Characterization of acute heart failure hospitalizations in a Portuguese cardiology department

Introduction and AimsWe describe the clinical characteristics, management and outcomes of patients hospitalized with acute heart failure in a south-west European cardiology department. We sought to identify the determinants of length of stay and heart failure rehospitalization or death during a 12-month follow-up period.Methods and ResultsThis was a retrospective cohort study including all patients admitted during 2010 with a primary or secondary diagnosis of acute heart failure. Death and readmission were followed through 2011.Of the 924 patients admitted, 201 (21%) had acute heart failure, 107 (53%) of whom had new-onset acute heart failure. The main precipitating factors were acute coronary syndrome (63%) and arrhythmia (14%). The most frequent clinical presentations were heart failure after acute coronary syndrome (63%), chronic decompensated heart failure (47%) and acute pulmonary edema (21%). On admission 73% had left ventricular ejection fraction <50%. Median length of stay was 11 days and in-hospital mortality was 5.5%. The rehospitalization rate was 21% and 24% at six and 12 months, respectively. All-cause mortality was 16% at 12 months. The independent predictors of rehospitalization or death were heart failure hospitalization during the previous year (Hazard ratio ? HR ? 3.177), serum sodium <135 mmol/l on admission (HR 1.995) and atrial fibrillation (HR 1.791). Reduced left ventricular ejection fraction was associated with a lower risk of rehospitalization or death (HR 0.518).ConclusionsOur patients more often presented new-onset acute heart failure, due to an acute coronary syndrome, with reduced left ventricular ejection fraction. Several predictive factors of death or rehospitalization were identified that may help to select high-risk patients to be followed in a heart failure management program after discharge.     

Co-morbidities and 90-day Outcomes in Hospitalized COPD Exacerbations

COPD exacerbations resulting in hospitalization are accompanied by high mortality and morbidity. The contribution of specific co-morbidities to acute outcomes is not known in detail: existing studies have used either administrative data or small clinical cohorts and have provided conflicting results. Identification of co-existent diseases that affect outcomes provides opportunities to address these conditions proactively and improve overall COPD care. Cases were identified prospectively on admission then underwent retrospective case note audit to collect data including co-morbidities on up to 60 unselected consecutive acute COPD admissions between March and May in each hospital participating in the 2008 UK National COPD audit. Outcomes recorded were death in hospital, length of stay, and death and readmission at 90 days after index admission. 232 hospitals collected data on 9716 patients, mean age 73, 50% male, mean FEV₁ 42% predicted. Prevalence of co-morbidities were associated with increased age but better FEV₁ and ex-smoker status and with worse outcomes for all four measures. Hospital mortality risk was increased with cor pulmonale, left ventricular failure, neurological conditions and non-respiratory malignancies whilst 90 day death was also increased by lung cancer and arrhythmias. Ischaemic and other heart diseases were important factors in readmission. This study demonstrates that co-morbidities adversely affect a range of short-term patient outcomes related to acute admission to hospital with exacerbations of COPD. Recognition of relevant accompanying diseases at admission provides an opportunity for specific interventions that may improve short-term prognosis.     

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.     

Co-morbidities and 90-day outcomes in hospitalized COPD exacerbations

COPD exacerbations resulting in hospitalization are accompanied by high mortality and morbidity. The contribution of specific co-morbidities to acute outcomes is not known in detail: existing studies have used either administrative data or small clinical cohorts and have provided conflicting results. Identification of co-existent diseases that affect outcomes provides opportunities to address these conditions proactively and improve overall COPD care. Cases were identified prospectively on admission then underwent retrospective case note audit to collect data including co-morbidities on up to 60 unselected consecutive acute COPD admissions between March and May in each hospital participating in the 2008 UK National COPD audit. Outcomes recorded were death in hospital, length of stay, and death and readmission at 90 days after index admission. 232 hospitals collected data on 9716 patients, mean age 73, 50% male, mean FEV1 42% predicted. Prevalence of co-morbidities were associated with increased age but better FEV1 and ex-smoker status and with worse outcomes for all four measures. Hospital mortality risk was increased with cor pulmonale, left ventricular failure, neurological conditions and non-respiratory malignancies whilst 90 day death was also increased by lung cancer and arrhythmias. Ischaemic and other heart diseases were important factors in readmission. This study demonstrates that co-morbidities adversely affect a range of short-term patient outcomes related to acute admission to hospital with exacerbations of COPD. Recognition of relevant accompanying diseases at admission provides an opportunity for specific interventions that may improve short-term prognosis.     

