Risk Of Heart Failure Readmission Research Articles

Incidence, Risk Factors, and Outcomes Associated With Permanent Pacemaker Implantation Following Tricuspid Valve Surgery.

Data regarding permanent pacemaker (PPM) implantation following tricuspid valve surgery (TVS) are limited. We sought to evaluate its incidence, risk factors, and outcomes. Medicare beneficiaries who underwent TVS from 2013 to 2020 were identified. Patients who underwent TVS for endocarditis were excluded. The primary exposure of interest was new PPM after TVS. Outcomes included all-cause mortality and readmission with endocarditis or heart failure on follow-up. Among the 13 294 patients who underwent TVS, 2518 (18.9%) required PPM placement. Risk factors included female sex (relative risk[RR], 1.26 [95% CI, 1.17-1.36], P<0.0001), prior sternotomy (RR, 1.12 [95% CI, 1.02-1.23], P=0.02), preoperative second-degree heart block (RR, 2.20 [95% CI, 1.81-2.69], P<0.0001), right bundle-branch block (RR, 1.21 [95% CI, 1.03-1.41], P=0.019), bifascicular block (RR, 1.43 [95% CI, 1.06-1.93], P=0.02), and prior malignancy (RR, 1.23 [95% CI, 1.01-1.49], P=0.04). Tricuspid valve (TV) replacement was associated with a significantly higher risk of PPM implantation when compared with TV repair (RR, 3.20 [95% CI, 2.16-4.75], P<0.0001). After a median follow-up of 3.1 years, mortality was not different in patients who received PPM compared with patients who did not (hazard ratio [HR], 1.02 [95% CI, 0.93-1.12], P=0.7). PPM placement was not associated with a higher risk of endocarditis but was associated with a higher risk of heart failure readmission (HR, 1.28 [95% CI, 1.14-1.43], P<0.001). PPM implantation frequently occurs after TVS, notably in female patients and patients undergoing TV replacement. Although mortality is not increased, it is associated with higher rates of heart failure rehospitalization.

Development and Validation of a Machine Learning Risk-Prediction Model for 30-Day Readmission for Heart Failure Following Transcatheter Aortic Valve Replacement (TAVR-HF Score)

Transcatheter aortic valve replacement (TAVR) is the treatment of choice for patients with severe aortic stenosis across the spectrum of surgical risk. About one-third of 30-day readmissions following TAVR are related to heart failure (HF). Hence, we aim to develop an easy-to-use clinical predictive model to identify patients at risk for HF readmission. We used data from the National Readmission Database (2015-2018) utilizing ICD-10 codes to identify TAVR procedures. Readmission was defined as the first unplanned HF readmission within 30-day of discharge. A machine learning framework was used to develop a 30-day TAVR-HF readmission score. The receiver operator characteristic curve was used to evaluate the predictive power of the model. A total of 92,363 cases of TAVR were included in the analysis. Of the included patients, 3299 (3.6%) were readmitted within 30 days of discharge with HF. Individuals who got readmitted, vs those without readmission, had more emergent admissions during index procedure (33.4% vs 19.8%), electrolyte abnormalities (38% vs 16.7%), chronic kidney disease (34.8% vs 21.2%), and atrial fibrillation (60.1% vs 40.7%). Candidate variables were ranked by importance using a parsimony plot. A total of 7 variables were selected based on predictive ability as well as clinical relevance: HF with reduced ejection fraction (25 points), HF preserved EF (20 points), electrolyte abnormalities (17 points), atrial fibrillation (12 points), Charlson comorbidity index (<6 = 0, 6-8 = 9, 9-10 = 13, >10 = 14 points), chronic kidney disease (7 points), and emergent index admission (5 points). On performance evaluation using the testing dataset, an area under the curve of 0.761 (95% CI 0.744-0.778) was achieved. Thirty-day TAVR-HF readmission score is an easy-to-use risk prediction tool. The score can be incorporated into electronic health record systems to identify at-risk individuals for readmissions with HF following TAVR. However, further external validation studies are needed.

