老年慢性心力衰竭患者的远程管理效果

目的探讨远程管理对老年慢性心力衰竭患者预后的影响。方法入选2014年6月至2018年12月解放军总医院第六医学中心老年医学科治疗的老年慢性心力衰竭患者256例,根据出院时间顺序分为远程管理组(125例)和常规管理组(131例)。采用SPSS 25.0软件对数据进行统计学分析。组间全因死亡分析采用Kaplan-Merier生存曲线。结果中位随访时间为25.0(17.0~38.8)个月,随访期间全因死亡51例(19.9%),其中呼吸道感染死亡28例。全因死亡率远程管理组12.8%(16/125),常规管理组26.7%(35/131)。与常规管理相比,远程监管能降低患者全因死亡率(HR=0.403,95%CI 0.210~0.773;P=0.006)。远程管理组心血管疾病死亡率[4.0%(5/125)]及呼吸道感染死亡率[7.2%(9/125)]均低于常规管理组[9.9%(13/131),14.5%(19/131)],但差异无统计学意义(P>0.05)。2组全因再住院次数比较,差异无统计学意义(P>0.05)。远程管理组全因再住院时间、心血管病再住院时间中位数(49.0,12.0d),均高于常规管理组(28.0,0.0d),差异有统计学意义(P<0.05)。结论远程管理能降低老年慢性心力衰竭患者全因死亡率,但增加全因再住院时间、心血管病再住院时间。     

以体重和脉率监测为中心的规范化管理对慢性心力衰竭病人预后的影响

目的:探讨以体重和脉率为中心的规范化管理对慢性心力衰竭病人生活质量及预后的影响。方法:选择2019年8月—2020年8月在我院住院的慢性心力衰竭病人100例,按1∶1比例随机分为管理组和对照组,每组50例。管理组采用规范化治疗方案,进行定期随访,观察期为12个月。结果:管理组出院后利尿剂、硝酸酯类、β受体阻滞剂类、血管紧张素转化酶抑制剂(ACEI)/血管紧张素受体拮抗剂(ARB)类药物使用率明显高于对照组(P<0.05)。管理组病死率和再住院率低于对照组(P<0.05)。管理组明尼苏达心力衰竭生活质量问卷(MLHFQ)分值和随访期费用明显低于对照组(P<0.05)。多因素Logistic回归分析显示,病人出院后未进行规范化管理是病死率及再住院率升高的独立危险因素。结论:慢性心力衰竭病人实施以体重和脉率监测为中心的规范化管理,对降低病人病死率、再住院率有重要意义。     

慢性心力衰竭患者NT-proBNP下降率对疗效及预后的评估价值

目的探讨血浆氨基末端脑利钠肽前体(NT-proBNP)下降率对慢性心力衰竭(CHF)患者疗效及预后的评估价值。方法连续入选2011年10月至2012年6月在包头市中心医院心内科住院心功能(NYHA分级)Ⅲ~Ⅳ级的CHF患者120例,根据血浆NT-proBNP下降率分为两组,其中A组64例(血浆NT-pro BNP下降率≥50%);B组56例(血浆NT-proBNP下降率50%)。比较两组患者的一般临床资料(包括年龄、性别、体重指数,合并症有无高血压病、糖尿病、高脂血症)、出院时疗效及在出院后6个月内再住院率及死亡率。结果两组患者在出院时疗效评估,A组患者治疗效果良好比例为87.5%,显著高于B组患者(71.4%),差异有统计学意义(P0.05)。两组患者出院后随访6个月时,A组患者再住院率为6.3%,显著低于B组患者再住院率(21.4%);A组患者死亡率为1.6%,显著低于B组患者死亡率(12.5%),差异均有统计学意义(P0.05)。结论 NT-proBNP的下降率对判断慢性心力衰竭患者的住院治疗效果及预后有帮助。     