急性心肌梗死患者经皮冠状动脉介入治疗后血清sST2、NT-proBNP浓度预测心力衰竭的价值

目的探讨急性心肌梗死患者经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗后血清可溶性致癌抑制因子2(solube suppression tumorigenicity 2,sST2)、氨基末端脑钠肽前体(N-terminal pro-brain natriuretic peptide,NT-proBNP)浓度对心力衰竭的预测价值。方法选取2015年6月至2018年10月六安市人民医院收治的120例急性心肌梗死患者,均行PCI治疗。对比入院时、术后即刻、术后24 h及术后72 h的血清sST2、NT-proBNP浓度;另随访6个月,根据患者是否发生心力衰竭情况将其分为心力衰竭组与未心力衰竭组,比较2组血清sST2、NT-proBNP浓度,且采用Logistic回归分析法分析其对急性心肌梗死PCI治疗后发生心力衰竭的预测价值。结果患者术后即刻及术后24 h的血清sST2及NT-proBNP浓度均明显高于入院时,差异有统计学意义(P<0.05);术后24 h及术后72 h的血清sST2及NT-proBNP浓度均明显低于术后即刻,差异有统计学意义(P<0.05);术后72 h的血清sST2及NT-proBNP浓度均明显低于术后24 h及入院时,差异有统计学意义(P<0.05)。120例患者随访期间共有23例出现心力衰竭,发生率为19.17%;心力衰竭组术后即刻血清sST2及NT-proBNP浓度均明显高于未心力衰竭组,差异有统计学意义(P<0.05)。经Logistic回归分析发现,年龄≥60岁、多个部位梗死、病变支数≥2支、左心室射血分数(LVEF)<50%、并发原发性高血压(高血压)、并发糖尿病、并发高脂血症、有吸烟史、发病至行PCI治疗时间≥12 h、术后即刻sST2浓度>56.68 ng/mL、术后即刻NT-proBNP浓度≥2853.14 pg/mL、PCI治疗后慢或无复流均是急性心肌梗死患者行PCI治疗后发生心力衰竭的危险因素(OR=2.085、2.568、2.375、3.056、2.740、2.241、2.188、2.314、3.374、3.031、4.035,P<0.05)。结论急性心肌梗死患者PCI治疗后短期内血清sST2、NT-proBNP浓度呈现不同程度的升高,但随着时间的推移呈逐渐降低趋势,另术后发生心力衰竭患者血清sST2、NT-proBNP浓度明显高于未发生者,且术后即刻sST2浓度>56.68 ng/mL、术后即刻NT-proBNP浓度≥2853.14 pg/mL、PCI治疗后慢或无复流以及年龄≥60岁等均可增加心力衰竭发生风险。     

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.     

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.     

Clinical presentation,hospital length of stay,and readmission rate in patients with heart failure with preserved and decreased left ventricular systolic function

BACKGROUND: Congestive heart failure is the leading cause of hospital admissions for adults in the United States. To our knowledge, there are limited data comparing the clinical presentation, hospital length of stay, and readmission in patients with preserved and decreased left ventricular (LV) systolic function. HYPOTHESIS: The goal of the study was to determine whether there are differences in clinical presentation, hospital length of stay, and readmission in patients with preserved (> or = 50%) and reduced (< 50%) systolic function. METHODS: We prospectively evaluated 187 patients admitted with congestive heart failure confirmed by the presence of pulmonary vascular congestion on chest x-ray, and with recent (< 6 months) documentation of LV systolic function by two-dimensional echocardiography. History and physical examination findings, patient demographics, comorbidities, discharge medications, and length of hospital stay data were documented. Readmission rate over a 6-month follow-up period was also documented. RESULTS: Of the 187 patients, 130 (70%) patients had an ejection fraction (EF) <50%, and 57 (30%) patients had an EF > or = 50%. Patients with EF < 50% were more likely to be men (54 vs. 37%, p = 0.03). African Americans (79 vs. 60%, p = 0.007), had a higher prevalence of previous stroke (17 vs. 5%, p = 0.03), and were more likely to carry no medical insurance at the time of admission (14 vs. 2%, p = 0.01) and to be discharged on digoxin (60 vs.30%, p<0.001). There were no significant differences in symptoms (exertional dyspnea, rest dyspnea, orthopnea, or paroxysmal nocturnal dyspnea), or in physical examination findings (S3, S4, elevated jugular venous pressure, rales, or peripheral edema). According to chest x-ray, patients with EF <50% had more frequent cardiomegaly (88 vs. 72% p = 0.008), but there were no differences in the presence of pleural effusion or pulmonary vascular congestion (p = NS). The mean length of stay was 5.9 and 5.2 days, respectively (p = 0.34). During the 6-month follow-up period, the readmission rates were 33% (43 patients) and 26% (15 patients), respectively (p = 0.36). CONCLUSION: The clinical presentation, hospital length of stay, and readmission rate for congestive heart failure are similar in patients with preserved and decreased LV systolic function.     