Association of sodium-glucose cotransporter 2 inhibitors with post-discharge outcomes in patients with acute heart failure with type 2 diabetes: a cohort study

BackgroundGiven the cumulative evidence on the effectiveness of sodium-glucose cotransporter 2 inhibitors (SGLT2is) on chronic heart failure, demand is emerging for further information on their effects in patients who are hospitalized for acute heart failure. However, there is still limited evidence about the class effect of SGLT2is on acute heart failure. We investigated whether initiating treatment with SGLT2is after an episode of acute heart failure reduces the risks of post-discharge heart failure readmission or cardiovascular mortality among patients with type 2 diabetes.MethodsA retrospective cohort study was conducted in a cohort of patients with type 2 diabetes who hospitalized for heart failure, using Korean Health Insurance Review & Assessment database (2015–2020). The exposure was defined as initiation of SGLT2is during hospitalization or at discharge. We assessed hazards of post-discharge heart failure readmission and cardiovascular death at 1-year, and 30-, 60-, and 90-day from the date of discharge in the SGLT2is users and non-users. Cox proportional hazards models with propensity score-based inverse probability of treatment weighting were used to estimate hazard ratios and 95% confidence intervals.ResultsAmong 56,343 patients with type 2 diabetes hospitalized for heart failure, 29,290 patients were included in the study cohort (mean [SD] age, 74.1 [10.8] years; 56.1% women); 818 patients (2.8%) were prescribed SGLT2is during index hospitalization or at discharge. Patients with a prescription for SGLT2i vs. those without prescription had lower rates of heart failure readmission or cardiovascular death at 1 year (22.4% vs. 25.3%; adjusted hazard ratio, 0.90 [95% confidence interval, 0.87–0.93]), and also at 30 days (7.0% vs. 7.7%%; 0.74 [0.69–0.79]).ConclusionsAmong patients with type 2 diabetes, initiating SGLT2i treatment after an episode of acute heart failure was significantly associated with a reduced combined risk of heart failure readmission and cardiovascular mortality in a nationwide cohort reflecting routine clinical practice.

The Charlson comorbidity index and short-term readmission in patients with heart failure: A retrospective cohort study.

The relationship between the Charlson comorbidity index (CCI) and short-term readmission is as yet unknown. Therefore, we aimed to investigate whether the CCI was independently related to short-term readmission in patients with heart failure (HF) after adjusting for other covariates. From December 2016 to June 2019, 2008 patients who underwent HF were enrolled in the study to determine the relationship between CCI and short-term readmission. Patients with HF were divided into 2 categories based on the predefined CCI (low < 3 and high > =3). The relationships between CCI and short-term readmission were analyzed in multivariable logistic regression models and a 2-piece linear regression model. In the high CCI group, the risk of short-term readmission was higher than that in the low CCI group. A curvilinear association was found between CCI and short-term readmission, with a saturation effect predicted at 2.97. In patients with HF who had CCI scores above 2.97, the risk of short-term readmission increased significantly (OR, 2.66; 95% confidence interval, 1.566-4.537). A high CCI was associated with increased short-term readmission in patients with HF, indicating that the CCI could be useful in estimating the readmission rate and has significant predictive value for clinical outcomes in patients with HF.

BNP AND NT-PRO BNP AS INDEPENDENT DIAGNOSTIC BIOMARKERS FOR CARDIOVASCULAR DISEASE IN TYPE 2 DIABETES MELLITUS

The risk of developing heart failure (HF) with a reduced and preserved ejection fraction is known to increase with pre-diabetes and diabetic mellitus (DM). Natriuretic peptides (NPs) have been shown to be an important tool for assessing the risk of cardiovascular diseases (CVD) in people with pre-diabetes and Type 2 diabetes (T2DM), regardless of HF characteristics. Elevated levels of NPs were associated with an increased risk of readmission for HF, all-cause mortality, CVD mortality, HF progression, and readmission due to HF, according to earlier clinical investigations. In pre-diabetes and T2DM populations, the discriminative power of NPs for CVD death and HF-related clinical events has not been established beyond conventional CVD risk variables. The purpose of the review is to gather details regarding the predictive value of circulating NPs based on pre-diabetes and established T2DM presentation. Researchers have found that HFrEF or HFpEF in T2DM patients may necessitate a change in NP cutoff values to diagnose primary HF and identify HF-related risks. The relationship between clinical outcomes and the dynamic of circulating levels of NPs in diabetics treated with glucagon-like peptide-1 agonists and sodium-glucose cotransporter-2 inhibitors has to be clarified in big clinical trials in the future.

