Recurrent Heart Failure Hospitalizations Research Articles

Herat failure and chronic obstructive airway disease as combined comorbidities. Meta-analysis and Review

Background: The existence of COPD and heart failure in elderly population adds additional morbidity and mortality risk than if those with only one of the two comorbidities. The aim of the current metaanalysis was to explore the effect of COPD on heart failure patient in terms of all-cause mortality, cardiac mortality and recurrent heart failure hospitalization.

Predictors of Recurring Hospitalizations for Heart Failure during Long-Term Follow-Up in MADIT-CRT

Background There are limited data regarding predictors of recurrent hospitalization for heart failure (HHF) in mild heart failure (HF) patients during long-term follow-up. Objective We aimed to evaluate baseline risk factors for first and subsequent HHF among mild HF patients in MADIT-CRT. Methods Data regarding recurring HHF were prospectively collected for MADIT-CRT participants during long-term (7-year) follow-up. Multivariate regression analysis was used to identify predictors of recurring HHF, adjusting for treatment with cardiac resynchronization therapy with defibrillator (CRT-D). Results During long-term follow-up, 1442 patients had 0 HHF, 209 had 1 HHF, 90 had 2 HHF, and 77 had ≥3 HHFs. Predictors of first HHF included: atrial arrhythmia prior to enrollment, diabetes, prior coronary revascularization, glomerular filtration rate Conclusions Our data from the long-term follow-up of MADIT-CRT show that there are multiple baseline risk factors for first HHF following device implantation in mild HF patients, many of which do not predict subsequent HHF. These findings suggest a need to identify novel time-dependent risk factors for recurrent HHF.

Functional tricuspid regurgitation and recurrent admissions in patients with acute heart failure

BackgroundFunctional tricuspid regurgitation (TR) is a common echocardiographic finding in patients with heart failure (HF), and its role in disease progression and prognosis stratification is becoming increasingly relevant in recent years. However, data regarding its association with the burden of HF-readmission is scarce. In this work, we sought to evaluate the association between TR severity and HF-related readmissions following a hospitalization for acute heart failure (AHF). MethodsWe prospectively included a cohort of 2101 patients admitted with the diagnosis of AHF. TR severity was assessed using a multiparametric integrative approach, and classified as none, mild, moderate, and severe. We used negative binomial regression to identify the association between TR grade and HF-related recurrent admissions. The risk associated to severity of TR was expressed as incidence rate ratio (IRR). ResultsAt a median follow-up of 2.53 years (IQR: 1.03–4.36), 978 (46.5%) patients died, and 1657 HF-readmissions occurred in 842 patients (40.0%). The proportion of patients with two or more admissions was 18.4%. The proportion of patients with moderate to severe TR was 17.2%. There was a stepwise increase in the incidence of readmissions from none to severe TR. After multivariable adjustment, only patients with severe TR were independently associated with higher risk of recurrent HF admissions (IRR = 1.34, CI 95%: 1.05–1.71; p = .019). ConclusionsIn patients with AHF, severe functional TR is independently associated with an increased risk of long-term recurrent HF hospitalizations.

Abstract P225: Hyperhomocysteinemia Mediates the Association of Food Deserts With Recurrent Heart Failure Hospitalizations

