Strategies For Management Of Heart Failure Research Articles

The response of total isovolumic time (t-IVT) to transcatheter aortic valve implantation (TAVI)

Abstract Background Total isovolumic time (t-IVT), the period of neither filling nor ejection, reflects global cavity dyssynchrony. It is free of geometric assumptions and has been demonstrated to serve as a reliable predictor of early response to various heart failure management strategies, medical and interventional. Purpose The aim of this prospective study is to assess the response of t-IVT to transcatheter aortic valve implantation (TAVI) as well as its relation to other echocardiographic parameters of myocardial function. Methods This is a single-center prospective study, which included patients with symptomatic, severe aortic stenosis (AS) who underwent TAVI. Echocardiographic myocardial function parameters included LV ejection fraction (EF), Tei-index and t-IVT and were assessed at three occasions; at baseline; within one month of TAVI and 3 months after procedure. Results The studied population consisted of 35 consecutive (81.6 ± 5.4 years, 19 males) patients. No deaths or major cardiovascular events were reported during the study period of 3 months after the TAVI. Seven (7) patients had LV EF ≤45%. After TAVI LV EF increased (from 51.7 ± 6.6 to 53.7 ± 5.6%; p=0.008), while Tei-index remained normal (from 0.33 ± 0.09 to 0.39 ± 0.06, p=0.02). Likewise, t-IVT shortened (from 9.1 ± 4.7 to 6.8 ± 4.8 s/min, p=0.005). Neither E/A (0.93 ±0.43 vs.0.94± 0.47, p=0.9) nor E/E’ (18±10.6 vs. 17.2± 8.7, p= 0.6) demonstrated any significant change. Finally, the BNP levels were reduced after TAVI (from 408.9 ± 497.9 to 289.5 ±276.9, p=0.03). An increase in LV EF>10% was observed in 17 patients in whom there was a significantly profound fall in t-IVT compared to the rest (36.3 ±16.2 vs. 24±12.2, p=0.001). Conclusion In patients with severe AS, t-IVT is prolonged particularly in those with worse LV EF. The significant recovery of both markers reflect better procedure related systolic and synchronous function recovery.

Right ventricular remodeling in complex congenital heart disease.

In congenital heart diseases (CHD) of moderate to great complexity involving the right ventricle (RV), the morphologic RV can be exposed to significant stressors across the lifespan either in a biventricular circulation in a sub-pulmonary or sub-aortic position, or as part of a univentricular circulation. These include pressure and/or volume overload, hypoxia, ischemia, and periprocedural surgical stress leading to remodeling, maladaptation, dilation hypertrophy and dysfunction. This review examines the macroscopic remodeling of the RV in various forms of CHD and explores remodeling trajectories, along with the effects of surgeries and residual lesion repair, in tetralogy of Fallot, Ebstein anomaly, congenitally corrected transposition of the great arteries, transposition of the great arteries with atrial switch surgery, and single ventricle palliated by Fontan. Additionally, the role of metabolism, genetic markers and imaging criteria of RV remodeling are explored. Finally, the optimal timing for addressing residual lesions in CHD through surgery or percutaneous interventions is discussed, along with advanced heart failure management strategies and medical therapy aimed at preventing further RV dilation and/or systolic deterioration or promoting reverse remodeling.

Contemporary pharmacological treatment and management of heart failure.

The prevention and treatment strategies for heart failure (HF) have evolved in the past two decades. The stages of HF have been redefined, with recognition of the pre-HF state, which encompasses asymptomatic patients who have developed either structural or functional cardiac abnormalities or have elevated plasma levels of natriuretic peptides or cardiac troponin. The first-line treatment of patients with HF with reduced ejection fraction includes foundational therapies with angiotensin receptor-neprilysin inhibitors, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, mineralocorticoid receptor antagonists, sodium-glucose cotransporter 2 (SGLT2) inhibitors and diuretics. The first-line treatment of patients with HF with mildly reduced ejection fraction or with HF with preserved ejection fraction includes SGLT2 inhibitors and diuretics. The timely initiation of these disease-modifying therapies and the optimization of treatment are crucial in all patients with HF. Reassessment after initiation of these therapies is recommended to evaluate patient symptoms, health status and left ventricular function, and timely referral to a HF specialist is necessary if a patient has persistent advanced HF symptoms or worsening HF. Lifestyle modification and treatment of comorbidities such as diabetes mellitus, ischaemic heart disease and atrial fibrillation are crucial through each stage of HF. This Review provides an overview of the management strategies for HF according to disease stages that are derived from the recommendations in the latest US and European HF guidelines.

