Preliminary data on the potential usefulness of B-type natriuretic peptide levels in predicting outcome after hospital discharge in patients with heart failure

PURPOSE: Among patients admitted for treatment of heart failure, we aimed to evaluate the value of B-type natriuretic peptide levels in predicting subsequent death or hospital readmission. SUBJECTS AND METHODS: We observed and followed 50 consecutive patients admitted with decompensated heart failure. B-type natriuretic peptide levels were measured using an immunofluorometric assay at admission and at discharge. We followed patients for 6 months and ascertained readmissions for cardiovascular causes and death. RESULTS: Forty-three patients were discharged. There were 20 events during follow-up (15 readmissions and 5 deaths). Mean (+/- SD) B-type natriuretic peptide levels decreased during the initial hospitalization, from 619 +/- 491 pg/mL to 328 +/- 314 pg/mL (P <0.001) among patients who were event free during follow-up, whereas declines were less marked among patients with hospital readmission or death (from 779 +/- 608 pg/mL to 643 +/- 465 pg/mL, P = 0.08). Among the 7 patients with in-hospital increases in B-type natriuretic peptide level, 6 had events, compared with 14 of the 36 patients whose levels declined (P = 0.04). An increase in B-type natriuretic peptide levels during hospital stay was associated with an increased event rate (hazard ratio [HR] = 3.3; 95% confidence interval [CI]: 1.3 to 8.8). Patients whose B-type natriuretic peptide level at discharge was above the median (321 pg/mL) had a somewhat higher rate of dying or being readmitted (HR = 2.3; 95% CI: 0.9 to 5.8). CONCLUSION: These preliminary results in a small number of patients suggest that changes in B-type natriuretic peptide levels, as well as predischarge levels, are related to hospital readmission and death within 6 months.     

C-reactive protein as a predictor of improvement and readmission in heart failure

OBJECTIVES: Only recently, new risk factors to explain atherosclerotic disease have been identified. One of the most important clinical manifestations of atherosclerosis is heart failure. Our study was aimed at investigating C-reactive protein (CRP), a marker of systemic inflammation, in the context of heart failure, and to determine its usefulness in predicting the need for readmission in patients with heart failure and their degree of improvement. DESIGN: We studied patients admitted to our hospital due to heart failure, independent of the cause. CRP levels were measured with a sensitive standard assay on a Nephelometer analyser. Patients were classified on admission and discharge following New York Heart Association (NYHA) functional criteria; left ejection fraction was also determined by transthoracic echocardiography. Patients presenting clear sources of infection or inflammatory disease were excluded. Our control group consisted of patients admitted for syncope. Each patient was followed up through a computer system controlling admissions to and discharge from the hospital, for a period of 18 months after initial admission. End points considered were NYHA functional class on discharge, readmission and death. RESULTS: We studied prospectively 76 patients with a mean age of 73.5+/-11 [95% confidence interval (CI) 71.2-75.8]; 44 were male (58%) and 32 female (42%). The mean CRP level in patients with heart failure was 3.94+/-5.87 (95% CI, 1.26-7.60), while in 15 patients with syncope it was 0.84+/-1.95 (95% CI, 0.96-2.94) (P=0.0007). The principal causes of heart failure included dilated cardiomyopathy due to coronary arterial disease (30%), valvular disease (28%) and heart failure secondary to hypertension (25%). The mean left ejection fraction adequately measured in 72 (95%) patients was 50.41+/-9.88 (95% CI, 41.20-59.65). We observed a trend of higher CRP levels in relation to ejection fractions below 35%: 7.50+/-9.88 vs. 3.75+/-4.57, (P=0.09). Our results showed that on discharge CRP levels increased in relation to NYHA class: I: 0.74+/-0.69; II: 3.78+/-3.76; III: 7.4+/-8.65; IV: 12.2+/-15.27 (P<0.05). On follow-up of each patient for 18 months, 32 (43%) were readmitted due to deterioration of their heart condition. For patients who were readmitted, those presenting CRP levels >0.9 mg/dl were identified as candidates for earlier hospitalisation than those with levels below 0.9 mg/dl (P=0.02) RR=1.43. In logistic-regression analysis the only group of tested variables predicting readmission were levels of CRP, NYHA class and plasmatic K on discharge and left ventricle ejection fraction. Analysis of covariates yields CRP levels as being an independent predictor of readmission. CONCLUSIONS: An inflammatory response is present in deteriorating heart failure. We observed higher CRP levels in patients with higher NYHA functional class, perhaps signalling a poor therapeutic response. Higher CRP levels were also related to higher rates of readmission and mortality and it could be an independent marker of improvement and readmission in heart failure.     