微信小程序慢病随访模式在冠心病伴慢性心力衰竭出院病人中的应用效果

目的观察微信小程序慢病随访模式在冠心病伴慢性心力衰竭出院病人中的应用效果。方法选取冠心病合并慢性心力衰竭病人200例,经住院规范治疗病情缓解后出院,分为对照组(98例)与观察组(102例)。对照组行常规出院指导,出院后自行管理,定期门诊随访;观察组在对照组基础上实施微信小程序慢病随访模式,连续随访1年。比较两组的管理效果。结果随访1年后,观察组冠心病危险因素控制达标率、用药依从性、心脏结构、心功能及生活质量明显优于对照组(P均0.05);再住院率和死亡率明显低于对照组(P均0.05)。结论微信小程序慢病随访模式可改善冠心病伴慢性心力衰竭出院病人的心功能和生活质量,降低再入院率和死亡率。     

醛固酮拮抗剂治疗慢性心力衰竭的疗效分析

目的观察醛固酮拮抗剂在慢性心力衰竭治疗中的作用。方法选择符合慢性心力衰竭诊断标准的患者106例,随机分为治疗组(56例)和对照组(50例)。对照组应用慢性心衰的常规治疗;治疗组除应用常规治疗外每天服用螺内酯20～40mg,并且长期应用,定期测定血清钾和肝、肾功能,随访2年。结果治疗组56例因心衰恶化反复住院18例(占32%),死亡14例(占25%);对照组50例因心衰恶化反复住院26例(占52%),死亡21例(占42%)。经卡方检验两组对比,差异有统计学意义(P<0.05),治疗组再次住院率和死亡率明显低于对照组。结论慢性心力衰竭患者在常规治疗的基础上加用醛固酮拮抗剂,有助于改善心功能。     

慢性心力衰竭病人自我管理能力中西医结合方案干预的随机对照研究

目的探讨慢性心力衰竭病人自我管理能力中西医结合方案干预的临床疗效。方法将符合慢性心力衰竭临床诊断标准的60例病人随机分为强化组与普通组,每组30例。强化组2例、普通组4例因资料较少,设置为失访,未纳入分析。强化组病人给予发放《中西医结合心衰知识手册》和每日症状记录本,出院后进行规律健康教育、电话随访、家访、医患沙龙等。普通组仅按目前住院或门诊常规处理模式进行。结果强化组病人随访期间再住院率、再住院次数、干预前后中医四诊计分差值、明尼苏达生存质量评分及欧洲心力衰竭自我护理行为量表评分明显优于对照组。强化组出现再入院事件的概率为常规组的0.208倍[OR=0.208,95%CI(0.054,0.805),P=0.023],血清肌酐水平为有无再入院的独立影响因素[OR=0.985,95%CI(0.974,0.996),P=0.010]。结论针对慢性心力衰竭病人加强自我管理能力中西医结合方案干预的效果较显著,可降低再住院率和再住院次数,提高生活质量。血清肌酐水平为有无再入院的独立影响因素。     

老年慢性心力衰竭合理治疗对预后影响

目的　评估老年慢性心力衰竭经合理治疗对改善预后的影响。方法　对 83例慢性收缩期心力衰竭患者 ,进行随机分组研究 ,即合理治疗加生活指导组 (观察组 )和一般治疗组 (对照组 ) ,随访一年 ,分析统计因间接或直接原因引起心力衰竭的死亡率及因心力衰竭恶化再住院率和住院时间。结果　随访一年内直接死于心力衰竭者 ,观察组 6例 ( 6 / 4 2 ,14 3% ) ,对照组 15例 ( 15 / 4 1,36 6 % ) ,前者明显低于后者 (P <0 0 5 )。因心力衰竭再入院例数 ,观察组为 10例( 10 / 4 2 ,2 3 8% ) ,对照组 2 2例 ( 2 2 / 4 1,5 3 7% ) ,两组差异显著 (P <0 0 1)。再住院总人次 ,观察组为 14人次 ,对照组为 30人次 ,两组差异显著 (P <0 0 1)。再住院平均天数 ,观察组 13天 ,对照组 2 9天 ,两组差异显著 (P <0 0 1)。结论　老年慢性心力衰竭患者在合理治疗 ,去除心力衰竭恶化的因素 ,积极抗心力衰竭治疗 ,可明显改善患者预后。     

