Risk of Readmission and Mortality Following Hospitalization with Hypercapnic Respiratory Failure

Lung - Hypercapnic respiratory failure (HRF) is a frequent cause of hospitalization and a common comorbidity in hospitalized patients. There are few studies addressing what factors might predict...     

Impact of Modifiable Cardiovascular Risk Factors on Mortality After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of 100 Studies

Modifiable cardiovascular risk factors such as obesity, hypertension, dyslipidemia, smoking, diabetes mellitus, and metabolic syndrome can easily give rise to coronary heart disease (CHD). However, due to the existence of the so-called “obesity paradox” and “smoking paradox,” the impact of these modifiable cardiovascular risk factors on mortality after percutaneous coronary intervention (PCI) is still not clear.Therefore, in order to solve this issue, we aim to compare mortality between patients with low and high modifiable cardiovascular risk factors after PCI.Medline and EMBASE were searched for studies related to these modifiable cardiovascular risk factors. Reported outcome was all-cause mortality after PCI. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated, and the pooled analyses were performed with RevMan 5.3 software.A total of 100 studies consisting of 884,190 patients (330,068 and 514,122 with high and low cardiovascular risk factors respectively) have been included in this meta-analysis. Diabetes mellitus was associated with a significantly higher short and long-term mortality with RR 2.11; 95% CI: (1.91–2.33) and 1.85; 95% CI: (1.66–2.06), respectively, after PCI. A significantly higher long-term mortality in the hypertensive and metabolic syndrome patients with RR 1.45; 95% CI: (1.24–1.69) and RR 1.29; 95% CI: (1.11–1.51), respectively, has also been observed. However, an unexpectedly, significantly lower mortality risk was observed among the smokers and obese patients.Certain modifiable cardiovascular risk subgroups had a significantly higher impact on mortality after PCI. However, mortality among the obese patients and the smokers showed an unexpected paradox after coronary intervention.     

Association of Cognitive Impairment With Mortality and Readmission in Patients With Heart Failure: A Meta-analysis

Cognitive impairment is a frequent condition in patients with heart failure (HF). This meta-analysis aimed to evaluate the prognostic impact of cognitive impairment on all-cause mortality and readmission among HF patients. We systematically searched articles indexing in PubMed and Embase databases until August 5, 2022. Original studies investigating the association of cognitive impairment with mortality and/or readmission for more than 3-month follow-up in patients with HF were selected. Twelve studies including 9556 patients were eligible. The prevalence of cognitive impairment ranged from 13.5% to 63.4% in HF patients. For patients with cognitive impairment vs those without, the pooled adjusted risk ratio (RR) was 1.88 (95% confidence intervals [CI] 1.42-2.48) for all-cause mortality, 1.48 (95% CI 1.19-1.84) for readmission, and 1.53 (95% CI 1.35-1.73) for combined endpoints of all-cause mortality/readmission, respectively. Cognitive impairment is a significant predictor of all-cause mortality/readmission in patients with HF, even after adjustment for the conventional confounding. Evaluation of cognitive function may help to improve risk classification of HF patients.     

The Effect of Renin-Angiotensin System Inhibitors on Mortality and Heart Failure Hospitalization in Patients With Heart Failure and Preserved Ejection Fraction: A Systematic Review and Meta-Analysis