Non-cardiovascular medication and readmission for heart failure: an observational cohort study

Background Among heart failure (HF) patients, hospital readmissions are a major concern. The medication taken by a patient may provide information on comorbidities and conditions and may be used as an indicator to identify populations at an increased risk of HF readmission. Aim This study explored the use of non-cardiovascular medication at hospital discharge from the first HF admission in search of indicators of high risk of readmission for HF. Method The study included 22,476 HF patients from the Dutch PHARMO Database Network at their first HF hospitalization. The data was divided into training and validation sets. A Cox regression model with demographics, date of first HF hospital admission and non-cardiovascular medication present at discharge, adjusted for cardiovascular medication, was developed in the training set and subsequently implemented in the validation set. Results The study included 22,476 patients, mean age 76.7years (range 18-104) and median follow-up time 2.5years (range 0-15.7years). During the study period 6,725 (29.9%) patients were readmitted for HF, with a median time-to-readmission of 7months (range 0-14.3years). Non-cardiovascular medication associated with a high risk of readmission for HF were identified as indicators of high risk, with no implied causal relationship. Patients prescribed antigout medications presented a 25% increased risk of readmission (HR 1.25, 95%CI 1.09-1.45, P = 0.002). Patients using insulin had an 18% higher risk of readmission versus patients not using insulin (HR 1.18, 95%CI 1.06-1.32, P = 0.002), but not versus patients treated with other blood-glucose-lowering drugs. No association between the risk of readmission and NSAIDs use was observed. Conclusion The results suggest that diabetes is responsible for the higher HF-readmission risk observed in patients prescribed insulin. The observed risk in users of antigout medication should be further investigated. The absence of an association with the use of NSAIDs should be interpreted with caution.

Prognostic value of postural hypotension in hospitalized patients with heart failure

Although postural hypotension (PH) is reportedly associated with mortality in the general population, the prognostic value for heart failure is unclear. This was a post-hoc analysis of FRAGILE-HF, a prospective multicenter observational study focusing on frailty in elderly patients with heart failure. Overall, 730 patients aged ≥ 65 years who were hospitalized with heart failure were enrolled. PH was defined by evaluating seated PH, and was defined as a fall of ≥ 20 mmHg in systolic and/or ≥ 10 mmHg in diastolic blood pressure within 3 min after transition from a supine to sitting position. The study endpoints were all-cause death and heart failure readmission at 1 year. Predictive variables for the presence of PH were also evaluated. PH was observed in 160 patients (21.9%). Patients with PH were more likely than those without PH to be male with a New York Heart Association classification of III/IV. Logistic regression analysis showed that male sex, severe heart failure symptoms, and lack of administration of angiotensin-converting enzyme inhibitors were independently associated with PH. PH was not associated with 1-year mortality, but was associated with a lower incidence of readmission after discharge after adjustment for other covariates. In conclusion, PH was associated with reduced risk of heart failure readmission but not with 1-year mortality in older patients with heart failure.

Carbohydrate antigen 125 and risk of heart failure readmissions in patients with heart failure and preserved ejection fraction

We aimed to assess the association between CA125 and the long-term risk of total acute heart failure (AHF) admissions in patients with an index hospitalization with AHF and preserved ejection fraction (HFpEF). We prospectively included 2369 patients between 2008 and 2019 in three centers. CA125 and NT-proBNP were measured during early hospitalization and evaluated as continuous and categorized in quartiles (Q). Negative binomial regressions were used to assess the association with the risk of recurrent AHF admission. The mean age of the sample patients was 76.7 ± 9.5 years and 1443 (60.9%) were women. Median values of CA125 and NT-proBNP were 38.3 (19.0–90.0) U/mL, and 2924 (1590–5447) pg/mL, respectively. During a median follow-up of 2.2 (0.8–4.6) years, 1200 (50.6%) patients died, and 2084 AHF admissions occurred in 1029 (43.4%) patients. After a multivariate adjustment, CA125, but not NT-proBNP, was positively and non-linearly associated with the risk of cumulative AHF-readmission (p < 0.001). Compared to Q1, patients belonging to Q2, Q3, and Q4 showed a stepwise risk increase (IRR = 1.29, 95% CI 1.08–1.55, p = 0.006; IRR = 1.35, 95% CI 1.12–1.63, p = 0.002; and IRR = 1.62, 95% CI 01.34–1.96, p < 0.001, respectively). In conclusion, CA125 predicted the risk of long-term AHF-readmission burden in patients with HFpEF and a recent admission for AHF.