慢性心力衰竭患者院外督导治疗的临床观察

目的探讨规范化督导治疗对慢性心力衰竭的影响。方法将慢性心力衰竭患者116例随机分成督导治疗观察组(58例)和对照组(58例)。所有心力衰竭患者均按常规治疗。观察组通过医生每周电话随访对每一个患者进行督导治疗,包括健康教育、药物调整、改良生活方式等。而对照组3月电话随访1次。观察1年后所有患者遵医嘱服药情况、不良生活方式改变情况、年住院次数、年住院总日数、年医疗费用、出院时及观察终点时6 min步行试验、生活质量评分对比。结果观察组与对照组相比,在遵医行为、生活方式改良、年住院次数、年住院总日数及年医疗费用、心功能改善、生活质量评分等方面均较后者有明显改善,二者比较有统计学意义(P0.05)。结论通过心内科医生对慢性心力衰竭患者长期、规范的督导治疗,能提高患者对治疗的依从性,可有效改善患者生活质量,减少年住院总日数,降低再住院率及医疗费用。     

电话询诊在慢性心力衰竭社区管理中的应用

目的观察电话询诊在慢性心力衰竭社区管理中的作用。方法对120例慢性心力衰竭患者进行研究。对照组:常规药物治疗基础上,体重监测;干预组:在对照组基础性上提供电话询诊。随机入组,比较两组的住院率、住院天数、社区随访率、LVDd、LVEF、BNP,随访1年。结果干预组在心脏彩超指标(LVDd、LVEF)改善方面与对照组相当,在BNP控制方面优于对照组(P0.05)。干预组在住院率、住院天数均较对照组下降(P0.05),且社区随访率明显提高(P0.01)。结论电话询诊在慢性心力衰竭管理中有利,值得推广。     

阿托伐他汀在COPD治疗中的作用

目的探讨阿托伐他汀在COPD治疗中的作用。方法将60例COPD患者分为治疗组和对照组,每组30例。两组患者均给予COPD常规治疗,治疗组加用阿托伐他汀10 mg/d,1次/d,疗程为1年。观察两组患者疗效、不良反应等。结果治疗组总有效率明显高于对照组(96.7%比80.0%,P0.05),住院时间明显短于对照组[(13.6±5.4)d比(17.8±4.9)d,P0.05],随访期间再住院率低于对照组(10.0%比20.0%,P0.05),但两组病死率比较差异无统计学意义(P0.05)。治疗组未出现严重不良反应。结论 COPD患者在常规治疗的基础上加用阿托伐他汀可明显提高疗效,缩短住院时间,降低再住院率。     

All-Payer Analysis of Heart Failure Hospitalization 30-Day Readmission: Comorbidities Matter

Background

Thirty-day readmission following heart failure hospitalization impacts hospital performance measures and reimbursement. We investigated readmission characteristics and the magnitude of 30-day hospital readmissions after hospital discharge for heart failure using the Healthcare Cost and Utilization Project State Inpatient Databases (SID).

Early readmission of elderly patients with congestive heart failure

Repetitive hospitalizations are a major health problem in elderly patients with chronic disease, accounting for up to one fourth of all inpatient Medicare expenditures. Congestive heart failure, one of the most common indications for hospitalization in the elderly, is also associated with a high incidence of early rehospitalization, but variables identifying patients at increased risk and an analysis of potentially remediable factors contributing to readmission have not previously been reported. We prospectively evaluated 161 patients 70 years or older that had been hospitalized with documented congestive heart failure. Hospital mortality was 13% (n = 21). Among patients discharged alive, 66 (47%) were readmitted within 90 days. Recurrent heart failure was the most common cause for readmission, occurring in 38 patients (57%). Other cardiac disorders accounted for five readmissions (8%), and noncardiac illness led to readmission in 21 cases (32%). Factors predictive of an increased probability of readmission included a prior history of heart failure, four or more admissions within the preceding 8 years, and heart failure precipitated by an acute myocardial infarction or uncontrolled hypertension (all P less than .05). Using subjective criteria, 25 first readmissions (38%) were judged possibly preventable, and 10 (15%) were judged probably preventable. Factors contributing to preventable readmissions included noncompliance with medications (15%) or diet (18%), inadequate discharge planning (15%) or follow-up (20%), failed social support system (21%), and failure to seek medical attention promptly when symptoms recurred (20%). Thus, early rehospitalization in elderly patients with congestive heart failure may be preventable in up to 50% of cases, identification of high risk patients is possible shortly after admission, and further study of nonpharmacologic interventions designed to reduce readmission frequency is justified.     