Hypochloremia in heart failure: A new prognostic and therapeutic aspect of refractory heart failure

Heart failure (HF) is one of the most common cardiovascular diseases, bearing a significant burden of morbidity, mortality, and disability. Low serum chloride (Cl) levels have been observed to play an important role in predicting mortality and planning management strategies for HF. This review aims to investigate the influence of hypochloremia on individuals suffering from HF and its correlation with various underlying pathophysiological mechanisms. We conducted a literature review of articles published in the past 10 years, employing specific keywords to identify relevant studies from databases such as PubMed, Google Scholar, EBSCO, and Biomed Central. There is a significant paucity of studies relevant to low serum Cl levels in patients with HF. We found that hypochloremia is commonly observed in HF cases, an often overlooked aspect in clinical setting, and is associated with poor outcomes. Substantial evidence supports the notion that hypochloremia can worsen HF, reduce the response to guideline-mediated therapies, and increase mortality. Hypochloremia activates numerous neurohormonal mechanisms, further worsening the cardiorenal circuit in HF. Furthermore, low Cl levels are associated with the development of diuretic resistance, making HF difficult to manage, particularly with loop diuretics. Studies reveal associations between hypochloremia and various kinases, with a particular emphasis on with-no-lysine kinases. These kinases, involved in regulating salt and water reabsorption, exacerbate the condition when Cl levels are low. Notably, a low serum Cl level is associated with high mortality in HF and worsens the condition. HF with hypochloremia poses challenges in treatment and should, therefore, be considered in management.

Impact of Ayurveda-based lifestyle modification, diet, and panchakarma on the hemodynamic parameters in heart failure patients with preserved ejection fraction

Abstract Background: Heart failure (HF) with preserved ejection fraction (HFpEF) is a medical problem with a growing prevalence that requires sophisticated management techniques. New management strategies for HF have constantly been called for by researchers, which has drawn our attention to Ayurveda, the traditional alternative medicine practiced extensively in India. One such treatment used to treat heart failure is Heart Failure Reversal Therapy (HFRT), which combines herbal therapies including Snehan, Swedan, Basti (per rectal drug administration), and Hridaydhara. Objective: The study is aimed to evaluate the effects of HFRT and Ayurveda Dinacharya on known chronic HFpEF patients. Materials and Methods: This observational study was conducted between May 2021 and October 2021, wherein patients (both genders) with HF (New York Heart Association, NYHA Class I, II, and III) having a left ventricular ejection fraction of more than 40 and aged between 18 and 60 years were identified. The effect of study therapy, HFRT, and Ayurveda Dinacharya over 7 days in 14 sittings was observed. A total of 73 patients with HFpEF underwent study therapy for 7 days. Data related to patient demographics on Cardiac Output (CO), Diastolic Blood Pressure (DBP), Heart Rate (HR), Left Ventricular (LV), Systolic Blood Pressure (SBP), Systemic Vascular Resistance (SVR), Systolic (SYS), End-diastolic volume (EDV), Ejection factor (EF), etc. were analyzed pre- and post-study. Results: There was a remarkable improvement in the mean values of SVR from day 1 to day 7. The mean value of SVR on day 1 was 2271.39 ± 509.66, and on day 7 was 1876.18 ± 315.21. Reduced SVR values mean the amount of LV force needed to open the aortic valve is also reduced. This causes more efficient pumping action in the left ventricle, reflected by increased CO and increased VO2 max, thus improving the quality of life. Conclusion: The HFRT therapy and Ayurveda Dinacharya for seven days demonstrated a significant change in the hemodynamics of HFpEF patients, thus improving the quality of life.