Background: Food deserts (FD) are low-income areas with low access to healthful foods. Prior studies have shown that a diet rich in fruits, vegetables and dairy products substantially lowers homocysteine (Hcy) levels by supplementing folate, vitamin B 12 , B 6 and choline intake. Since Hcy is an independent risk factor for cardiovascular disease, and may be abnormal in subjects living in a FD, we examined the impact of living in a FD on serum Hcy levels and the risk of recurrent heart failure hospitalizations (HFH). Methods: FD status was assessed using the USDA FD Research Atlas in 173 HF patients (mean age 57 ± 12 yrs, 63% male, 38% black), prospectively enrolled in the Atlanta Cardiomyopathy Consortium from 2007 to 2011. Hcy values were log-transformed (log 2 Hcy) for analysis. Linear regression was used to determine the association of FD with log 2 Hcy, and Poisson regression to examine the association of FD with risk of repeat HFH. Models were adjusted for age, gender, race, HF etiology, NYHA class, smoking status, EF, DM, hyperlipidemia, mean arterial pressure, BMI and serum creatinine. Results: Patients who lived in a FD (n=29) were younger (p=0.08) and more likely to be black (p<0.001). After adjusting for covariates, FD status was associated with higher log 2 Hcy levels (adjusted β estimate: 0.32, 95% CI: 0.11- 0.52, p=0.003). During a median follow-up of 827 (IQR 506, 1379) days, 60 (34.7%) subjects had at least 1 HFH. The overall frequency of HFH (40.9 vs. 29.2 per 100 patient-years) was higher in patients who lived in a FD. In a fully adjusted model, for each unit increase in log 2 Hcy, there were 1.98 (adjusted, 95% CI: 1.38-2.82, p<0.001) times more HFH. Living in a FD was associated with 1.46 (adjusted, 95% CI: 1.1-1.94, p=0.009) times more HFH. Addition of log 2 Hcy to the Poisson model eliminated the association of FD with recurrent HFH (adjusted HR: 1.14, 95% CI: 0.74- 1.76, p=0.54). Conclusions: Living in a FD is associated with higher serum Hcy. These results provide insights into the mechanisms by which FD status influences the risk of recurrent HFH.

Clinical Course of Patients With Worsening Heart Failure With Reduced Ejection Fraction

BackgroundEpidemiology of patients with worsening heart failure and reduced ejection fraction (HFrEF) in the real-world setting is not well described. ObjectivesThe purpose of this study was to describe incidence, clinical characteristics, treatment, and outcomes of patients with HFrEF who develop worsening heart failure (HF) in the real-world setting. MethodsData on patients with incident HFrEF from the National Cardiovascular Data Registry PINNACLE were linked to pharmacy, private practitioner, and hospital claims databases. Incidence, clinical characteristics, treatment (angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta-blocker, and mineralocorticoid receptor antagonist) and outcomes of patients with worsening HF, defined as ≥90 days of stable HF with subsequent worsening requiring intravenous diuretic agents, were assessed. ResultsOf 11,064 HFrEF patients, 1,851 (17%) developed worsening HF on average 1.5 years following initial HF diagnosis. Patients who developed worsening HF were more likely to be African American, be octogenarians, and have higher comorbidity burden (p < 0.001). At the onset of worsening HF, 42.4% of patients were on monotherapy, 43.4% were on dual therapy, and 14.1% were on triple therapy. A total of 48%, 61%, and 98% of patients were on >50% target dose for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta-blocker, and mineralocorticoid receptor antagonist, respectively. The 2-year mortality rate was 22.5%, and 56% of patients were rehospitalized within 30 days of the worsening HF event. ConclusionsIn the real-world setting, 1 in 6 patients with HFrEF develop worsening HF within 18 months of HF diagnosis. These patients have a high risk for 2-year mortality and recurrent HF hospitalizations. The use of standard-of-care therapies both before and after the onset of worsening HF is low. With high unmet medical need, patients with worsening HF require novel treatment strategies as well as greater optimization of existing guideline-directed therapy.