血浆N末端原脑利钠肽水平对慢性心力衰竭患者长期预后的预测价值

目的探讨N末端原脑利钠肽（Nt-proBNP）水平对慢性心力衰竭（心衰）患者长期预后的临床价值。方法选择慢性心衰患者,以纽约心脏病心功能分级方法评估心功能,采用双抗体夹心免疫荧光法测定血浆Nt-proBNP水平;并随访2年。结果（1）135例慢性心衰患者平均随访（6404-100）d,发现发生心血管事件组比不发生事件组的Nt-proBNP基线水平明显为高。（2）全模型多元logistic回归分析显示,Nt-proBNP和是否发生事件明显相关,Log Nt-proBNP每变化1个单位,风险增加14倍;Nt-proBNP≤1246ng／L组的生存曲线高于Nt-proBNP〉1246ng／L组。（3）Nt-proBNP水平对预后判定的ROC曲线下面积为0．885,其对心血管事件的阳性预测价值为88．5％,阴性预测价值为11．5％。结论（1）慢性心衰患者中Nt-proBNP水平明显增高,且随着心功能不全级别的增高相应递增;（2）血浆Nt-proBNP水平升高的程度对慢性心衰患者发生心血管事件或死亡的预测具有一定的价值。     

Predictors of costs of caring for elderly patients discharged with heart failure

BACKGROUND: Investments in programs to improve outcomes and reduce readmissions for patients who survive hospitalization with heart failure will be economically most favorable for those who have the highest risk. Little information is available, however, to stratify the risk of these patients incurring costs after discharge. In this study, we sought to determine correlates of costs in a representative sample of patients with heart failure in the 6 months after discharge. METHODS: We reviewed medical records of 2181 patients aged > or = 65 years who were discharged alive from 18 Connecticut hospitals in 1994 and 1995 with a principal discharge diagnosis of heart failure. Outcomes 6 months after discharge, including all-cause readmission and cost, heart failure-related readmission and cost, and death, were obtained from the Medicare administrative database. A 2-stage sample selection model was used to identify the independent correlates of cost. Risk scores were calculated to identify subsets of patients at risk for generating high costs. RESULTS: On average, patients discharged with heart failure incurred costs of $2388 resulting from heart failure-related admissions and $7101 resulting from admissions from any cause during the 6 months after discharge. An average admission for heart failure cost $7174, whereas an admission resulting from any cause cost $8589. The multivariate models explained 7% of the variation in cost, although clinical characteristics such as recent heart failure admissions, kidney failure, and hypertension were significant independent correlates of increased cost. Older age and a history of stroke were independently associated with decreased cost. Patients without any of the risk factors associated with increased costs still incurred $1500 to $5000, on average, in the 6 months after discharge. CONCLUSIONS: Patients with heart failure generate substantial hospital costs in the 6 months after discharge. Given the emerging evidence for effective programs to reduce readmission, investments in interventions that produce even modest reductions in risk would be economically favorable.     

Hyponatremia and long-term mortality in survivors of acute ST-elevation myocardial infarction

BACKGROUND: Hyponatremia, a marker of neurohormonal activation, is a common electrolyte disorder among patients with acute ST-elevation myocardial infarction. The long-term prognostic value of hyponatremia during the acute phase of infarction is not known. METHODS: We studied 978 patients with acute ST-elevation myocardial infarction and without a history of heart failure who survived the index event. During the hospital stay, sodium levels were obtained on admission and at 24, 48, and 72 hours. The median duration of follow-up after hospital discharge was 31 months (range, 9-61 months). RESULTS: Hyponatremia, defined as a mean serum sodium level less than 136 mEq/L, was present during admission in 108 patients (11.0%). In a multivariable Cox proportional hazards model adjusting for other potential clinical predictors of mortality and for left ventricular ejection fraction, hyponatremia during admission remained an independent predictor of postdischarge death (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.3-3.2; P = .002). Hyponatremia during admission was also independently associated with postdischarge readmission for heart failure (HR, 1.6; 95% CI, 1.1-2.6; P = .04). When serum sodium level was used as a continuous variable, the adjusted HR for death or heart failure was 1.12 for every 1-mEq/L decrease (95% CI, 1.07-1.18; P<.001). CONCLUSION: Hyponatremia in the early phase of ST-elevation myocardial infarction is a predictor of long-term mortality and admission for heart failure after hospital discharge, independent of other clinical predictors of adverse outcome and left ventricular ejection fraction.     