Assessment of Heart Failure Post-discharge Management Strategies, Needs and Acceptance of Mobile Application-based Remote Patient Management in South India.

The demand for digital platforms in managing heart failure (HF) is expected to increase with promising effects on readmission and health expenditure. The study aims to explore current post-discharge management strategies and identify the need and acceptance of digital platforms, to ensure the development of a user-friendly mobile application for HF patients. Using a cross-sectional analytical research design, 90 consecutive patients diagnosed with HF who were discharged from a Tertiary Care Center were enrolled. Tele-interview was conducted using a self-developed and validated tool. The mean age of participants was 55.54 ± 10.33 years. The participants' adherence to HF management strategies was low in terms of physical exercise and weight monitoring. More than one-third were willing to self-record their measurements and use a mobile application. The common mobile application features requested were medication information/reminder (88.6%), health education (84.3%), chat with nurses (84.3%), physical activity (81.4%), symptoms (78.6%), diet (78.6%) and weight management (72.9%). The findings from this initial phase of mobile development are expected to help leverage better development of digital interventions for HF patients.

Regional Differences in the Epidemiology of Heart Failure.

Heart failure (HF) epidemiology, patient characteristics, and clinical outcomes exhibit substantial regional variations, reflecting diverse etiologies and health system capacities. This review comprehensively analyses these variations, drawing on data from recent global registries and clinical trials. Our review indicates that ischemic and hypertensive heart diseases are prevalent globally but differ in dominance depending on the region. Notably, regions such as Africa and Latin America show higher instances of HF from hypertensive heart disease and Chagas cardiomyopathy, respectively. Moreover, disparities in age and comorbidity profiles across regions highlight younger populations with HF in lower-income countries compared to older populations in high-income regions. This review also highlights the global disparity in guideline-directed medical and device therapy, underscoring significant underuse in lower-income regions. These insights emphasize the need for targeted HF management strategies considering regional clinical and demographic characteristics to enhance global HF care and outcomes.

Remote Patient Management Facilitates Guideline Directed Medical Therapy Improving Outcomes.

<h3>Introduction</h3> Prior Remote Patient Management (RPM) studies in Heart Failure (HF) yielded mixed results. These trials did not achieve sufficient patient and/or clinician compliance, used different monitoring tools, and failed to integrate RPM into daily workflow. GDMT is the most evidenced based strategy for HF management. However, episodic office visits (OV) do not adequately achieve optimization of therapy. Real-time, data-based, therapeutic adjustments using RPM drives better outcomes through improved HF management. A patient-centric RPM approach improves compliance, decreases OV, and reduces hospitalizations. Ultimately, this should lead to less morbidity and increased longevity. Establishing workflows that incorporate GDMT enabled by RPM is essential for providers to achieve next generation HF care. <h3>Hypothesis</h3> RPM will reduce HF hospitalizations and Emergency Department (ED)/Hospital Outpatient IV diuretic visits. <h3>Methods</h3> We retrospectively studied the 2-year experience of 40 subjects with New York Heart Association Class II or Class III HF regardless of EF. All patients utilized the Cordella Heart Failure System to transmit daily weight, blood pressure, heart rate, and pulse-ox data, as well as symptoms via wireless tablet. The cardiologist and nursing staff established workflow patterns to facilitate daily monitoring. GDMT optimization recommendations and lifestyle adjustments were communicated to patients via telephone and tablet-based messaging. <h3>Results</h3> Patient compliance (data sent 5 of 7 days) was >90% (after patient training) and increased to 95% 2 years later. Clinician compliance (checking data at least twice weekly) was 100%. HF hospitalizations and ED/Hospital Outpatient IV diuretic visits were reduced as shown in Table 2. Volume of phone calls leading to medication changes increased 6-fold with RPM while OV decreased by 14.5%. HF hospitalizations decreased by nearly 85%. <h3>Conclusion</h3> New workflow patterns allowed this practice to use RPM to facilitate real-time GDMT optimization and lifestyle changes that achieved reduced HF Hospitalizations, OV, and HF ED/Hospital Outpatient IV diuretic visits with excellent patient compliance.