Abstract 13422: The Impact of Cardiac Resynchronization Therapy With Defibrillator in Patients With Nonischemic Cardiomyopathy

Introduction: Real-world data on the significance of adding a defibrillator to cardiac resynchronization therapy (CRT-D) in patients with nonischemic cardiomyopathy (NICM) are limited. Hypothesis: CRT-D is associated with a lower risk of mortality and heart failure (HF) readmissions compared to CRT-P in NICM. Methods: We identified patients with NICM who underwent CRT-D and CRT without an ICD (CRT-P) by analyzing the nationwide readmission database from October 2015- December 2018 and using appropriate ICD-10 CM codes. Propensity score matching was performed to adjust for the confounders. Kaplan Meier curves were utilized for time to event analysis. Cox proportional hazard regression was used to generate hazard ratios. All-cause mortality at 6 months was the primary outcome whereas readmission due to HF and any other cause at 6 months were defined as secondary outcomes. Results: Post-PSM, 3054 patients with NICM underwent CRT-P, and 2863 patients underwent CRT-D placement. CRT-D did not show any benefit over CRT-P in reducing all-cause mortality at 6 months (2.92% vs. 2.79%, HR: 0.84, 95% CI: 0.61-1.16, p=0.29). Similarly, there was no difference in terms of readmissions due to other causes among both groups of patients (36.25% vs. 31.85%, HR: 0.98, 95% CI: 0.89-1.08, p=0.77). However, patients with CRT-P implantations had a lower risk of HF readmissions compared to the CRT-D group (10.05% vs. 14.25%, HR: 0.67, 95% CI: 0.58-0.79, p&lt;0.0001). Conclusions: The addition of a defibrillator to CRT failed to show a survival benefit in patients with NICM. Moreover, HF readmissions were higher in CRT-D patients compared to CRT-P.

Prognostic impact of hospital-acquired disability in elderly patients with heart failure.

AimsFunctional decline is associated with worse outcomes in patients with elderly heart failure (HF), but little is known about the prognostic impact of hospital‐acquired disability (HAD) during hospital stay after acute HF. The present study examines the prognostic significance of HAD in the prediction of all‐cause mortality in elderly patients who admitted for acute HF.Methods and resultsThis retrospective study was performed in 1941 elderly patients aged ≥65 years or older from the cardiovascular physiotherapy for acute HF patients in the Tokyo metropolitan area registry and excluded those who died in hospital. HAD was defined as any decline in the Barthel index (BI) before discharge compared with the BI within 1 month before hospital admission. The primary outcome of this study was all‐cause death and HF readmission. A total of 565 (29%) deaths and 789 (41%) HF readmission occurred over a median follow‐up period of 1.7 years. A total of 476 patients (25%) had HAD during hospital stay after acute HF. In multivariable analysis, HAD predicted all‐cause death [hazard ratio (HR): 1.772; 95% confidence interval (CI): 1.450–2.167; P < 60; 0.001] and with risk of HF readmission (HR: 1.193; 95% CI: 1.005–1.416; P = 0.043) after adjusting for the Meta‐analysis Global Group in Chronic Heart Failure risk score.ConclusionsHospital‐acquired disability is associated with an increased risk of all‐cause death and readmission for HF in elderly patients with acute HF.

Impact of Canagliflozin in Patients with Type 2 Diabetes after Hospitalization for Acute Heart Failure: A Cohort Study.