Prognostic value of plasma renin activity in heart failure

The prognostic role of specific biomarkers of the renin-angiotensin-aldosterone system and sympathetic activation pathways in heart failure has never been investigated in populations with current evidence-weighted treatment. To establish whether the plasma renin activity (PRA), among several neurohormonal biomarkers, is able to predict cardiac events in a population of patients with heart failure on up-to-date treatment, we selected 996 consecutive patients with systolic left ventricular dysfunction (ejection fraction <50%, mean age 65 ± 13 years), who underwent a complete clinical and humoral characterization and were then followed up (median 36 months, range 0 to 72) for cardiac death and appropriate implantable cardioverter device shock. We recorded 170 cardiac deaths and 27 shocks. On Cox multivariate analysis, only ejection fraction (hazard ratio 0.962, 95% confidence interval 0.938 to 0.986), N-terminal pro-brain natriuretic peptide (NT-proBNP; hazard ratio 1.729, 95% confidence interval 1.383 to 2.161) and PRA (hazard ratio 1.201, 95% confidence interval 1.024 to 1.408) were independent predictors of cardiac death. Receiver operating characteristic curve analysis identified a cutoff value for PRA of 2.30 ng/ml/hour that best predicted cardiac mortality. Independent predictors of PRA were ejection fraction, functional class, sodium, potassium, NT-proBNP, norepinephrine, aldosterone, C-reactive protein, and medical therapy. The association of high NT-proBNP and high PRA identified a subgroup (22% of the study population) with the greatest risk of cardiac death. In conclusion, PRA resulted an independent prognostic marker in patients with systolic heart failure additive to NT-proBNP level and ejection fraction. PRA might help to select those patients needing an enhanced therapeutic effort, possibly targeting incomplete renin-angiotensin-aldosterone system blockade.     

血管紧张素受体脑啡肽酶抑制剂对HFmrEF患者预后的影响

目的 探索血管紧张素受体脑啡肽酶抑制剂(ARNI)对射血分数中间值的心力衰竭(HFmrEF)患者预后的影响。 方法 自2019年1月起连续性收集河北省人民医院因心力衰竭入院的HFmrEF（射血分数在40%～49%之间）患者86例,对照组和实验组各43人。所有病人入院后在规范的心力衰竭治疗的基础上,对照组口服培哚普利片,实验组口服沙库巴曲缬沙坦片,均从小剂量起始,逐渐增加至目标剂量。收集患者的一般信息、入院时的生命体征、NYHA分级,既往病史、用药史、实验室检查、超声心动图及6 min步行实验等资料。随访患者出院1年后的NT-proBNP水平、左室射血分数、6 min步行试验、NYHA分级的改善、病死和心衰再住院的发生率以及两者的复合终点事件发生率。 结果 两组基线资料均衡无统计学差异,随访1年,两组NT-ProBNP水平明显降低,左室射血分数明显升高（P<0.05）,但两组之间无统计学差异。随访6WMT及心功能改善的结果 两组治疗后6WMT的数值比治疗前有明显提高（P<0.05）,与培哚普利组相比,沙库巴曲缬沙坦组提高的更加明显（P<0.01）。在NYHA分级改善方面,沙库巴曲缬沙坦组改善率明显高于培哚普利组（P<0.05）。随访1年的预后事件,包括全因病死、因心力衰竭再住院、以及两者的复合事件发生率。沙库巴曲缬沙坦组病死率与培哚普利组相比无显著差异;因心力衰竭再住院的发生率及复合终点事件发生率明显低于培哚普利组（均P<0.05）。 结论 血管紧张素受体脑啡肽酶抑制剂可改善射血分数中间值的心力衰竭患者的症状及运动耐力,并降低因心力衰竭再住院的发生率以及病死和再住院的复合终点事件。     