Pediatric Mechanical Circulatory Support: Pathophysiology of Pediatric Hemostasis and Available Options.

Pediatric mechanical circulatory support (MCS) is considered a strategy for heart failure management as a bridge to recovery and transplantation or as a destination therapy. The final outcome is significantly impacted by the number of complications that may occur during MCS. Children on ventricular assist devices (VADs) and extracorporeal membrane oxygenation (ECMO) are at high risk for bleeding and thrombotic complications that are managed through anticoagulation. The first detailed guideline in pediatric VADs (Edmonton Anticoagulation and Platelet Inhibition Protocol) was based on conventional antithrombotic drugs, such as unfractionated heparin (UFH) and warfarin. UFH is the first-line anticoagulant in pediatric MCS, although its profile is not considered optimal in pediatric setting. The broad variation in heparin doses among children is associated with frequent occurrence of cerebrovascular accidents, bleeding, and thrombocytopenia. Direct thrombin inhibitors (DTIs) have been utilized as alternative strategies to heparin. Since 2018, bivalirudin has become the chosen anticoagulant in the long-term therapy of patients undergoing MCS implantation, according to the most recent protocols shared in North America. This article provides a review of the non-traditional anticoagulation strategies utilized in pediatric MCS, focusing on pharmacodynamics, indications, doses, and monitoring aspects of bivalirudin. Moreover, it exposes the efforts and the collaborations among different specialized centers, which are committed to an ongoing learning in order to minimize major complications in this special pediatric population. Further prospective trials regarding DTIs in a pediatric MCS setting are necessary and in specific well-designed randomized control trials between UFH and bivalirudin. To conclude, based on the reported literature, the clinical use of the bivalirudin in pediatric MCS seems to be a value added in controlling and maybe reducing thromboembolic complications. Further research is necessary to confirm all the results provided by this literature review.

Sex and Heart Failure Treatment Prescription and Adherence

Heart disease is the leading cause of death in both men and women in developed countries. Heart failure (HF) contributes to significant morbidity and mortality and continues to remain on the rise. While advances in pharmacological therapies have improved its prognosis, there remain a number of unanswered questions regarding the impact of these therapies in women. Current HF guidelines recommend up-titration of neurohormonal blockade, to the same target doses in both men and women but several factors may impair achieving this goal in women: more adverse drug reactions, reduced adherence and even lack of evidence on the optimal drug dose. Systematic under-representation of women in cardiovascular drug trials hinders the identification of sex differences in the efficacy and safety of cardiovascular medications. Women are also under-represented in device therapy trials and are 30% less likely to receive a device in clinical practice. Despite presenting with fewer ventricular arrythmias and having an increased risk of implant complications, women show better response to resynchronization therapy, with lower mortality and HF hospitalizations. Fewer women receive advanced HF therapies. They have a better post-heart transplant survival compared to men, but an increased immunological risk needs to be acknowledged. Technological advances in mechanical circulatory support, with smaller and more hemocompatible devices, will likely increase their implantation in women. This review outlines current evidence regarding sex-related differences in prescription, adherence, adverse events, and prognostic impact of the main management strategies for HF.

Recent Advances in β2-Agonists for Treatment of Chronic Respiratory Diseases and Heart Failure.

β2-Adrenoceptor (β2-AR) agonists are widely used as bronchodilators. The emerge of ultralong acting β2-agonists is an important breakthrough in pulmonary medicine. In this review, we will provide mechanistic insights into the application of β2-agonists in asthma, chronic obstructive pulmonary disease (COPD), and heart failure (HF). Recent studies in β-AR signal transduction have revealed opposing functions of the β1-AR and the β2-AR on cardiomyocyte survival. Thus, β2-agonists and β-blockers in combination may represent a novel strategy for HF management. Allosteric modulation and biased agonism at the β2-AR also provide a theoretical basis for developing drugs with novel mechanisms of action and pharmacological profiles. Overlap of COPD and HF presents a substantial clinical challenge but also a unique opportunity for evaluation of the cardiovascular safety of β2-agonists. Further basic and clinical research along these lines can help us develop better drugs and innovative strategies for the management of these difficult-to-treat diseases.