Persistent high NTpro-BNP concentration as a negative prognostic factor in patients with decompensated heart failure

INTRODUCTION: Monitoring of natriuretic peptide concentration may be useful for the identification of high-risk patients presenting with decompensated chronic heart failure (CHF). AIM: Assessment of the predicting value of a significant decrease (by > or =20% vs. baseline) of N-terminal proBNP (NTpro-BNP, ROCHE) concentration during hospitalisation in patients with decompensated CHF. METHODS: This study involved 54 patients admitted to our centre because of CHF decompensation. Concentration of NTpro-BNP was measured on admission and at discharge from hospital. Primary end-points of this study were overall mortality and mortality with a number of cardiovascular-related readmissions. RESULTS: Mean NTpro-BNP concentration on admission was 7435+/-10040 pg/ml and at the time of discharge from hospital -- 4816+/-7822 pg/ml. In 31 (57%) patients a significant decrease (> or =20% vs baseline value) in NTpro-BNP level (mean: -58%+/-21%) was noted, while in the remainder (23 patients; 43%) neither an increase nor a decrease in NTpro-BNP levels was observed (mean: +72%+/-132%) despite optimal treatment and stabilisation of the clinical status. The mean follow-up duration was 358+/-240 days. Cox analysis showed that the absence of significant NTpro-BNP level decrease was associated with an increased risk of death -- RR: 3.69 (95% CI: 1.10-12.37; p=0.035) and was the single independent risk factor for readmission due to cardiovascular-related reasons and/or death -- RR: 2.29 (95% CI: 1.20-4.35; p=0.01). In the group of 23 patients with an increase or decrease in NTpro-BNP concentration of more than or equal to 20%, the survival rate was 65% vs. 87% in the remainder (p=0.02). CONCLUSIONS: The lack of a significant (> or =20%) decrease of NTpro-BNP level during hospitalisation correlates with a higher mortality and rate of readmissions. NTpro-BNP level monitoring may be of clinical importance for risk stratification in patients hospitalised for decompensated CHF.     

Clinical events leading to the progression of heart failure: insights from a national database of hospital discharges.

AIMS: To describe the sequence of clinically apparent events causing readmission and antedating death, subsequent to a first-time hospital admission for heart failure, in order to give insights into the natural history and mechanisms of progression of heart failure. METHODS: A national database of linked hospital discharge and mortality data for Scotland (population 5.1 million) was used. Patients with a first-time admission to hospital with heart failure in 1992 (index population) were identified and, using a record linkage system, hospital readmissions and their cause according to the hospital physician and deaths were recorded over the subsequent 3 years. A flowchart showing the sequence of events leading to death or recurrent admission was constructed. RESULTS: 12 640 patients had first-time admissions with heart failure in 1992; their mean age was 74 years and 46.2% were men. A cohort of 2922 (23%) patients died on their first admission. Among the remaining 9718 patients there were 22 747 readmissions and 4877 deaths over the subsequent 3 years; only 15% had neither event reported. Nine per cent of patients died without any readmission and a further 6% without a further readmission for cardiovascular reasons. A cohort of 5992 (61% of patients at risk) had at least one cardiovascular readmission and half of these had occurred within 6 months. Heart failure without a report of any cardiovascular precipitating event was responsible for 37% (2188 patients) of first cardiovascular readmissions and of these patients approximately 12% had evidence of renal failure or acute respiratory infection as possible triggers for readmission. Acute ischaemic events including myocardial infarction (19%), myocardial infarction alone (8%) and atrial fibrillation (11%) were associated with a substantial number of first readmissions. First readmission precipitated by acute myocardial infarction was associated with a particularly poor prognosis (40% inpatient mortality). CONCLUSIONS: Recurrent ischaemic events and atrial fibrillation may be the predominant mechanisms leading to exacerbation of and progression of heart failure and death. A substantial proportion of readmissions appear related to heart failure alone. Whether this reflects progressive ventricular remodelling leading to worsening heart failure or other unidentified mechanisms cannot be discerned from this data.     