Background: Heart failure (HF) is one of the mayor contributors to cardiovascular morbidity and mortality in patients with diabetes. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have demonstrated to reduce the risk of hospitalization for HF in patients with type 2 diabetes mellitus (T2D). We aimed to assess the risk for re-hospitalization in a cohort of patients hospitalized for HF according to whether or not they received canagliflozin at discharge, as well as changes in N-terminal pro–B-type natriuretic peptide (NT-ProBNP) concentration during follow-up. Methods: We conducted a retrospective longitudinal study at a tertiary centre including 102 consecutive T2D patients discharged for acute HF without contraindication for SGLT2 inhibitors. We compared adverse clinical events (HF rehospitalization and cardiovascular death) and NT-ProBNP changes according to canagliflozin prescription at discharge. Results: Among the 102 patients included, 45 patients (44.1%) were prescribed canagliflozin and the remaining 57 (55.9%) were not prescribed any SGLT2 inhibitors (control group). After a median follow-up of 22 months, 45 patients (44.1%) were hospitalized for HF. Most of the rehospitalizations occurred during the first year (37.3%). HF readmission at first year occurred in 10 patients (22.2%) in the canagliflozin group and 29 patients (49.1%) in the control group (hazard ratio (HR): 0.45; 95% confidence interval (CI): 0.21–0.96; p < 0.039). A composite outcome of hospitalization for HF or death from cardiovascular causes was lower in the canagliflozin group (37.8%) than in the control group (70.2%) (HR: 0.51; 95% CI: 0.27–0.95; p < 0.035). Analysis of NT-ProBNP concentration showed an interaction between canagliflozin therapy and follow-up time (p = 0.002). Conclusions: Canagliflozin therapy at discharge was associated with a lower risk of readmission for HF and a reduction in NT-ProBNP concentration in patients with diabetes after hospitalization for HF.

Heart failure medication after a first hospital admission and risk of heart failure readmission, focus on beta-blockers and renin-angiotensin-aldosterone system medication: A retrospective cohort study in linked databases.

This study assessed the association between heart failure (HF) medication (angiotensin-converting-enzyme inhibitors (ACEI)/angiotensin-receptor blockers (ARB), beta-blockers (BB), mineralocorticoid-receptor antagonists (MRA) and diuretics) and HF readmissions in a real-world unselected group of patients after a first hospital admission for HF. Furthermore we analysed readmission rates for ACEI versus ARB and for carvedilol versus β1-selective BB and we investigated the effect of HF medication in relation to time since discharge. Medication at discharge was determined with dispensing data from the Dutch PHARMO Database Network including 22,476 patients with HF between 2001 and 2015. After adjustment for age, gender, number of medications and year of admission no associations were found for users versus non-users of ACEI/ARB (hazard ratio, HR = 1.01; 95%CI 0.96-1.06), BB (HR = 1.00; 95%CI 0.95-1.05) and readmissions. The risk of readmission for patients prescribed MRA (HR = 1.11; 95%CI 1.05-1.16) or diuretics (HR = 1.17; 95%CI 1.09-1.25) was higher than for non-users. The HR for ARB relative to ACEI was 1.04 (95%CI 0.97-1.12) and for carvedilol relative to β1-selective BB 1.33 (95%CI 1.20-1.46). Post-hoc analyses showed a protective effect shortly after discharge for most medications. For example one month post discharge the HR for ACEI/ARB was 0.77 (95%CI 0.69-0.86). Although we did try to adjust for confounding by indication, probably residual confounding is still present. Patients who were prescribed carvedilol have a higher or at least a similar risk of HF readmission compared to β1-selective BB. This study showed that all groups of HF medication -some more pronounced than others- were more effective immediately following discharge.

Abstract 17502: Using Patient-Centered Outcomes Research Principles to Develop and Implement a Mobile Heart Failure Self-Care Program

