 OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) patients linked to Medicare outcomes data (through Dec 2008), 10429 patients age ≥65 years with HF-PEF (LVEF ≥40%) were discharged alive. Of these, 866 (8.3%) received a discharge prescription for aldosterone antagonists. Propensity scores for aldosterone antagonist use, estimated for each of the 10429 patients, were used to assemble a cohort of 864 pairs of patients receiving and not receiving these drugs who were balanced on 116 baseline characteristics. Results: Patients (n=1728) had a mean (±SD) age of 80 (±8) years, a mean (±SD) LVEF of 54% (±9%), 63% were women, and 8% African American. During ∼6 years of follow-up, all-cause mortality occurred in 71% and 70% of matched patients receiving and not receiving aldosterone antagonists (hazard ratio, 1.01; 95% CI, 0.90-1.24; p=0.929; Figure). A similar propensity-adjusted association was observed in the 10429 pre-match patients (hazard ratio, 0.99; 95% CI, 0.91-1.08; p=0.800). Aldosterone antagonist use also had no significant association with HF or all-cause hospitalization. Conclusions: Discharge prescription of aldosterone antagonists had no association with mortality or hospitalization in a propensity-matched balanced cohort of older HF-PEF patients. Whether these results differ from younger RCT-eligible patients will await results of the ongoing TOPCAT trial.