Propeptide of procollagen type I (PIP) and outcomes in decompensated heart failure

BACKGROUND: Changes in extracellular matrix are recognized as a contributing factor in the cardiac remodeling process. Several studies have addressed the value of turnover markers of collagen as predictors of death or new heart failure episodes. The aim of the present study was to evaluate the relationship between peripheral serum concentration of propeptide of procollagen type I (PIP) and outcomes in patients with decompensated heart failure. METHODS: A total of 111 patients admitted to our Unit between September 2000 and May 2003 for decompensated heart failure were analyzed. Death from any cause or due to heart failure and readmission were considered primary endpoints. RESULTS: The mean PIP concentration was 80.84+/-36.40 ng/mL. The PIP serum level was significantly higher among those patients who suffered some endpoint during follow-up (88.12+/-37.31 ng/mL vs 73.13+/-34.06 ng/mL; p=0.029). Twenty-five (22.52%) of the 111 patients died during the 21 months of follow-up, and 54 (48.6%) were readmitted with new bouts of heart failure. Using Cox proportional hazards regression analyses, serum PIP levels, systolic dysfunction, and diabetes mellitus were identified as independent predictors of death. Serum PIP levels, age, and sex were independent predictors of new heart failure episodes and readmission. CONCLUSION: A single serum measurement of PIP seems to have prognostic value in patients with decompensated heart failure. Accordingly, patients with higher values of PIP at decompensation are at a higher risk of death or readmission during follow-up.     

Acute changes in N-terminal pro-B-type natriuretic peptide during hospitalization and risk of readmission and mortality in patients with heart failure

The level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a predictor of adverse events in patients with heart failure. We examined the relation between acute changes in NT-proBNP during a single hospitalization and subsequent mortality and readmission. The data from a cohort of 241 consecutive patients aged ≥ 25 years who had been admitted to an urban tertiary care hospital with a primary diagnosis of heart failure were analyzed. Creatinine and NT-proBNP were measured at admission and at discharge of the first admission. The patient demographics, co-morbidities, and length of stay were collected. The patients were prospectively grouped into 2 categories according to the acute changes in NT-proBNP: a decrease of ≥ 50% or <50% from admission to discharge. The primary composite outcome was readmission or death within 1 year of the first hospital admission. The unadjusted hazard ratio of readmission/death was 1.40 (95% confidence interval 0.97 to 2.01; p = 0.07) for those with a < 50% decrease in NT-proBNP compared to their counterparts with a ≥ 50% decrease. After adjustment for age, gender, race, and admission creatinine and NT-proBNP, the risk of readmission/death was 57% greater for those with a < 50% decrease (hazard ratio 1.57, 95% confidence interval 1.08 to 2.28; p = 0.02). An adjustment for co-morbidity, length of stay, and left ventricular ejection fraction did not significantly change this relation. Reductions in NT-proBNP of < 50% during an acute hospitalization for heart failure might be associated with an increased hazard of readmission/death, independent of age, gender, race, creatinine, admission NT-proBNP, co-morbidities, left ventricular ejection fraction, and length of stay. In conclusion, patients with a < 50% reduction in NT-proBNP might benefit from more intensive medical treatment, monitoring, and follow-up.     

Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial

OBJECTIVES: To examine the effectiveness of a transitional care intervention delivered by advanced practice nurses (APNs) to elders hospitalized with heart failure. DESIGN: Randomized, controlled trial with follow-up through 52 weeks postindex hospital discharge. SETTING: Six Philadelphia academic and community hospitals. PARTICIPANTS: Two hundred thirty-nine eligible patients were aged 65 and older and hospitalized with heart failure. INTERVENTION: A 3-month APN-directed discharge planning and home follow-up protocol. MEASUREMENTS: Time to first rehospitalization or death, number of rehospitalizations, quality of life, functional status, costs, and satisfaction with care. RESULTS: Mean age of patients (control n=121; intervention n=118) enrolled was 76; 43% were male, and 36% were African American. Time to first readmission or death was longer in intervention patients (log rank chi(2)=5.0, P=.026; Cox regression incidence density ratio=1.65, 95% confidence interval=1.13-2.40). At 52 weeks, intervention group patients had fewer readmissions (104 vs 162, P=.047) and lower mean total costs ($7,636 vs $12,481, P=.002). For intervention patients, only short-term improvements were demonstrated in overall quality of life (12 weeks, P<.05), physical dimension of quality of life (2 weeks, P<.01; 12 weeks, P<.05) and patient satisfaction (assessed at 2 and 6 weeks, P<.001). CONCLUSION: A comprehensive transitional care intervention for elders hospitalized with heart failure increased the length of time between hospital discharge and readmission or death, reduced total number of rehospitalizations, and decreased healthcare costs, thus demonstrating great promise for improving clinical and economic outcomes.     