Hydrogen- and Methane-Based Breath Testing and Outcomes in Patients With Heart Failure

Recent evidence endorses gut microbiota dysregulation in the pathophysiology of heart failure (HF). Small intestinal bacterial overgrowth (SIBO) might be present in HF and associated with poor clinical outcomes. Lactulose breath testing is a simple noninvasive test that has been advocated as a reliable indicator of SIBO. In patients with HF, we aimed to evaluate the association with clinical outcomes of the exhaled hydrogen (H2) and methane (CH4) concentrations through the lactulose breath test. We included 102 patients with HF in which lactulose SIBO breath tests were assessed. Cumulative gas was quantified by the area under the receiver operating characteristic curve of CH4 (AUC-CH4) and H2 (AUC-H2). Clinical end points included the composite of all-cause death with either all-cause or HF hospitalizations, recurrent all-cause hospitalizations, and recurrent HF hospitalizations. Medians (interquartile ranges) of AUC-H2 and AUC-CH4 were 1290 U (520-2430) and 985 U (450-2120), respectively. In multivariable analysis, AUC-H2 (per 1000 U) was associated with all-cause death/all-cause hospitalization (hazard ratio [HR] 1.21, 95% CI 1.04-1.40; P = .012), all-cause death/HF hospitalization (HR 1.20, 95% CI 1.03-1.40; P = .021), and an increase in the rate of recurrent all-cause (incidence rate ratio [IRR] 1.31, 95% CI 1.14-1.51; P < .001) and HF (IRR 1.41, 95% CI 1.15-1.72; P = .001) hospitalizations. AUC-CH4 was not associated with any of these end points. AUC-H2, a safe and noninvasive method for SIBO estimation, is associated with higher risk of long-term adverse clinical events in patients with HF. In contrast, AUC-CH4 did not show any prognostic value.

Cardiovascular Outcomes Assessment of the MitraClip in Patients with Heart Failure and Secondary Mitral Regurgitation: Design and rationale of the COAPT trial

Patients with heart failure (HF) and symptomatic secondary mitral regurgitation (SMR) have a poor prognosis, with morbidity and mortality directly correlated with MR severity. Correction of isolated SMR with surgery is not well established in this population, and medical management remains the preferred approach in most patients. The Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial was designed to determine whether transcatheter mitral valve (MV) repair with the MitraClip device is safe and effective in patients with symptomatic HF and clinically significant SMR. The COAPT trial is a prospective, randomized, parallel-controlled, open-label multicenter study of the MitraClip device for the treatment of moderate-to-severe (3+) or severe (4+) SMR (as verified by an independent echocardiographic core laboratory) in patients with New York Heart Association class II-IVa HF despite treatment with maximally tolerated guideline-directed medical therapy (GDMT) who have been determined by the site's local heart team as not appropriate for MV surgery. A total of 614 eligible subjects were randomized in a 1:1 ratio to MV repair with the MitraClip plus GDMT versus GDMT alone. The primary effectiveness end point is recurrent HF hospitalizations through 24 months, analyzed when the last subject completes 12-month follow-up, powered to demonstrate superiority of MitraClip therapy. The primary safety end point is a composite of device-related complications at 12 months compared to a performance goal. Follow-up is ongoing, and the principal results are expected in late 2018. HF patients with clinically significant SMR who continue to be symptomatic despite optimal GDMT have limited treatment options and a poor prognosis. The randomized COAPT trial was designed to determine the safety and effectiveness of transcatheter MV repair with the MitraClip in symptomatic HF patients with moderate-to-severe or severe SMR.

POOR PROGNOSIS FOLLOWING DIABETES MELLITUS IN PATIENTS WITH HEART FAILURE: A NATIONWIDE COHORT STUDY

Prevalent diabetes mellitus (DM) is associated with higher risk of death and recurrent heart failure hospitalization (HFH) in patients with HF. However, little is known about the prognosis in HF patients developing DM after HF diagnosis. We examined the risk of death and HFH in HF patients with

Heart failure with mid-range ejection fraction in CHARM: characteristics, outcomes and effect of candesartan across the entire ejection fraction spectrum.