The RightSTEPS initiative: Continuing education impact on clinicians’ optimal medical therapy practices for chronic heart failure

Purpose Despite the existence of expert recommendations that can improve morbidity and mortality, reduce the need for hospitalization or readmission, and enhance quality of life in patients with heart failure (HF), many patients do not receive optimal medical therapy (OMT). The goal of this initiative, titled RightSTEPS, was to help physicians take the right steps to apply-evidence-based HF management strategies in clinical practice. Methods Using the PRECEDE-PROCEED Model aimed at improving the clinical behavior of the learner, the instructional design featured 23 online and live face-to-face activities offering up to 16 credit hours of CME/CNE credit. These activities were delivered sequentially in three phases: predisposing, enabling and reinforcing. The lessons provided concise, pragmatic, stepwise management strategies aimed at empowering clinicians to prescribe evidence-based, guideline-directed OMT for patients with HF. Results The predisposing and reinforcing online activities within the initiative reached a total of 71,510 learners with 23,902 successfully completed activities and post-tests; the enabling face-to-face activities reached a total audience of 763 clinicians. This initiative resulted in a statistically significant (p < 0.0001) increase in knowledge and competence related to HF OMT among the clinician learners. Furthermore, follow-up surveys indicated a commitment from learners to implement these guideline-directed strategies in their clinical practice. Conclusions This initiative demonstrated that the design of the RightSTEPS curriculum, using the Precede-Proceed model with sequentially-delivered, blended learning, provides a methodological framework to help learners translate knowledge into improvements in clinical behavior with the potential to improve patient health outcomes.

Reducing Readmissions for Heart Failure.

Reducing Readmissions for Heart Failure.

Current Role of the CardioMEMS Device for Management of Patients with Heart Failure.

Heart failure (HF) remains a significant burden to our healthcare system and a leading cause of hospitalizations. Current reactive strategies to treat and manage HF have failed to reduce hospitalizations and improve survival. The CardioMEMS device has recently been demonstrated to improve quality of life in HF and reduce HF-related hospitalizations. Current HF management strategies are reviewed with a particular emphasis on the current role of the CardioMEMS device. The CHAMPION trial is the only randomized trial looking at the CardioMEMS device. Patients managed with targeted pulmonary artery pressures resulted in 28% reduction in the primary end-point of HF-related hospitalization at 6months (HR 0.72, 95% CI 0.60-0.85, p = 0.0002) and 37% reduction during the entire follow-up period, which averaged 15months (HR 0.63, 95% CI 0.52-0.77, p < 0.0001). The prospective open-label post-approval study recently presented a 58% reduction in HF hospitalizations per patient year (HR 0.42, 95% CI 0.38-0.47, p < 0.0001). Management of HF using the CardioMEMS device has been shown to reduce HF hospitalizations and improve quality of life regardless of ejection fraction. Patients best suited for this device are those with recurrent congestive symptoms despite optimal medical therapy.

Pharmacotherapy in paediatric heart failure: a Delphi process.

Little evidence exists to support pharmacotherapeutic strategies for heart failure management in paediatrics. A recent Europe-wide survey suggests that this translates into substantial variability in clinical practice. To conduct a formal discussion among an expert group of paediatric cardiology physicians on controversial aspects regarding the pharmacotherapy of children heart failure, facilitate consensus, and highlight areas of agreement and disagreement. A two-round modified Delphi process was conducted between July and August 2015. Topics addressed were predominantly selected from the results of a previous Europe-wide survey. Fourteen statements were presented for discussion grouped under three categories; Angiotensin-converting-enzyme-inhibitors: Considerations for optimal dosage; Angiotensin-converting-enzyme-inhibitors for the management of CHDs; Neurohumoral antagonists for the management of dilated cardiomyopathy-related heart failure. A total of 13 paediatricians dedicated to cardiology from across Europe and the United States of America completed the study; of them, 92% had a working experience in the field of more than 10 years and were working in a specific paediatric cardiology unit. Agreement on the acceptance/rejection of 11 statements was achieved. Results show agreement on the importance of a set of topics relevant to the standardisation of the therapy as well as consensus upon specific therapeutic attitudes. We have found areas of common thinking and motivation, which can provide a means of triggering scientific collaboration. Our results might also contribute to disseminate available paediatric evidence and promote reducing unjustified variability in everyday practice. Until solid evidence is available, other research methods can contribute to advancing the goal of safe and effective paediatric heart failure pharmacotherapy.