Serum magnesium is an independent predictor of frequent readmissions due to acute exacerbation of chronic obstructive pulmonary disease

INTRODUCTION: Predictors of readmission for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are not well defined. Identifying modifiable predictors may help reduce the burden of readmissions. This study was done to evaluate the role of serum magnesium in frequent readmissions. METHODS: One hundred patients admitted with a diagnosis of AECOPD to a tertiary care center from April 2004 to March 2006 were retrospectively followed from the time of index admission until the next admission or death. Number of admissions was calculated for the year after index admission, and frequent readmission was defined as > or =3 per year. Patients with other respiratory diseases, renal failure, and congestive heart failure were excluded. Serum magnesium was assayed at the time of admission by the colorimetric method. Logistic regression analysis was used to find independent risk factors for readmission. RESULTS: The mean age of patients was 71.9 (+/-10.9 standard deviation (SD)) years. Fifty-seven were females. Ninety percent were current or ex-smokers. The median duration of time to next admission was 108 days (range 2-842). A total of 87 patients were readmitted at least once during the first year of follow-up, while 5% died; 23% had frequent readmissions; 85% had received pneumococcal vaccine within 5 years; and 29% received influenza vaccine in the current season. Frequency of readmissions was not influenced by the administration of inhaled or oral steroids, and diuretics at the time of discharge. Vaccination did not protect against frequent readmissions. The sole predictor of frequent readmissions was serum magnesium level (1.77+/-0.19 vs. 1.86+/-0.24mEq/L; adjusted odds ratio 0.003, 95% Confidence intervals <0.001-0.55; p=0.03). CONCLUSIONS: Lower serum magnesium level independently predicts readmission for AECOPD. This is an easily modifiable risk factor.     

Elimination of early rehospitalization in a randomized, controlled trial of multidisciplinary care in a high-risk, elderly heart failure population: the potential contributions of specialist care, clinical stability and optimal angiotensin-converting enzyme inhibitor dose at discharge

BACKGROUND: Despite a growing body of data demonstrating the benefits of multidisciplinary care in heart failure, persistently high rates of readmission, especially within the first month of discharge, continue to be documented. AIMS: As part of an ongoing randomized study on the value of multidisciplinary care in a high risk (NYHA Class IV), elderly (mean age 69 years) heart failure population, we examined the effects of this intervention on previously high (20%) 1-month readmission rates. METHODS: Unlike previous studies of this approach, both multidisciplinary (MC) and routine care (RC) populations were cared for by the cardiology service, complied with adherence to clinical stability criteria prior to discharge (100% of patients) and received at least target dose angiotensin-converting enzyme (ACE) inhibition with perindopril prior to discharge (94% of indicated patients). We analysed death and unplanned readmission for heart failure at 1 month. RESULTS: This early report from the first 70 patients (67% male, 71% systolic dysfunction with a mean ejection fraction of 31.0+/-6.7%) enrolled in this study demonstrates elimination of 1-month hospital readmission in both RC and MC groups. This unexpected result represents a dramatic improvement both for this patient cohort (20% 30-day readmission rate prior to enrollment reduced to 0% following the index admission in both care groups) and in comparison with available data. CONCLUSIONS: Critical contributors to this improvement appear to be specialist cardiology care, adherence to clinical stability criteria prior to discharge and routine use of target or high-dose ACE inhibitor therapy prior to discharge. Widespread application of this approach may have a dramatic improvement in morbidity of CHF while limiting the escalating costs of this condition.     