Amino terminal B-type natriuretic peptide, renal function, and prognosis in acute heart failure: a hospital cohort study

BackgroundAmino-terminal pro-brain natriuretic peptide (NT-proBNP) is a valuable diagnostic and prognostic test in heart failure (HF). Limited information is available concerning its use in patients with renal failure, in whom dependence on renal clearance may negatively affect its performance.Methods and ResultsWe evaluated influence of renal function on NT-proBNP levels and on its prognostic value after hospital discharge in 283 acute HF patients. Admission and discharge NT-proBNP levels were higher in patients with decreased estimated glomerular filtration rate (eGFR). In these patients discharge NT-proBNP above median was associated to occurrence of death or readmission at 6 months (hazard ratio [HR] 2.53, 95% confidence interval [CI] 1.27–5.03); in patients with normal eGFR, a trend to this association was found (HR 1.64, CI 0.98–2.76). Decrease in NT-proBNP less than 30% of baseline was associated to outcome in patients with normal eGFR (HR 2.68, CI 1.54–4.68) and decreased eGFR (HR 2.54, CI 1.49–4.33).ConclusionsAcute HF patients with renal failure have higher NT-proBNP levels than those with normal renal function. Discharge NT-proBNP has long-term prognostic value in HF patients with renal dysfunction. NT-proBNP variations during hospitalization provide additional prognostic information either in patients with normal or reduced eGFR.     

Diagnosis for readmission of senile patients hospitalized with acute decompensated heart failure in different departments: a retrospective cross-sectional study

BackgroundShort-term hospital readmissions for acute heart failure lead to the rise of health care budget and all-cause death. Elderly patients with acute or decompensated heart failure are often admitted to different wards (either the geriatric department or other departments). The diagnosis for readmission, cost and length of hospital stay in different wards are not well known.MethodsA retrospective study was conducted examining senile patients admitted to the hospital over a 1-year period. Data related to demographic information, comorbidities, ejection fraction (EF), brain natriuretic peptide (BNP) levels, costs, and discharge disposition were collected from electronic medical record.ResultsA total of 3,922 cases were enrolled in this study. There were 1,316 patients with heart failure who were re-hospitalized, among which, 893 were admitted to the geriatric department. The top 3 diagnosis for re-hospitalization for more than 7 days in the geriatric department were pneumonia (38.5%), blood pressure fluctuations (19.4%), and acute coronary syndrome (ACS) (13.3%). The factors for readmission to other departments were pneumonia (32.5%), arrhythmia (17.7%), and blood pressure fluctuations (15.5%). The top 3 diagnosis for rehospitalizations lasting 7 days or less in the geriatric department were blood pressure fluctuations (26.5%), arrhythmia (23.4%), and fatigue or stress (16.9%), while ACS (24.1%), blood pressure fluctuations (22.5%), and arrhythmia (14.7%) were the top 3 diagnosis for other departments. The geriatric department tended to receive more senile patients, with lower BNP levels (625.13±823.71 vs. 929.31±873.38 pg/mL), and longer duration of hospitalization (24.38±5.228 vs. 15.65±5.907 days). However, there was no significant difference in the total cost of admission between geriatric department and other departments ($4,483 vs. $4,415, P=0.129).ConclusionsOur study identified a higher readmission rate in senile acute decompensated heart failure patients. Pneumonia was listed as the top 1 diagnosis for longer hospital stay in different department. Those rehospitalized with pneumonia may benefit from geriatric department.     

Association of early acute-phase rehabilitation initiation on outcomes among patients aged ≥90 years with acute heart failure

Background

Data on the potential benefit of acute-phase rehabilitation initiation in very old (aged ≥90) patients with acute heart failure (AHF) have been scarce.

Methods

We retrospectively analyzed data from the Diagnosis Procedure Combination database, which is a nationwide inpatient database. This study included patients hospitalized for heart failure (HF) from January 2010 to March 2018, those aged ≥90 years, who had a length of stay of ≥3 days, New York Heart Association (NYHA) class of ≥II, and had not undergone major procedures under general anesthesia. Propensity score matching and generalized linear models were used to compare in-hospital mortality, length of stay, 30-day readmission rate due to HF, all-cause 30-day readmission, and improvement in activities of daily living (ADL) between patients with and without an acute-phase rehabilitation initiation, which is defined as the rehabilitation initiation within 2 days after hospital admission.