We tested the hypothesis that candesartan improves outcomes in heart failure (HF) with mid-range ejection fraction [HFmrEF; ejection fraction (EF) 40-49%]. In 7598 patients enrolled in the CHARM Programme (HF across the spectrum of EF), we assessed characteristics, outcomes and treatment effect of candesartan according to EF. Patients with HFmrEF (n = 1322, 17%) were similar to those with HF with reduced EF (HFrEF; n = 4323, 57%) with respect to some characteristics, and intermediate between HFrEF and HF with preserved EF (HFpEF; n = 1953, 26%) with respect to others. Over a mean follow-up of 2.9 years, the incidence rates for the primary outcome of cardiovascular death or HF hospitalization were 15.9, 8.5 and 8.9 per 100 patient-years in HFrEF, HFmrEF and HFpEF. In adjusted analyses, the rates of the primary outcome declined with increasing EF up to 50%. For treatment effect, the incidence rates for the primary outcome for candesartan vs. placebo were 14.4 vs. 17.5 per 100 patient-years in HFrEF [hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.75-0.91; P < 0.001], 7.4 vs. 9.7 per 100 patient-years in HFmrEF (HR 0.76, 95% CI 0.61-0.96; P = 0.02), and 8.6 vs. 9.1 per 100 patient-years in HFpEF (HR 0.95, 95% CI 0.79-1.14; P = 0.57). For recurrent HF hospitalization, the incidence rate ratios were 0.68 in HFrEF (95% CI 0.58-0.80; P < 0.001), 0.48 in HFmrEF (95% CI 0.33-0.70; P < 0.001), and 0.78 in HFpEF (95% CI 0.59-1.03; P = 0.08). With EF as a continuous spline variable, candesartan significantly reduced the primary outcome until EF well over 50% and recurrent HF hospitalizations until EF well over 60%. Candesartan improved outcomes in HFmrEF to a similar degree as in HFrEF. ClinicalTrials.gov: CHARM Alternative NCT00634400, CHARM Added NCT00634309, CHARM Preserved NCT00634712.

Effect of sacubitril/valsartan on recurrent events in the Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure trial (PARADIGM-HF).

AimsRecurrent hospitalizations are a major part of the disease burden in heart failure (HF), but conventional analyses consider only the first event. We compared the effect of sacubitril/valsartan vs. enalapril on recurrent events, incorporating all HF hospitalizations and cardiovascular (CV) deaths in PARADIGM‐HF, using a variety of statistical approaches advocated for this type of analysis.Methods and resultsIn PARADIGM‐HF, a total of 8399 patients were randomized and followed for a median of 27 months. We applied various recurrent event analyses, including a negative binomial model, the Wei, Lin and Weissfeld (WLW), and Lin, Wei, Ying and Yang (LWYY) methods, and a joint frailty model, all adjusted for treatment and region. Among a total of 3181 primary endpoint events (including 1251 CV deaths) during the trial, only 2031 (63.8%) were first events (836 CV deaths). Among a total of 1195 patients with at least one HF hospitalization, 410 (34%) had at least one further HF hospitalization. Sacubitril/valsartan compared with enalapril reduced the risk of recurrent HF hospitalization using the negative binomial model [rate ratio (RR) 0.77, 95% confidence interval (CI) 0.67–0.89], the WLW method [hazard ratio (HR) 0.79, 95% CI 0.71–0.89], the LWYY method (RR 0.78, 95% CI 0.68–0.90), and the joint frailty model (HR 0.75, 95% CI 0.66–0.86) (all P < 0.001). The effect of sacubitril/valsartan vs. enalapril on recurrent HF hospitalizations/CV death was similar.ConclusionsIn PARADIGM‐HF, approximately one third of patients with a primary endpoint (time‐to‐first) experienced a further event. Compared with enalapril, sacubitril/valsartan reduced both first and recurrent events. The treatment effect size was similar, regardless of the statistical approach applied.

Employment status at time of first hospitalization for heart failure is associated with a higher risk of death and rehospitalization for heart failure.