Correlates of Early Hospital Readmission or Death in Patients With Congestive Heart Failure

Among patients with heart failure who survive an admission to the hospital, those who are readmitted or die soon after discharge may warrant special attention. Therefore, we prospectively followed 257 patients admitted nonelectively to an urban university hospital, with a complaint of shortness of breath or fatigue and evidence of congestive heart failure on admission chest radiograph, who were discharged alive. Through survey of patients and families, review of the hospital computer system, and a search of the National Death Index, we recorded death and hospital readmission. Within 60 days of discharge, 13 patients (5%) died and 82 (32%) died or were readmitted to the hospital. Using Cox proportional-hazards modeling, the multivariable correlates of readmission or death were single marital status (adjusted hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.3 to 3.3), Charlson Comorbidity Index score (HR 1.3 per point to maximum 4 points, 95% CI 1.1 to 1.6), admission systolic blood pressure of ≤100 mm Hg (HR 2.8, 95% CI 1.6 to 5.0), and absence of new ST-T-wave changes on the initial electrocardiogram (HR 1.9, 95% CI 1.1 to 3.3). Self-reported patient compliance and clinical instability at discharge were not correlates. Almost all patients stratified by these factors had at least a 25% risk of readmission or death. Our independent correlates of readmission or death support the importance of both medical and social factors in the pathway to clinical decline. However, we could not reliably identify a truly low-risk group. Interventions to decrease early readmission or death among patients with heart failure should target both medical management and the adequacy of social support, and probably need to be applied to all admitted patients.

To determine correlates of early readmission or death, we prospectively followed 257 patients admitted to an urban university hospital with a complaint of shortness of breath or fatigue and evidence of congestive heart failure on admission chest radiograph. Single marital status, increasing comorbidity, relative hypotension, and absence of new ST-T-wave changes on initial electrocardiogram were the correlates, but we could not reliably identify a truly low-risk group.     

Racial differences in patients with heart failure

BACKGROUND AND HYPOTHESIS: Limited data exist regarding racial differences in heart failure. The objective of this prospective study was to document racial differences in the baseline demographics and patterns of health care utilization and outcomes in patients with heart failure. METHODS: The data on 163 consecutive patients (113 black, 50 white) admitted with a diagnosis of heart failure confirmed by pulmonary congestion on chest x-ray were prospectively evaluated. Patient demographics, physical examination findings at admission, comorbid conditions, and medications at admission and discharge were analyzed. Follow-up was performed to document visits to the physician's office after discharge and readmission rate during a 6-month time period. RESULTS: Compared with whites, blacks were younger in age (mean age 63.8 +/- 13.7 years vs. 70.8 +/- 13.1, p = 0.003), and had a higher prevalence of hypertension (86 vs. 66%, p = 0.004), left ventricular hypertrophy (24 vs. 8%, p = 0.02), ejection fraction < 40% (64 vs. 43%, p = 0.03), and readmission rate (33 vs. 18%, p = 0.05). Whites had a higher prevalence of atrial fibrillation (42 vs. 21%, p = 0.006) and more frequently followed up with their cardiologists as outpatients (58 vs. 39%, p = 0.04). CONCLUSION: Significant racial differences exist in patients with heart failure with regard to age, incidence, etiologic factors, left ventricular hypertrophy, left ventricular function, and clinical follow-up. It is important to consider these racial differences in the evaluation and management of patients with heart failure.     

Brain natriuretic peptide and QRS duration as a predictor for cardiac events in patients with heart failure

OBJECTIVES: Brain natriuretic peptide (BNP) and QRS duration have been reported as independent predictors for cardiac events in patients with heart failure. The present study investigated the relationships between BNP and QRS duration to assess the prognostic value in patients with heart failure. METHODS: We prospectively examined 93 patients presenting to our emergency department with heart failure between April 2000 and April 2003 (age 69 +/- 13 years, 53 males, 40 females). BNP level and QRS duration were measured after treatment for heart failure. The efficacy end point was the composite incidence of sudden death, death for progressive heart failure, or readmission for worsening heart failure. RESULTS: During the mean follow-up period of 720 +/- 470 days, cardiac events occurred in 35 patients (sudden death in 6, death for progressive heart failure in 9, and readmission for worsening heart failure in 20). BNP level was almost equally higher in the three groups with cardiac events (mean +/- SEM; sudden death: 348 +/- 128 pg/ml, death for progressive heart failure: 390 +/- 97 pg/ml, readmission for worsening heart failure: 354 +/- 79 pg/ml) than in patients without cardiac events (213 +/- 34 pg/ml). In contrast, QRS duration was exclusively prolonged in patients with sudden death(mean +/- SEM, 125 +/- 10 msec) compared with the remaining three groups (death for progressive heart failure: 100 +/- 5 msec, readmission for worsening heart failure: 103 +/- 4 msec, no cardiac events: 108 +/- 3 msec). No relationship was found between BNP level and QRS duration in all patients with heart failure (Spearman r = 0.13, p = 0.22). CONCLUSIONS: Increased BNP level was associated with poor prognosis irrespective of mode of cardiac events, and prolonged QRS duration was related to sudden death in our cohort with heart failure. The combination of BNP level and QRS duration may have adjunctive value in predicting the prognosis in patients with heart failure.     