Results

Acute-phase rehabilitation was initiated in 8588 of 41,896 eligible patients. Propensity score matching created 8587 pairs. Patients with acute-phase rehabilitation initiation have lower in-hospital mortality (9.0% vs. 11.2%, p < 0.001). Acute-phase rehabilitation initiation was associated with lower in-hospital mortality (odds ratio, 0.778; 95% confidence interval, 0.704–0.860). Patients with acute-phase rehabilitation initiation have a shorter median length of stay (17 days vs. 18 days, p < 0.001), lower 30-day readmission rate due to HF (5.5% vs. 6.4%, p = 0.011) and all-cause 30-day readmission (10.2% vs. 11.2%, p = 0.036), and better ADL improvement (49.7% vs. 46.9%, p < 0.001). Subgroup analysis revealed consistent results (sex, body mass index, NYHA class, and Barthel Index).

Conclusions

The acute-phase rehabilitation initiation was associated with improved short-term clinical outcomes in patients aged ≥90 years with AHF.     

Pre-discharge,but not admission,levels of NT-proBNP predict adverse prognosis following acute LVF

BACKGROUND: Circulating natriuretic peptide levels provide prognostic information following acute coronary syndromes and in chronic heart failure. Little evidence exists of their utility following hospitalisation with acute left ventricular failure (LVF). AIMS: To examine the relative prognostic value of admission and pre-discharge plasma N-terminal pro B-type natriuretic peptide (NT-proBNP) following hospitalisation with acute heart failure. METHODS: NT-proBNP was measured at admission in 96 patients hospitalised with acute LVF. In a subset of 34 patients, NT-proBNP was also measured prior to discharge. Multivariate analysis was performed of the clinical and serological predictors of a combined primary endpoint of death or heart failure (hospitalisation or as an outpatient). RESULTS: During follow up (median 350 days, range 2-762), 37 (38.5%) patients died (n=16, 16.7%), or experienced at least 1 heart failure event (n=21, 21.9%). For the entire cohort of 96 patients, only a prior history of heart failure was associated with the primary endpoint (OR 3.5 [1.10-11.08], P=0.034). Admission plasma NT-proBNP was not predictive (OR 1.84 [0.75-4.51], P=0.185). In the 34 patients for whom both admission and pre-discharge NT-proBNP was available, 19 (55.9%) died (n=8, 23.5%) or experienced heart failure (n=11, 32.4%). Only pre-discharge plasma NT-proBNP (OR 15.30 [95% CI: 1.4-168.9], P=0.026) was independently predictive of the composite endpoint. The area under the receiver-operator-characteristic (AUC ROC) curve for pre-discharge NT-proBNP was superior to that for admission NT-proBNP for prediction of death or heart failure (AUC ROC 0.87 cf 0.70), for death (0.79 cf 0.66), LVF hospitalisation (0.78 cf 0.70) or heart failure as an outpatient (0.71 cf 0.61). CONCLUSIONS: Plasma NT-proBNP measured pre-discharge provides useful prognostic information following hospitalisation with acute LVF.     

The independent effects of left ventricular ejection fraction on short-term outcomes and resource utilization following hospitalization for heart failure

BACKGROUND: While depressed left ventricular ejection fraction is clearly associated with poor long-term outcome in heart failure (HF), the effect of ejection fraction on short-term outcomes and resource utilization following hospitalization for HF remains unclear. HYPOTHESIS: We evaluated the independent effect of depressed ejection fraction (< or = 40%) on short-term outcomes and resource utilization following hospitalization for HF. METHODS: The study population included 443 consecutive patients hospitalized for DRG 127 (HF and shock) with known ejection fraction. For each patient, we assessed the hospitalization cost (1995 US$), length of stay, in-hospital mortality, 30-day mortality, and 30-day readmission rates. RESULTS: Despite similar disease severity at admission, patients with ejection fraction < or = 40% (Group 1) had longer length of stay (4.0 vs. 3.7 days; p = 0.03), a tendency toward higher hospitalization cost ($3,054 vs. $2,770; p = 0.08), more readmissions for any cause (0.4 vs. 0.3; p = 0.05) and for HF (0.2 vs. 0.1; p = 0.01), but similar in-hospital (2.5 vs. 2.6%) and 30-day mortality (4.0 vs. 4.6%) compared with patients with ejection fraction > 40% (Group 2). In multivariate analyses, Group 1 patients were more likely to have higher than median hospitalization cost [odds ratio (OR) = 1.98; 95% confidence intervals (CI) = 1.02-3.91] and longer than median hospital stay (OR = 1.68; CI = 1.08-3.91); they were also more likely to be readmitted for any cause (OR = 2.07; CI = 1.15-3.78) or for HF (OR = 5.71; CI = 1.64-21.94), and they tended to have a higher 30-day incidence of death or readmission (OR = 1.65; CI = 0.96-2.84). CONCLUSIONS: Depressed left ventricular ejection fraction is associated with higher resource utilization and readmission rates following hospitalization for HF. Greater focus on patients with depressed ejection fraction may increase cost savings from HF disease management programs.     