Employment status at time of first heart failure (HF) hospitalization may be an indicator of both self-perceived and objective health status. In this study, we examined the association between employment status and the risk of all-cause mortality and recurrent HF hospitalization in a nationwide cohort of patients with HF. We identified all patients of working age (18-60 years) with a first HF hospitalization in the period 1997-2015 in Denmark, categorized according to whether or not they were part of the workforce at time of the index admission. The primary outcome was death from any cause and the secondary outcome was readmission for HF. Cumulative incidence curves, binomial regression and Cox regression models were used to assess outcomes. Of 25 571 patients with a first hospitalization for HF, 15 428 (60%) were part of the workforce at baseline. Patients in the workforce were significantly younger (53 vs. 55 years) more likely to be male (75% vs 64%) and less likely to have diabetes (13% vs 22%) and chronic obstructive pulmonary disease (5% vs 10%) (all P < 0.0001). Not being part of the workforce was associated with a significantly higher risk of death [hazard ratio (HR) 1.59; 95% confidence interval (CI) 1.50-1.68] and rehospitalization for HF (HR 1.09; 95% CI 1.05-1.14), in analyses adjusted for age, sex, co-morbidities, education level, calendar time, and duration of first HF hospitalization. Not being part of the workforce at time of first HF hospitalization was independently associated with increased mortality and recurrent HF hospitalization.

Clinical presentation at first heart failure hospitalization does not predict recurrent heart failure admission.

AimsThere are limited data on whether clinical presentation at first heart failure (HF) hospitalization predicts recurrent HF events. We aimed to assess predictors of recurrent HF hospitalizations in mild HF patients with an implantable cardioverter defibrillator or cardiac resynchronization therapy with defibrillator.Methods and resultsData on HF hospitalizations were prospectively collected for patients enrolled in MADIT‐CRT. Predictors of recurrent HF hospitalization (HF2) after the first HF hospitalization were assessed using Cox proportional hazards regression models including baseline covariates and clinical presentation or management at first HF hospitalization. There were 193 patients with first HF hospitalization, and 156 patients with recurrent HF events. Recurrent HF rate after the first HF hospitalization was 43% at 1 year, 52% at 2 years, and 55% at 2.5 years. Clinical signs and symptoms, medical treatment, or clinical management of HF at first HF admission was not predictive for HF2. Baseline covariates predicting recurrent HF hospitalization included prior HF hospitalization (HR = 1.59, 95% CI: 1.15–2.20, P = 0.005), digitalis therapy (HR = 1.58, 95% CI: 1.13–2.20, P = 0.008), and left ventricular end‐diastolic volume >240 mL (HR = 1.62, 95% CI: 1.17–2.25, P = 0.004).ConclusionsRecurrent HF events are frequent following the first HF hospitalization in patients with implanted implantable cardioverter defibrillator or cardiac resynchronization therapy with defibrillator. Neither clinical presentation nor clinical management during first HF admission was predictive of recurrent HF. Prior HF hospitalization, digitalis therapy, and left ventricular end‐diastolic volume at enrolment predicted recurrent HF hospitalization, and these covariates could be used as surrogate markers for identifying a high‐risk cohort.

Echocardiographic pulmonary artery pressure estimation and heart failure rehospitalization burden in patients with acute heart failure