The importance of admission and discharge BNP assessment in patients hospitalized for acutely decompensated chronic systolic heart failure

IntroductionThe assessment of B-type natriuretic peptide (BNP) plasma levels is not only useful for the differential diagnosis of acute dyspnea, but also for the prognostic stratification of patients with heart failure. However, available studies that have addressed monitoring of hospitalized patients are burdened with significant limitations: (1) measurement of plasma BNP levels only at admission or at discharge, (2) lack of details regarding the cause of heart failure, and (3) small sample size. Therefore, we conducted a prospective study of all patients presenting to our hospital with acutely decompensated chronic systolic heart failure.AimTo determine the importance of admission and discharge values of BNP and its changes during hospitalization for identification of patients with acutely decompensated chronic systolic heart failure at higher risk of unfavorable course of the disease.MethodsA prospective monocentric study determining plasma BNP levels at admission and at discharge in patients hospitalized for acutely decompensated chronic systolic heart failure. Patients: 130 consecutive patients, 77% men, mean age 70 years, body mass index (BMI) 27.8 kg/m²; etiology of chronic heart failure—65.9% ischemic heart disease, 29.5% dilated cardiomyopathy, 4.6% others; signs and symptoms at admission—peripheral edema 58.9%, pulmonary rates 88.3%, orthopnea 53.1%, median of admission BNP 1101 pg/ml, median of discharge BNP 650 pg/ml, median left ventricular ejection fraction 26.5%, average length of hospitalization 9 days.ResultsDuring the follow-up (mean 15 months) the total mortality rate reached almost 40% and the annual mortality of our cohort was 29%. The most common causes of death included progression of heart failure and acute coronary syndromes. To evaluate the long-term risk of mortality, we used time-dependent ROC curves for the definition of cut-off values of BNP at admission and discharge. The relationship of BNP levels and the survival of patients was assessed using the hazard ratio (HR) calculated by the Cox proportional hazards model. BNPs at admission and at discharge with a cut-off value of 1699 pg/ml and 434.5 pg/ml are significant prognostic factors for patients hospitalized for acutely decompensated chronic systolic heart failure with a HR 2.79 and 3.29, respectively. During the follow-up, more than half of the patients required readmission to the hospital. The most common reasons for rehospitalization were cardiovascular causes.ConclusionBNP levels at admission and at discharge are an important predictive factor of survival in patients with acutely decompensated chronic systolic heart failure.     

Healthcare utilization of elderly persons hospitalized after a noninjurious fall in a Swiss academic medical center

OBJECTIVES: To determine the risk of hospital readmission, nursing home admission, and death, as well as health services utilization over a 6-month follow-up, in community-dwelling elderly persons hospitalized after a noninjurious fall. DESIGN: Prospective cohort study with 6-month follow-up. SETTING: Swiss academic medical center. PARTICIPANTS: Six hundred ninety persons aged 75 and older hospitalized through the emergency department. MEASUREMENTS: Data on demographics and medical, physical, social, and mental status were collected upon admission. Follow-up data were collected from the state centralized billing system (hospital and nursing home admission) and proxies (death). RESULTS: Seventy patients (10%) were hospitalized after a noninjurious fall. Fallers had shorter hospital stays (median 4 vs 8 days, P<.001) and were more frequently discharged to rehabilitation or respite care than nonfallers. During follow-up, fallers were more likely to be institutionalized (adjusted hazard ratio=1.82, 95% confidence interval=1.03-3.19, P=.04) independent of comorbidity and functional and mental status. Overall institutional costs (averaged per day of follow-up) were similar for both groups ($138.5 vs $148.7, P=.66), but fallers had lower hospital costs and significantly higher rehabilitation and long-term care costs ($55.5 vs $24.1, P<.001), even after adjustment for comorbidity, living situation, and functional and cognitive status. CONCLUSION: Elderly patients hospitalized after a noninjurious fall were twice as likely to be institutionalized as those admitted for other medical conditions and had higher intermediate and long-term care services utilization during follow-up, independent of functional and health status. These results provide direction for interventions needed to delay or prevent institutionalization and reduce subsequent costs.     