Introduction: Patients admitted with decompensated heart failure (HF) are at risk for hospital readmission and poor quality of life. Remote monitoring and mobile health (mHealth) technologies can help prevent hospitalization for community-dwelling patients. We aimed to develop a HF mHealth application to enhance self-care after HF hospitalization. Hypothesis: We hypothesized that 1) a mHealth platform could be designed to increase HF self-care after hospital discharge for a population at high risk for HF readmission and 2) our tool would be user friendly and feasibly deployed. Methods: Intervention development included input from the following stakeholders: patients, clinicians, information technology developers, patient education experts, and mHealth researchers. We recruited 32 inpatient adults with HF and randomized them 1:1 to the mHealth program plus usual HF care or usual care only. Patients discharged to a nursing home, with end-stage HF (e.g. awaiting transplant/ventricular assist device or on palliative inotropes), or without a smart phone were excluded. Feasibility was determined by ease of deployment, duration of participant recruitment, and participant attrition. We measured program usability by how often the application was opened and used by patients. Results: We developed an educational HF mHealth patient self-care tool consisting of daily videos and self-assessments. Of 202 patients screened: 13 were excluded due to discharge to nursing home; 28 were excluded for end-stage HF; 9 were excluded because they did not have a smart phone. We enrolled 32 patients, 14 of which were randomized to receive the program. Mean age was 60 years (range 22-85). There were 53% male and 81% White. Four of 14 (28.6%) did not fully complete the 90-day program. All survey respondents expressed satisfaction with the intervention. Conclusions: We conducted a pilot study of a HF self-care mHealth tool for adults at risk for HF readmission and have determined it to be both feasible and acceptable. Our intervention, although a research prototype, may serve as a novel approach to reduce hospital admission and improve patient ability to manage HF as an outpatient.

Early follow up visit by a heart failure team after acute heart failure hospitalization and impact in outcomes

Abstract Background Hospitalization for Acute Heart Failure (AHF) remains an important turning point for patients and families, presenting itself as an index event after which the rate of readmission and mortality are particularly high. Hospitalization for Heart Failure (HF) also has a considerable cost impact on healthcare systems. Strategies that reduce the risk of readmission for HF are, therefore, crucial for patients and healthcare systems. A possible strategy to reduce HF readmissions currently recomended by the European Society of Cardiology is guaranteeing an outpatient follow-up visit carried out by a multidisciplinary HF team (combining specialized medical and nurse care) shortly after discharge. Our goal was to describe and demonstrate the feasibility of an early follow-up visit carried out by a multidisciplinary HF team in the transition care of HF patients, after hospital discharge, and to evaluate its association with early HF readmission and all-cause mortality. Methods This was a retrospective cohort study of acute heart failure (AHF) patients consecutively admitted to an AHF Unit during one year. Exclusion criteria were in-hospital death and transfer to another hospital. We compared patients who were evaluated in a follow-up visit carried out 7 to 14 days after hospital discharge where treatment adjustments could be made, with those who were not. Primary outcomes: AHF readmissions and all-cause mortality at 3 months after discharge were analysed. Cox proportional hazards regression was used. Results Of 181 admissions for AHF, 153 were analysed. Patients were 77±11 years-old; 54% were male and 46% had reduced left ventricular ejection fraction. At hospital discharge median NT-proBNP was 3258 (1429–5995) pg/mL. One-hundred and forty-four (94%) patients were referred to a follow-up visit by the same multidisciplinary HF team with a compliance rate of 81% (n=116). The mortality rate after 3 months was 6.5% (n=10) and the AHF readmission rate was 14.3% (n=22). An early follow-up visit was independently associated with a lower risk of AHF readmission at 3 months after discharge (crude HR 0.35, 95% Confidence Interval (CI): 0.15–0.82, p=0.015; adjusted HR for age and implantable cardiac defibrillator: 0.31, 95% CI: 0.12–0.79, p=0.014) (Figure 1A). and a lower combined risk of all-cause mortality or AHF readmission at 3 months (crude HR 0.37, 95% CI: 0.18–0.78, p=0.009; adjusted HR for age, implantable cardiac defibrillator, pacemaker presence and NYHA &amp;gt;2: 0.29, 95% CI: 0.13–0.67, p=0.004) (Figure 1B). Conclusion Conducting an early specialized follow-up visit after AHF hospitalization is highly feasible and associated with an excelent patient compliance. A multidisciplinary HF team visit in the vulnerable phase after AHF hospitalization was associated with a significantly lower risk of HF readmission and all-cause death at 3 months, mostly due to preventable readmissions. Funding Acknowledgement Type of funding source: None