Ambulatory Hemodynamic Monitoring Strategy for Heart Failure Management Reduces Utilization of Emergency Room Services

Background: Ambulatory hemodynamic monitoring through the St. Jude Medical CardioMEMS™ HF System allows for assessment of pulmonary artery (PA) pressures and heart rate. Although several remote monitoring strategies have been explored, the CHAMPION Trial highlights the significant effectiveness of using longitudinal PA pressure guided heart failure (HF) management. This is the first and only FDA-approved monitoring strategy shown to significantly reduce HF hospital admissions and improve quality of life in NYHA class III patients. Objective: To examine whether management strategy using ambulatory hemodynamic monitoring through the CardioMEMS HF system reduced Emergency Department (ED) visits. Methods: A retrospective chart review of patients implanted with CardioMEMS HF system from March 30, 2015 to March 6, 2017 was performed. We examined ED visit event rates over the 1 year prior to implant compared with ED visits post implant. An ED visit was defined as a patient arriving at an ED within the health system and being discharged from the ED or arriving at the ED and being admitted as an observation stay for monitoring. Patients who were admitted as inpatients were not included. Patients were followed post implant until death, heart transplant, or VAD implant. Poisson regression was used to compare pre-implant event rates to post-implant event rates. Results: From 3/30/15 to 3/6/17, 52 patients were implanted. Average age at time of implant was 65 ± 14 y, 30 (58%) of the patients were male and 35 (67%) of the patients had an LVEF < 40% (Table 1). ED visits were significantly reduced in these 52 patients (Fig. 1). In the 1 year prior to implant, 80 ED visits occurred resulting in an average of 0.76 events per patient per 180 days compared with 34 ED visits in the post-implant phase resulting in an average of 0.52 events per patient per 180 days, P = .04 (Fig. 1.) Discussion: Utilization of remote hemodynamic monitoring via the CardioMEMS HF system in monitoring PA pressures is statistically significant in reducing ED visits in our health system.Table 1Baseline Demographics (Pre-Implant)IndicatorFreq (%); Mean+/−STDTotal implants52Age at implant64.6+/−14.2 (28–86)Male30 (57.7%)Race: Caucasian42 (80.8%)Height (cm)171.7+/−9.5 (152–190.5)Weight (kg)96.6+/−18.8 (57–134)BMI32.7+/−6 (20.9–45.4)LVEF32.1+/−17.6 (0.2–65)LVEF 40% or greater17 (32.7%)Laboratory and hemodynamic analysis Systolic blood pressure Diastolic blood pressure Heart rate (beats/min) Pulmonary Artery Pressure (mean) Serum creatinine (mg/dL) (median [Q1-Q3]) CRT/CRT-D ICD implant117.3+/−12.9 (91–142) 68.7+/−9.1 (52–84) 75.6+/−13.3 (50–103) 27.4+/−7.9 (13–43) 1.32 [1.02–1.62] 20 (38.5%) 19 (36.5%)Comorbidities Ischemic cardiomyopathy Hypertension Coronary artery disease Diabetes mellitus Atrial tachycardia flutter or fibrillation COPD Chronic kidney disease22 (42.3%) 34 (65.4%) 30 (57.7%) 24 (46.2%) 24 (46.2%) 15 (28.8%) 24 (46.2%)Drugs Angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers Beta-blocker Aldosterone antagonist Loop diuretic Hydralazine Nitrate37 (71.2%) 45 (86.5) 31 (59.6%) 52 (100%) 4 (7.7%) 12 (23.1%) Open table in a new tab

Capacity for diagnosis and treatment of heart failure in sub-Saharan Africa

ObjectiveHeart failure is a major cause of disease burden in sub-Saharan Africa (SSA). There is an urgent need for better strategies for heart failure management in this region. However, there...