Clinical utility of antigen carbohydrate 125 for planning the optimal length of stay in acute heart failure

BackgroundThe optimal length of stay (LOS) in patients hospitalized for acute heart failure (AHF) remains controversial. Plasma antigen carbohydrate 125 (CA125) has emerged as a reliable proxy of congestion. We aimed to evaluate whether there is a differential impact of LOS on the risk of 6-month AHF readmission across CA125 levels.MethodsThis is a retrospective study that included 1,387 patients discharged for AHF in two third-level centers. CA125 was measured 48±24 h after admission. The association between CA125 and LOS with the risk of subsequent AHF readmission at 6 months was analyzed by Cox regression analysis accounting for death as a competing event.ResultsThe median (IQR) age of the sample was 78 (69–83) years, 625 (41.1%) patients were women, and 832 (60%) exhibited preserved left ventricular ejection fraction. The median LOS and CA125 were 6 (4–9) days and 36 (17–83) U/mL, respectively. A total of 707 (51%) patients displayed high CA125 levels (≥35 U/mL). At 6 months, 87 deaths (6,3%) and 304 AHF readmissions (21,9%) were registered, respectively. A multivariate analysis revealed a differential effect of LOS on 6-month AHF readmission across CA125 levels (p-value for interaction=0.010). In those with CA125<35 U/mL, LOS≥7 days did not modify the risk (HR:1.31; 95% CI: 0.92-1.87, p=0.131). Conversely, in those with CA125≥35 U/mL, LOS≥7 days was associated with a lower risk of AHF readmission (HR:0.70; 95% CI: 0.51-0.98, p=0.036).ConclusionsIn patients with AHF, high CA125 levels may identify those patients that benefit from a more prolonged hospitalization in terms of reducing the risk of mid-term AHF readmissions.     

Right ventricular systolic pressure – Non-invasive bedside predictor of mortality and readmission in heart failure with reduced and preserved ejection fraction hospitalization

ObjectiveTo study the prognostic role of right ventricular systolic pressure (RVSP) in patients with heart failure (HF).BackgroundAlthough RVSP is a readily available echocardiographic parameter, it is often underused. Its prognostic role in patients with heart failure is not well established compared with pulmonary artery pressure measured by right heart catheterization.MethodsThis single-center retrospective cohort study included patients with acute heart failure hospitalization admitted to the hospital from January 2005 to December 2018. The primary predictor was right ventricular systolic pressure (RVSP) obtained from bedside transthoracic echocardiography at admission. We divided RVSP into two groups, RVSP <40 mm Hg (reference group) and RVSP ≥40 mm Hg. Primary outcome was all-cause mortality. Secondary outcomes were all-cause readmission and cardiac readmission. We conducted propensity-score matching and applied cox-proportional hazard model to compute hazard ratio (HR) with 95% confidence interval (CI).ResultsOut of 972 HF patients, 534 patients had RVSP <40 mm Hg and 438 patients had RVSP ≥40 mm Hg. Patients with RVSP ≥40 mm Hg compared with RVSP <40 mm Hg were associated with higher rates of death [HR: 1.60, 95% CI: 1.22–2.09, P-value = 0.001], all-cause readmissions [HR: 1.37, 95% CI: 1.09–1.73, P-value = 0.008] and cardiac readmissions [HR: 1.41, 95% CI: 1.07–1.85, P-value = 0.014].ConclusionHigher RVSP (≥40 mm Hg) in HF patients was associated with higher rates of death, all-cause readmissions, and cardiac readmissions. RVSP can be considered as a prognostic marker for mortality and readmission.