Sleep apnea in heart failure: in search of a better prognosis predictor

Abstract Background Sleep apnea (SA) is a burdensome and often underdiagnosed condition in heart failure (HF). Portable devices, such as ApneaLinkTM, are currently validated as a screening tool for SA. The apnea-hypopnea index (AHI) as been long considered the gold-standard measurement for the diagnosis of SA, also having a prognosis impact. Recently, however, other respiratory variables have been proposed as better prognosis predictors in patients with HF. The main goal of this study was to assess the prognostic value of other respiratory measurements evaluated by ApneaLinkTM at discharge in a population admitted for HF. Methods This was a single-center retrospective study enrolling consecutive patients admitted in a HF Clinic for acute HF from 2013 and 2018. All stable patients without previously known sleep-disordered breathing underwent ApneaLinkTM screening the night before discharge in the euvolemic state. Those with a total respiratory evaluation time &amp;lt;180 minutes or in need of supplemental oxygen were excluded. A primary endpoint of long-term HF hospitalizations was evaluated. Results Overall, 231 patients (mean age 74.5±10.6 years; 47% male; 83% hypertension; 41% chronic kidney disease; 44% anemia; 18% with a NYHA&amp;gt;2 at discharge; 43% ischaemic HF; 41% with a left ventricle ejection fraction lower than 50%) were assessed. One-hundred and sixty-nine patients (59.1%) had an AIH &amp;gt;15, with a median of 19 (IQR 7–42); the median number of obstructive apneas and central apneas was 13 (IQR 2–68), and 2 (IQR 0–10), respectively. Two-hundred patients (69.9%) had nocturnal periods of an oxygen saturation below 85% (T85), with a median time under that value of 8 (IQR 0–47) minutes. Over a median follow-up of 34.1 (IQR 18.40–54.37) months, 105 (45.7%) patients died and 128 (55.7%) were readmitted for AHF. After adjustment for cofounders (namely, the presence of anemia) a T85 above the 75th percentile was significantly correlated with a higher risk of HF readmission in a multivariate analysis (adjusted HR: 1.58, 95% CI: 1.08–2.30, p=0.017) (figure 1). These results were independent of the apnea-hypopnea index. Conclusion Nocturnal hypoxemia (T85) was an independent predictor of rehospitalization in patients with HF. These results further validate the utility and prognosis impact of other respiratory measurements (other than AHI) evaluated by ApneaLinkTM screening at discharge in a population of patients admitted for HF. Figure 1 Funding Acknowledgement Type of funding source: None

Effect of insulin on readmission for heart failure following a hospitalization for acute heart failure.

AimsType 2 diabetes mellitus (T2DM) is common in patients with heart failure (HF) and is related with worse outcomes. Insulin treatment is associated with sodium and water retention, weight gain, and hypoglycaemia—all pathophysiological mechanisms related to HF decompensation. This study aimed to evaluate the association between insulin treatment and the risk of 1 year readmission for HF in patients discharged for acute HF.Methods and resultsWe prospectively included 2895 consecutive patients discharged after an episode of acute HF in a single tertiary hospital. Multivariable Cox regression, adapted for competing events, was used to assess the association between insulin treatment and 1 year readmission for HF in patients discharged after acute HF. Participants' mean age was 73.4 ± 11.2 years, 50.8% were women, 44.7% had T2DM [including 527 (18.2%) on insulin therapy], and 52.7% had preserved ejection fraction. At 1 year follow‐up, 518 (17.9%) patients had died and 693 (23.9%) were readmitted for HF. The crude risk of readmission for HF was higher in patients on insulin, with no differences in 1 year mortality. After multivariable adjustment, patients on insulin were at significantly higher risk of 1 year readmission for HF than patients with diabetes who were not on insulin (hazard ratio 1.28; 95% confidence interval 1.04–1.59, P = 0.022) and patients without diabetes (hazard ratio 1.26; 95% confidence interval 1.02–1.55, P = 0.035).ConclusionFollowing acute HF, patients with T2DM on insulin therapy are at increased risk of readmission for HF. Further studies unravelling the mechanisms behind this association are warranted.

Evidence-based beta blocker use associated with lower heart failure readmission and mortality, but not all-cause readmission, among Medicare beneficiaries hospitalized for heart failure with reduced ejection fraction.