BackgroundAlthough renin-angiotensin system (RAS) inhibitors have little demonstrable effect on mortality in patients with heart failure and preserved ejection fraction (HF-PEF), some trials have suggested a benefit with regard to reduction in HF hospitalization.Methods and ResultsHere, we systematically review and evaluate prospective clinical studies of RAS inhibitors enrolling patients with HF-PEF, including the 3 major trials of RAS inhibition (Candesartan in Patients with Chronic Heart Failure and Preserved Left Ventricular Ejection Fraction [CHARM-Preserved], Irbesartan in Patients with Heart Failure and Preserved Ejection Fraction [I-PRESERVE], and Perindopril in Elderly People with Chronic Heart Failure [PEP-CHF]). We also conducted a pooled analysis of 8021 patients in the 3 major randomized trials of RAS inhibition in HF-PEF (CHARM-Preserved, I-PRESERVE, and PEP-CHF) in fixed-effect models, finding no clear benefit with regard to all-cause mortality (odds ratio [OR] 1.03, 95% confidence interval [CI], 0.92-1.15; P = .62), or HF hospitalization (OR 0.90, 95% CI 0.80-1.02; P = .09).ConclusionsAlthough RAS inhibition may be valuable in the management of comorbidities related to HF-PEF, RAS inhibition in HF-PEF is not associated with consistent reduction in HF hospitalization or mortality in this emerging cohort.     

Cognitive Decline and Risk of Dementia in Individuals With Heart Failure: A Systematic Review and Meta-analysis

BackgroundWe sought to determine the association between heart failure (HF) and cognitive change and dementia.Methods and ResultsSystematic search of three electronic databases was performed and 29 eligible studies involving approximately 3 million participants were identified. Twelve studies examined dementia and 20 cognitive change, but only a subset of studies could be included in the meta-analysis. These findings indicated that HF was not significantly associated with dementia (n = 8, hazard ratio 1.18, 95% confidence interval 0.93–1.50), but increased the risk of cognitive impairment (n = 3, hazard ratio 1.80, 95% confidence interval 1.14–2.86) . Additionally, HF was associated with poorer mean cognitive performance in global cognition (Hedges’ g –0.73, 95% confidence interval –1.12 to –0.35), memory (Hedges’ g –0.57, 95% confidence interval –0.72 to –0.42), executive function (Hedges’ g –0.58, 95% confidence interval –0.72 to –0.43), attention/speed (Hedges’ g –0.50, 95% confidence interval –0.63 to –0.37) and language (Hedges’ g –0.61, 95% confidence interval –1.05 to –0.17).ConclusionsPatients with HF perform worse on all cognitive tests and have an increased risk of cognitive impairment. These findings highlight the need for clinicians to consider cognition as part of routine care for patients with HF.     

Impact of a Comprehensive Heart Failure Management Program on Hospital Readmission and Functional Status of Patients With Advanced Heart Failure

Objectives. To assess the impact of a comprehensive heart failure management program, functional status, hospital readmission rate and estimated hospital costs were determined and compared for the 6 months before and the 6 months after referral.Background. The course of advanced heart failure is characterized by progressive clinical deterioration reflected in frequent hospital admissions, which comprise the major financial cost.Methods. Over a 3-year period, 214 patients were accepted for heart transplantation and discharged after evaluation, which included adjustments in medical therapy and intensive patient education. Patients were in New York Heart Association functional class III or IV (94 and 120 patients, respectively), with a mean left ventricular ejection fraction of 0.21, peak oxygen consumption of 11 ml/kg per min and a total of 429 hospital admissions in the previous 6 months (average 2.0 per patient). Changes in the medical regimen included a 98% increase in angiotensin-converting enzyme inhibitor dose and a flexible diuretic regimen after 4.2-liter net diuresis, with counseling also regarding diet and progressive exercise.Results. During the 6 months after referral, there were only 63 hospital readmissions (85% reduction), with 0.29/patient (p < 0.0001). Functional status improved as assessed by functional class (p < 0.0001) and peak oxygen consumption (15.2 vs. 11.0 ml/kg per min, p < 0.001). The same results were seen after excluding the 35 patients without full 6-month follow-up (9 deaths, 14 urgent transplant procedures during hospital readmission, 12 elective transplant procedures from home); 34 hospital admissions occurred after referral, compared with 344 before referral. Even when adding in the initial hospital admission after referral for these 179 patients, there was a 35% decrease in total hospital admissions in the 6-month period. The estimated savings in hospital readmission costs after subtracting the initial hospital costs for management was $9,800 per patient.Conclusions. Comprehensive heart failure management led to improved functional status and an 85% decrease in the hospital admission rate for transplant candidates discharged after evaluation. The potential to reduce both symptoms and costs suggests that referral to a heart failure program may be appropriate not only for potential heart transplantation, but also for medical management of persistent functional class III and IV heart failure.     