CAPACITY FOR HEART FAILURE DIAGNOSIS AND TREATMENT IN SUB-SAHARAN AFRICA: ANALYSIS OF THE ACCESS, BOTTLENECKS, COSTS, AND EQUITY STUDY IN KENYA AND UGANDA

Background: Heart failure is a major cause of disease burden in Sub-Saharan Africa (SSA). There is an urgent need for better strategies for heart failure management in this region. However, there is little information on the capacity to diagnose and treat heart failure in SSA. Objective: To provide

Abstract 118: Physician Specific Practice Patterns and 30-day Heart Failure Readmission Rates: Is One Way Better Than the Other?

Background: Heart failure (HF) admissions place a significant burden on hospital resource utilization. Management of inpatient HF remains heterogeneous, from daily diuresis to discharge strategies. We sought to evaluate if specific physician practices were associated with two important contributors to resource utilization, readmission and length of stay (LOS). Methods: Physician-specific discharges, LOS, and 30-day readmission rates from 7/1/2015-6/30/2016 were extracted from the EHR. Patients with “shock” as the primary diagnostic code were excluded. We created a survey to assess HF management strategies that was administered to all cardiologists and hospitalists at our institution; physicians were blinded to LOS and readmission data. Many factors potentially impacting LOS and discharge decisions were queried, including physical examination, medication use and kidney function. Results: We received 62 of 69 (90%) survey responses – 26 cardiologists and 36 hospitalists. Overall, 52% (32 of 62) were male with a median 7 years in practice [IQR 3-13]. We tracked HF utilization metrics in 58 physicians, encompassing 753 patient discharges in the preceding year. Total 30-day readmission rate was 17.0% (128 of 753). No significant differences were seen in discharge practices between readmission rate tertiles. Median of the median LOS was 4.7 days (IQR 4.0-5.8), and physicians above median LOS were compared to physicians below median LOS. Point estimates suggest physicians with lower median LOS targeted a daily net diuresis goal greater than 3L (40% vs 11% for those above median LOS, p = 0.1), and were less likely to hold beta blockers (17% vs 37%, p = 0.1) or to consider 24 hours of inpatient oral diuretics prior to discharge to be “very important” (16% vs 56%, p &lt; 0.01). The pooled readmission rate of physicians below median LOS was not significantly different than those above median LOS (14.5% vs 16.2%, p = 0.6). Conclusions: We identified three specific HF management patterns that may be associated with lower LOS without a concomitant increase in 30-day readmission: (1) more aggressive daily diuresis, (2) continuation of beta blockade, and (3) not delaying discharge to observe 24 hours of an oral diuretic regimen. Further studies are warranted to confirm and quantify the impact of these changes on resource utilization.

Cognitive decline in heart failure.

Cognitive impairment (CI) is common in older adults with heart failure (HF). The prevalence of CI is higher among patients with HF than in those without. The spectrum of CI in HF is similar to that observed in the general population and may range from delirium to isolated memory or non-memory-related deficits to dementia. Both HF with reduced ejection fraction and HF with preserved ejection fraction have been associated with defects in different domains of cognition. Numerous risk factors have been shown to contribute to CI in HF. Additionally, various pathophysiological mechanisms related to HF can contribute to cognitive decline. These conditions are not routinely screened for in clinical practice settings with HF populations, and guidelines on optimal assessment strategies are lacking. Validated tools and criteria should be used to differentiate acute cognitive decline (delirium) from chronic cognitive decline such as mild cognitive impairment and dementia. CI in HF has been associated with higher rates of disability and impairment in self-care activities that may in turn increase healthcare cost, hospital readmission and mortality. Early detection of CI may improve clinical outcomes in older adults with HF. Appropriate HF management strategies may also help to reduce CI in patients with HF, and future research is needed to develop and test newer and more effective interventions to improve outcomes in patients with HF and CI.