The beta blockers carvedilol, bisoprolol, and sustained-release metoprolol succinate reduce readmissions and mortality among patients with heart failure with reduced ejection fraction (HFrEF), based upon clinical trial and registry studies. Results from these studies may not generalize to the typical patient with HFrEF. We conducted a retrospective cohort study of beneficiaries in the Medicare 5% sample hospitalized for HFrEF between 2007 and 2013 and were discharged alive. We compared the 30-day and 365-day heart failure (HF) readmission, all-cause readmission, and mortality rates between beneficiaries who filled a prescription for an evidence-based beta blocker and those who did not after being hospitalized for HFrEF. Out of 12,127 beneficiaries hospitalized for HFrEF, 20% were readmitted for HF, 62% were readmitted for any cause, and 27% died within 365 days. In competing risk models adjusted for demographics, healthcare utilization, and comorbidities, beta blocker use was associated with a lower risk of HF readmission between 8-365 days post discharge (hazard ratio 0.79 [95% confidence interval 0.76, 0.82]), but was not significantly associated with all-cause readmission (1.02 [0.97-1.07]). In Cox models adjusted for the same covariates, beta blocker use was associated with lower mortality 8-365 days post discharge (0.65 [0.60-0.71]). Results were similar when follow up was truncated at 30 days post discharge. Increasing the use of beta blockers following HFrEF hospitalization may not decrease all-cause readmissions among Medicare beneficiaries, but may reduce HF-specific readmissions and mortality.

Insuficiencia cardiaca de novo tras un síndrome coronario agudo en pacientes sin insuficiencia cardiaca ni disfunción ventricular izquierda

Introduction and objectivesCoronary heart disease is the leading cause of heart failure (HF). The aim of this study was to assess the risk of readmission for HF in patients with acute coronary syndrome without previous HF or left ventricular dysfunction. MethodsProspective study of consecutive patients admitted for acute coronary syndrome in 2 institutions. Risk factors for HF were analyzed by competing risk regression, taking all-cause mortality as a competing event. ResultsWe included 5962 patients and 567 (9.5%) experienced at least 1 hospital readmission for acute HF. Median follow-up was 63 months and median time to HF readmission was 27.1 months. The cumulative incidence of HF was higher than mortality in the first 7 years after hospital discharge. A higher risk of HF readmission was associated with age, diabetes, previous coronary heart disease, GRACE score> 140, peripheral arterial disease, renal dysfunction, hypertension and atrial fibrillation; a lower risk was associated with optimal medical treatment. The incidence of HF in the first year of follow-up was 2.73% and no protective variables were found. A simple HF risk score predicted HF readmissions risk. ConclusionsOne out of 10 patients discharged after an acute coronary syndrome without previous HF or left ventricular dysfunction had new-onset HF and the risk was higher than the risk of mortality. A simple clinical score can estimate individual risk of HF readmission even in patients without previous HF or left ventricular dysfunction.

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.

New-onset heart failure after acute coronary syndrome in patients without heart failure or left ventricular dysfunction

Introduction and objectivesCoronary heart disease is the leading cause of heart failure (HF). The aim of this study was to assess the risk of readmission for HF in patients with acute coronary syndrome without previous HF or left ventricular dysfunction. MethodsProspective study of consecutive patients admitted for acute coronary syndrome in 2 institutions. Risk factors for HF were analyzed by competing risk regression, taking all-cause mortality as a competing event. ResultsWe included 5962 patients and 567 (9.5%) experienced at least 1 hospital readmission for acute HF. Median follow-up was 63 months and median time to HF readmission was 27.1 months. The cumulative incidence of HF was higher than mortality in the first 7 years after hospital discharge. A higher risk of HF readmission was associated with age, diabetes, previous coronary heart disease, GRACE score> 140, peripheral arterial disease, renal dysfunction, hypertension and atrial fibrillation; a lower risk was associated with optimal medical treatment. The incidence of HF in the first year of follow-up was 2.73% and no protective variables were found. A simple HF risk score predicted HF readmissions risk. ConclusionsOne out of 10 patients discharged after an acute coronary syndrome without previous HF or left ventricular dysfunction had new-onset HF and the risk was higher than the risk of mortality. A simple clinical score can estimate individual risk of HF readmission even in patients without previous HF or left ventricular dysfunction.