Trends and outcomes of device-related 30-day readmissions after left ventricular assist device implantation

BackgroundLeft ventricular assist devices (LVAD) improve morbidity and mortality in end-stage heart failure patients, but high rates of readmissions remain a problem after implantation. We aimed to assess the incidence, trends, outcomes, and predictors of device-related 30-day readmissions after LVAD implantation.MethodsThe National Readmission Database was used to identify patients who underwent LVAD implantation between 2012 and 2017 and those with 30-day readmissions.ResultsThe analysis included a total of 16499 adults who survived the index hospitalization for LVAD implantation. Among those, 28.1% were readmitted at 30 days, and the readmission rate has been grossly stable during the study period. Most of the readmissions occurred in the first 15 days after discharge from the index admission. The most frequent cause of readmissions was gastrointestinal bleeding (14.9% of readmissions), followed by heart failure, arrhythmias, device infection, and device thrombosis. Among reasons for readmission, intracranial bleeding was associated with highest mortality (37.6%), followed by device thrombosis (13.1%), and ischemic stroke (7.6%). Intracranial bleeding and device thrombosis were associated with lengthier stay (20.4 and 15.5 days, respectively). Readmission rates for gastrointestinal bleeding decreased, whereas device infection increased. Multivariate logistic regression model revealed the length of stay, oxygen dependence, gastrointestinal bleeding at index admission, depression and ECMO, private insurance as independent predictors of 30-day readmission.ConclusionOver one-fourth of LVAD recipients have 30-day readmissions, with most of them occurring within 15 days. Most frequent cause of readmission was gastrointestinal bleeding, which was associated with the lowest in-hospital mortality among other complications.     

A validated risk model for prediction of early readmission in patients with hepatic encephalopathy

Introduction and aimHepatic encephalopathy (HE) is a common complication in cirrhotics and is associated with an increased healthcare burden. Our aim was to study independent predictors of 30-day readmission and develop a readmission risk model in patients with HE. Secondary aims included studying readmission rates, cost, and the impact of readmission on mortality.Materials and methodsWe utilized the 2013 Nationwide Readmission Database (NRD) for hospitalized patients with HE. A risk assessment model based on index hospitalization variables for predicting 30-day readmission was developed using multivariate logistic regression and validated with the 2014 NRD. Patients were stratified into Low Risk and High Risk groups. Cox regression models were fit to identify predictors of calendar-year mortality.ResultsOf 24,473 cirrhosis patients hospitalized with HE, 32.4% were readmitted within 30 days. Predictors of readmission included presence of ascites (OR: 1.19; 95% CI: 1.06–1.33), receiving paracentesis (OR: 1.43; 95% CI: 1.26–1.62) and acute kidney injury (OR: 1.11; 95% CI: 1.00–1.22). Our validated model stratified patients into Low Risk and High Risk of 30-day readmissions (29% and 40%, respectively). The cost of the first readmission was higher than index admission in the 30-day readmission cohort ($14,198 vs. $10,386; p-value <0.001). Thirty-day readmission was the strongest predictor of calendar-year mortality (HR: 4.03; 95% CI: 3.49–4.65).ConclusionsNearly one-third of patients with HE were readmitted within 30 days, and early readmission adversely impacted healthcare utilization and calendar-year mortality. With our proposed simple risk assessment model, patients at high risk for early readmissions can be identified to potentially avert poor outcomes.     

Change in Readmissions and Follow-up Visits as Part of a Heart Failure Readmission Quality Improvement Initiative

Objectives

The study objectives were to quantify the change in 7-day follow-up visits and 30-day readmissions as part of a hospital quality improvement initiative and to characterize events at 7-day follow-up visits. Some data suggest that outpatient assessments of patients with heart failure within 7 days of hospital discharge may prevent readmissions, although little is known about patient needs at 7-day follow-up visits.