Pulmonary hypertension (PH) is a strong predictor of mortality in patients with heart failure (HF). However, the relationship between PH, through echocardiographic pulmonary artery pressure (PASP) estimation, and the risk of HF rehospitalizations remains unclear. MethodsWe prospectively included 2343 consecutive patients discharged for acute heart failure (AHF). PH was estimated by echocardiography through PASP determination during the index admission. Patients were categorized as follows across PASP: non-measurable, normal (≤35mmHg), mild (36–45mmHg), moderate (46–60mmHg), or severe PH (>60mmHg). Negative binomial regression method was used to evaluate the association between PASP and recurrent HF hospitalizations across preserved (HFpEF: ≥50%), mid-range (HFmrEF: 40–49%) and reduced ejection fraction (HFrEF: <40%). ResultsMean age of the cohort was 72.8±11.2years, 1187 (50.5%) were women, and 1252 (53.4%) and 410 (17.5%) showed HFpEF and HFmrEF, respectively. At a median (interquartile range) follow-up of 2.3 (0.8–4.5) years, we registered 1114 (47.6%) deaths, and 1834 HF-related rehospitalizations in 943 (40.2%) patients. After multivariable adjustment, and compared to patients with normal PASP, severe PH exhibited an independent higher risk of recurrent HF admissions only in HFpEF (IRR=1.66; 95% confidence interval (CI), 1.16–2.38; p=0.005), whereas in HFmrEF patients there was a non-significant trend to higher HF readmissions (IRR: 1.73; 95% CI, 0.85–3.55; p=0.132). Severe PH was not related with recurrent hospitalizations in HFrEF (IRR: 1.19; 95% CI, 0.66–2.14; p=0.553). ConclusionsEchocardiography-derived PASP evaluated during an episode of AHF is related to HF readmission burden, particularly in those patients with HFpEF.

Recovered heart failure with reduced ejection fraction and outcomes: a prospective study

Significant recovery of left ventricular ejection fraction (LVEF) occurs in a proportion of patients with heart failure (HF) and reduced ejection fraction (HFrEF). We analysed outcomes, including mortality [all-cause, cardiovascular (CV), HF-related, and sudden death], and HF-related hospitalizations in this HF-recovered group. The primary endpoint was a composite of CV death or HF hospitalization. LVEF was assessed at baseline and at 1 year in 1057 consecutive HF patients. Patients were classified into three groups: (i) HF-recovered: LVEF <45% at baseline and ≥45% at 1 year (n = 233); (ii) HF with preserved EF (HFpEF): LVEF ≥45% throughout follow-up (n = 117); and (iii) HFrEF: LVEF <45% throughout follow-up (n = 707). Mean follow-up was 5.6 ± 3.1 years. HF-recovered patients differed from HFrEF and HFpEF groups in demographic and clinical characteristics. The mean LVEF increase was 21.1 ± 10 points in HF-recovered patients. Using the HF-recovered group as a reference, the risks for the primary composite endpoint (n = 376), with non-CV death as competing risk, for HFpEF and HFrEF groups were: hazard ratio (HR) 2.33 [95% confidence interval (CI) 1.60-3.39], P < 0.001 and HR 1.99 (95% CI 1.50-2.65), P < 0.001, respectively. All-cause (n = 429), CV (n = 245), HF-related (n = 127), and sudden death (n = 60) were significantly lower in HF-recovered subjects relative to HFrEF (all P < 0.01). HF-recovered patients also experienced less recurrent HF hospitalizations (P < 0.001). One in four treated patients with HFrEF showed recovery of systolic function. HF-recovered patients had significantly improved mortality and morbidity relative to HFpEF and HFrEF subjects. Further research is needed to identify optimal medications and device indications for HF-recovered patients.

WITHDRAWN: Percutaneous left ventricular restoration in chronic heart failure

Heart failure remains a leading cause of cardiovascular morbidity and mortality following myocardial infarction. Progressive cardiac remodeling results in altered shape and geometry of left ventricle with increased LV end diastolic volume and LV dilatation, reduced ejection fraction and heart failure. Medical therapy is the mainstay of management. Surgical ventricular restoration to reverse cardiac remodelling has been attempted with varying results. Percutaneous ventricular restoration using ventricular partition device is emerging as a new strategy for the treatment of ischemic heart failure. Research studies and recent meta-analysis have shown a success rate of 90% in device deployment. Procedural complications occurred in 6.6% patients. Device implantation resulted in improvement of Quality of Life, NYHA class and six minutes walking distance. Left ventricular end diastolic volume and left ventricular end systolic volume decreased by about 20% on 1–3 year follow up. Mortality and recurrent hospitalization for heart failure showed reduction after device implantation.