Usefulness of in-hospital change in B-type natriuretic peptide levels in predicting long-term outcome in elderly patients admitted for decompensated heart failure

The usefulness of repeated measures of B-type natriuretic peptide (BNP) in elderly subjects with decompensated heart failure to improve risk stratification remains poorly known. This prospective cohort study included 61 consecutive patients older than 70 years (mean age, 82.7 years) hospitalized for decompensated heart failure. Clinical, radiologic, biologic, and echographic data were collected at admission and at discharge. The median BNP level at admission was 1136 pg/mL and the mean change during the hospitalization was -32%. Cardiac death or readmission were best predicted by the change in BNP levels, with the poorest prognosis in patients who did not achieve a decrease of at least 40% (hazard ratio, 4.03; 95% confidence interval, 1.50-10.84 in multivariate analysis). Admission of an elderly patient for decompensated heart failure is a daily situation in clinical practice, in which 2 BNP measurements seem to provide reliable information on long-term prognosis.     

Risk Stratification With the Use of Serial N-Terminal Pro–B-Type Natriuretic Peptide Measurements During Admission and Early After Discharge in Heart Failure Patients: Post Hoc Analysis of the PRIMA Study

ObjectiveThe aim of this work was to assess the prognostic value of absolute N-terminal-pro–B-type natriuretic peptide (NT-proBNP) concentration in combination with changes during admission because of acute heart failure (AHF) and early after hospital discharge.BackgroundIn AHF, readmission and mortality rates are high. Identifying those at highest risk for events early after hospital discharge might help to select patients in need of intensive outpatient monitoring.Methods and resultsWe evaluated the prognostic value of NT-proBNP concentration on admission, at discharge, 1 month after hospital discharge and change over time in 309 patients included in the PRIMA (Can PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart fAilure morbidity and mortality?) study. Primary outcome measures were mortality and the combined end point of heart failure (HF) readmission or mortality. In a multivariate Cox regression analysis, change in NT-proBNP concentration during admission, change from discharge to 1 month after discharge, and the absolute NT-proBNP concentration at 1 month after discharge were of independent prognostic value for both end points (hazard ratios for HF readmission or mortality: 1.71, 95% confidence interval [CI] 1.13–2.60, Wald 6.4 [P = .011] versus 2.71, 95% CI 1.76–4.17, Wald 20.5 [P < .001] versus 1.81, 95% CI 1.13–2.89, Wald 6.1 [P = .014], respectively.ConclusionsKnowledge of change in NT-proBNP concentration during admission because of AHF in combination with change early after discharge and the absolute NT-proBNP concentration at 1 month after discharge allows accurate risk stratification.     

Early re-hospitalization of elderly people discharged from a geriatric ward

BACKGROUND AND AIMS: Hospitalized elderly patients generally have a high level of disability and comorbidity. In many cases, at hospital discharge, the achieved health status balance is poor, and consequently the risk of further disability and hospital readmission is great. Identifying factors leading to hospital readmission could be helpful in reducing such events. The aim of the study was to evaluate the incidence and predictive factors of hospital readmission. METHODS: We conducted an observational cohort study of a group of patients discharged from the Geriatric Ward of the San Giovanni Battista Hospital, Torino (Italy). The study sample contained 839 patients aged 80.6 +/- 6.3 years. The average hospital stay was 17.5 +/- 18.9 days (range 1-274 days). RESULTS: Follow-up lasted three months, at the end of which 107 patients (12.8%) had been readmitted, 83 (9.9%) had only one readmission and 24 (2.9%) one or more readmissions. The first readmission took place within 15 days of discharge for 24 patients (2.9%) and within 30 days of discharge for 27 (3.2%). A new hospital admission within 15 days of discharge increased the risk of mortality (RR=3) and also the probability of a second re-hospitalization. 10.1% patients died; 88.2% of the patients who died had at least one readmission, whereas only 4.2% of live patients had a new hospital admission. CONCLUSIONS: Tumors, dementia, comorbidity, high education level, day hospital course and period of convalescence were all significantly and independently related to readmission.