Methods

We performed a single-center, retrospective chart review of all heart failure discharges at the University of Connecticut Health Center (398 patients) the year before (2008) and the year after (2011) a quality improvement initiative that included mandatory 7-day follow-up visits. We quantified the change in 30-day readmission rate after the initiative, frequency of 7-day follow-up visits, and events at follow-up visits.

Results

The average age of patients with heart failure was 79.9 years in 2011, with 45.9% having systolic heart failure. Thirty-day all-cause readmissions decreased from 27.5% to 19.1% after our quality improvement initiative (P = .024). Frequency of 7-day follow-up visits increased from 19.6% to 46.9% (P < .01). Eighty-one percent of 7-day visits occurred in the University of Connecticut Heart Failure Center with a cardiologist or heart failure nurse practitioner. Fifty-one percent of patients had blood work drawn, and 26% had a medication dose changed. Only 13% of patients had no discrepancy between the discharge and follow-up medication lists.

Conclusions

Our hospital's 30-day readmission rate for patients with heart failure decreased in parallel with an increase in 7-day follow-up visits. Patients with heart failure were complex and often had diagnostic testing and medication changes at follow-up visits.     

肺动脉高压对心脏再同步治疗术后生存的预测价值

目的：分析肺动脉高压（ PAH ）对心脏再同步治疗（ CRT ）临床获益的预测价值。方法2007年3月至2012年6月在上海复旦大学附属中山医院植入CRT的165例患者回顾性分析,根据术前肺动脉收缩压（SPAP）将其分为SPAP〈50 mmHg（1 mmHg=0．133 kPa,n=107）与SPAP≥50 mmHg （n=58）两组。以全因死亡为主要终点事件,心力衰竭再住院为次要终点事件,分析两组生存函数差异,并通过Cox回归模型分析终点事件的预测因子。结果 SPAP≥50 mmHg组与SPAP〈50 mmHg组死亡例数分别为13例（22．4%）和8例（7．5%）,心力衰竭再住院例数分别为25例（43．1%）和21例（19．6%）,两者差异有统计学意义（P〈0．01）。 Kaplan-Meier生存分析显示,与SPAP〈50 mmHg组比较, SPAP≥50 mmHg者累积生存率较低（ P〈0．05）,累积再住院率则较高（ P〈0．01）。多因素回归分析显示,SPAP≥50 mmHg者主要终点事件风险比3．089（95%CI 1．117-8．543,P=0．03）,次要终点事件风险比2．465（95%CI 1．318－4．611,P=0．005）。结论中-重度PAH患者CRT后临床获益不佳,且是全因死亡和心力衰竭再住院的独立预测因子。     

和肽素在慢性心力衰竭急性发作期治疗中的变化与预后的关系

目的 研究和肽素在慢性心力衰竭急性发作期治疗前后的变化,及其对病情评估、预后判断的价值.方法 选择慢性心力衰竭急性发作患者80例为心力衰竭组,健康对照组30例.心力衰竭组分别于入院即刻、治疗10 d后测定血浆和肽素、氮末端脑钠肽前体（NT-proBNP）水平,入院后24h内行心脏超声检查,测量左心室舒张末期内径（LVIDd）和左心室射血分数（LVEF）;出院后3个月时随访其是否发生心血管事件（包括心力衰竭、恶性心律失常、死亡等）.结果 心力衰竭组入院即刻和肽素、NT-proBNP水平均高于对照组（均为P＜0.01）;心力衰竭组治疗10 d后和肽素、NT-proBNP水平较入院时明显下降（均为P＜0.01）;出院后3个月时间内,与未发生心血管事件的患者相比,发生心血管事件患者的和肽素、NT-proBNP水平在治疗前后均较高（均为P＜0.01）;用全模型多元Logistic回归分析,入院时和肽素水平为慢性心力衰竭患者独立预后指标（P＜0.01）.结论 慢性心力衰竭急性发作期和肽素、NT-proBNP水平升高,治疗后其水平明显下降;监测和肽素浓度对心力衰竭患者的危险分层及预后判断有重要意义.     