TCT-627 Cardiovascular Outcomes Assessment of MitraClip Therapy in Heart Failure Patients with Functional Mitral Regurgitation (The COAPT Trial): Baseline Characteristics and Preliminary 30-Day and 1-Year Outcomes of the Roll-In Cohort

Pts with functional mitral regurgitation (FMR) and heart failure (HF) have a poor prognosis. The COAPT Trial was designed to determine whether transcatheter mitral valve (MV) repair with the MitraClip is safe and effective for reducing recurrent HF hospitalizations in pts with FMR. Herein we

Heart failure hospitalization in women with signs and symptoms of ischemia: A report from the women's ischemia syndrome evaluation study

BackgroundWomen with signs and symptoms of ischemia, no obstructive coronary artery disease, and preserved left ventricular ejection fraction enrolled in the National Heart Lung and Blood Institute (NHLBI) sponsored Women's Ischemia Syndrome Evaluation (WISE) study have an unexpectedly high rate of subsequent heart failure (HF) hospitalization. We sought to verify and characterize the HF hospitalizations. MethodsA retrospective chart review was performed on 223 women with signs and symptoms of ischemia, undergoing coronary angiography for suspected coronary artery disease followed for 6±2.6years. Data were collected from a single site in the WISE study. ResultsAt the time of study enrollment, the women were 57±11years of age, all had preserved left ventricular ejection fraction, and 81 (36%) had obstructive CAD (defined as >50% stenosis in at least one epicardial artery). Among the 223 patients, 25 (11%) reported HF hospitalizations, of which 14/25 (56%) had recurrent HF hospitalizations (>2 hospitalizations). Medical records were available in 13/25 (52%) women. Left ventricular ejection fraction was measured in all verified cases and was found to be preserved in 12/13 (92%). HF hospitalization was not related to obstructive CAD. ConclusionAmong women with signs and symptoms of ischemia undergoing coronary angiography for suspected obstructive CAD, HF hospitalization at 6-year follow-up was predominantly characterized by a preserved ejection fraction and not associated with obstructive CAD.

Association of gender and length of stay among Puerto Ricans hospitalized with decompensated heart failure.

Heart failure (HF) is a serious, chronic, and progressive condition which may require hospitalization if decompensated. Each year, in the UnitedStates, there are approximately 1 million hospitalizations due to decompensated HF at a cost of $39 billion. Because limited information examining the association between gender and length of stay (LOS) is available in the published literature for Puerto Ricans hospitalized with decompensated HF, we aim to investigate gender differences related to LOS in this population.This study is a secondary data analysis of the Puerto Rico Cardiovascular Disease Surveillance System database, which is a nonconcurrent prospective study carried out in 2007 and 2009. LOS was dichotomized into ≤5 days or ≥6 days (extended) categories. The χ2 test was used to examine associations between categorical variables. Binary logistic regression was used to estimate unadjusted and adjusted odds ratios of extended LOS. Collinearity was assessed using Pearson correlation coefficients. A P value of 0.05 and 95% confidence intervals were used to evaluate statistical significance.A total of 1724 patients (47.6% women) comprised our study population. The average age of women was 72.5 ± 13.4 years; the average age of men was 67.2 ± 14.5 years. For both women and men, median LOS was 5 days (interquartile range = 5 days). Women were more likely than men to have diabetes mellitus, hypertension, and dyslipidemia, but current smoking was higher in men than in women. The proportion of patients with extended LOS was similar for men (43.3%) and women (45.1%) (P = 0.448). Likewise, the odds for extended LOS was comparable for both genders (OR = 1.1, 95% CI = 0.9, 1.4). Patients admitted with recurrent decompensated HF hospitalizations had shorter LOS than patients with initial episodes (OR = 0.7, 95% CI = 0.6, 0.9). However, factors that prolonged the LOS included the presence of renal failure (OR = 1.7; 95% IC = 1.3, 2.1) and ejection fraction (EF) <35% (OR 0.7; 95% CI 0.6, 0.9).Although we were not able to find statistically significant association between LOS and gender in Puerto Rican patients hospitalized with decompensated HF our findings suggest that incidental episodes and having an EF <35% increase the odds of extended LOS.

Prognostic and symptomatic benefits with ivabradine: lessons from the SHIFT trial

Ivabradine, a funny current (If) inhibitor, has been developed for symptomatic therapy of angina and in chronic heart failure (CHF) with low ejection fraction. A large outcome trial, SHIFT (Systolic Heart Failure Treatment with the If inhibitor ivabradine trial), was conducted in patients with EF ≤ 35% in sinus rhythm and increased heart rate ≥70 b.p.m. It demonstrated that the addition of this new compound to the best possible contemporary therapy, including beta-blockers, was associated with a 18% relative risk reduction in the occurrence of cardiovascular mortality or hospitalization for worsening heart failure (HF), 26% relative risk reduction in HF hospitalization, and in HF death. This beneficial effect was of greater magnitude in patients with heart rate ≥75 b.p.m. Ivabradine improved health-related quality of life significantly and reduced the number of recurrent hospitalizations for HF. Sub-studies conducted in subgroups with important co-morbidities, i.e. chronic obstructive pulmonary disease, renal dysfunction, diabetes mellitus and low systolic blood pressure, show that the efficacy and the safety of the drug are similar compared with those observed in patients without these comorbidities. The acute cardiac effect is characterized by a reversal of the abnormal force–frequency relationship, thus resulting in preserved contractile function and increased stroke volume despite heart rate reduction. The chronic cardiac effect is characterized by a reverse remodelling of the left ventricle with reduced cardiac dimensions which result from unloading of the left ventricle. Ivabradine is now indicated in CHF NYHA class II–IV with systolic dysfunction in patients in sinus rhythm and whose heart rate is ≥75 b.p.m. in combination with standard therapy including beta-blocker therapy or when beta-blocker therapy is contraindicated or not tolerated.

Effect of ivabradine on numbers needed to treat for the prevention of recurrent hospitalizations in heart failure patients

Background:Ivabradine, a specific heart rate lowering agent, was shown in the SHIFT study to reduce time to first hospitalization for worsening heart failure (HF) in chronic systolic HF patients and also to reduce recurrent/total hospitalizations over the study interval. We assessed the effects of adding ivabradine in patients with systolic HF on the number needed to treat (NNT) to reduce recurrent hospitalizations.Methods:The SHIFT trial included 6505 patients with symptomatic HF (NYHA II–IV), left ventricular ejection fraction ≤35% and heart rate ≥70 bpm in sinus rhythm. Patients were randomized to either ivabradine or placebo in addition to guidelines-based drug therapy. The times to first hospitalization were analyzed using a univariate Cox proportional-hazards model; the associated NNT was calculated using Kaplan–Meier estimates of the time-to-event curves at 1 year in each treatment arm. Recurrent hospitalizations were analyzed using a negative binomial and the estimated annual event rates used to calculate the associated patient-time NNTs respectively.Results:The estimated NNT (number needed to initiate treatment with ivabradine to prevent one first HF hospitalization within 1 year) was 27 (estimated hazard ratio: 0.75, P < 0.0001). For recurrent HF hospitalizations, one event would be prevented on average per 14 patient-years for any year of follow-up over the course of SHIFT (estimated rate ratio: 0.71, P < 0.0001). A key limitation of this analysis is that it did not account for a relationship between recurrent HF hospitalizations and subsequent mortality.Conclusion:In chronic systolic HF the effect of ivabradine on reducing recurrent HF hospitalizations results in a lower NNT compared to the effect on the time for first hospitalization. The effect of ivabradine on recurrent hospitalizations, in addition to first events, may be a more appropriate measure when considering the impact of a treatment with ivabradine on healthcare resource utilization.