Regional outcomes of heart failure in Canada

BACKGROUND: Heart failure is a condition associated with significant mortality and morbidity. However, demographic features and outcomes following hospitalization for heart failure, and associated regional comparisons have not been performed in Canada. METHODS: Anonymously rendered records of patients hospitalized for incident heart failure in Canada were selected from the Canadian Institute for Health Information discharge abstract and hospital morbidity databases from fiscal years 1997/1998 to 1999/2000. The demographics, in-hospital mortality rate and heart failure readmission rates were compared among provinces and health regions. RESULTS: A total of 83,406 patients were hospitalized for heart failure across Canada during the study period. The number of cases increased dramatically with each decade after age 50 years, with 85% of hospitalized patients being age 65 years and over. On average, in-hospital mortality per index admission in Canada was 9.5 deaths per 100 hospitalized cases. While the greatest burden of readmissions was among those 65 years of age and over, heart failure readmission rates were similar across age groups. Among all patients surviving the index admission, heart failure readmission rates were 8.7%, 14.1% and 23.6% at 30 days, 90 days and one year, respectively. The highest age- and sex-adjusted in-hospital mortality rates were 11.9% (95% CI 10.6 to 13.2) in Newfoundland/Labrador and 11.6% (95% CI 10.6 to 12.7) in Nova Scotia. The highest readmission rates at one year were 26.9% (95% CI 24.9 to 28.9) in Newfoundland/Labrador, 26.3% (95% CI 25.0 to 27.7) in Saskatchewan and 25.2% (95% CI 24.3 to 26.1) in British Columbia. There were significant regional variations in heart failure readmission rates and mortality. CONCLUSIONS: There is a great burden of heart failure in Canada, increasing significantly with age. The mortality and readmission rates for this condition are high and exhibit variation among health regions and provinces. Factors contributing to regional variations in these outcomes merit further study.     

Incidence,Causes, and Predictors of Early (≤30 Days) and Late Unplanned Hospital Readmissions After Transcatheter Aortic Valve Replacement

ObjectivesThe aim of this study was to determine the incidence, causes, and predictors of unplanned hospital readmissions after transcatheter aortic valve replacement (TAVR).BackgroundData regarding unplanned hospital readmissions after TAVR in a real-world all-comers population are scarce.MethodsA total of 720 consecutive patients undergoing TAVR at 2 centers who survived the procedure, were included. Median follow-up was 23 months (interquartile range [IQR]: 12 to 39 months), available in 99.9% of the initial population. The occurrence, timing, and causes of hospital readmission within the first year post-TAVR were obtained in all cases. Early and late readmissions were defined as those occurring ≤30 days and >30 days to 1 year post-TAVR, respectively.ResultsThere were 506 unplanned readmissions in 316 patients (43.9%) within the first year post-TAVR (median time: 63 days; IQR: 19 to 158 days post-discharge). Of these, early readmission occurred in 105 patients (14.6%), and 118 patients (16.4%) had multiple (≥2) readmissions. Readmissions were due to noncardiac and cardiac causes in 59% and 41% of cases, respectively. Noncardiac readmissions included, in order of decreasing frequency, respiratory, infection, and bleeding events as the main causes, whereas heart failure and arrhythmias accounted for most cardiac readmissions. The predictors of early readmission were periprocedural major bleeding complications (p = 0.001), anemia (p = 0.019), lower left ventricular ejection fraction (p = 0.042), and the combined presence of antiplatelet and anticoagulation therapy at hospital discharge (p = 0.014). The predictors of late readmission were chronic obstructive pulmonary disease (p = 0.001), peripheral vascular disease (p = 0.023), chronic renal failure (p = 0.013), and atrial fibrillation (p = 0.012). Early readmission was an independent predictor of mortality during the follow-up period (hazard ratio: 1.56, 95% confidence interval: 1.02 to 2.39, p = 0.043).ConclusionsThe readmission burden after TAVR in an all-comers population was high. Nearly one-fifth of the patients were readmitted early after hospital discharge, increasing the risk of mortality at follow-up. Reasons for readmission were split between noncardiac and cardiac causes, with respiratory causes and heart failure as the main diagnoses in each group, respectively. Whereas early readmissions were mainly related to periprocedural bleeding events, most late readmissions were secondary to baseline patient comorbidities. These results underscore the importance of and provide the basis for implementing specific preventive measures to reduce readmission rates after TAVR.