Trends for Readmission and Mortality After Heart Failure Hospitalisation in Malaysia, 2007 to 2016

Background and objectives:Data on population-level outcomes after heart failure (HF) hospitalisation in Asia is sparse. This study aimed to estimate readmission and mortality after hospitalisation among HF patients and examine temporal variation by sex and ethnicity.Methods:Data for 105,399 patients who had incident HF hospitalisations from 2007 to 2016 were identified from a national discharge database and linked to death registration records. The outcomes assessed here were 30-day readmission, in-hospital, 30-day and one-year all-cause mortality.Results:Eighteen percent of patients (n = 16786) were readmitted within 30 days. Mortality rates were 5.3% (95% confidence interval (CI) 5.1–5.4%), 11.2% (11.0–11.4%) and 33.1% (32.9–33.4%) for in-hospital, 30-day and 1-year mortality after the index admission. Age, sex and ethnicity-adjusted 30-day readmissions increased by 2% per calendar year while in-hospital and 30-day mortality declined by 7% and 4% per year respectively. One-year mortality rates remained constant during the study period. Men were at higher risk of 30-day readmission (adjusted rate ratio (RR) 1.16, 1.13–1.20) and one-year mortality (RR 1.17, 1.15–1.19) than women. Ethnic differences in outcomes were evident. Readmission rates were equally high in Chinese and Indians relative to Malays whereas Others, which mainly comprised Indigenous groups, fared worst for in-hospital and 30-day mortality with RR 1.84 (1.64–2.07) and 1.3 (1.21–1.41) relative to Malays.Conclusions:Short-term survival was improving across sex and ethnic groups but prognosis at one year after incident HF hospitalisation remained poor. The steady increase in 30-day readmission rates deserves further investigation.     

Resting Heart Rate as an Important Predictor of Mortality and Morbidity in Ambulatory Patients With Heart Failure: A Systematic Review and Meta-Analysis

BackgroundResting heart rate is a risk factor of adverse heart failure outcomes; however, studies have shown controversial results. This meta-analysis evaluates the association of resting heart rate with mortality and hospitalization and identifies factors influencing its effect.Methods and ResultsWe systematically searched electronic databases in February 2019 for studies published in 2005 or before that evaluated the resting heart rate as a primary predictor or covariate of multivariable models of mortality and/or hospitalization in adult ambulatory patients with heart failure. Random effects inverse variance meta-analyses were performed to calculate pooled hazard ratios. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to assess evidence quality. Sixty-two studies on 163,445 patients proved eligible. Median population heart rate was 74 bpm (interquartile range 72–76 bpm). A 10-bpm increase was significantly associated with increased risk of all-cause mortality (hazard ratio 1.10, 95% confidence interval 1.08–1.13, high quality). Overall, subgroup analyses related to patient characteristics showed no changes to the effect estimate; however, there was a strongly positive interaction with age showing increasing risk of all-cause mortality per 10 bpm increase in heart rate.ConclusionsHigh-quality evidence demonstrates increasing resting heart rate is a significant predictor of all-cause mortality in ambulatory patients with heart failure on optimal medical therapy, with consistent effect across most patient factors and an increased risk trending with older age.     

Association Between Beta-Blockers and Mortality and Readmission in Older Patients with Heart Failure: an Instrumental Variable Analysis

BackgroundThe demographics of heart failure are changing. The rate of growth of the “older” heart failure population, specifically those ≥ 75, has outpaced that of any other age group. These older patients were underrepresented in the early beta-blocker trials. There are several reasons, including a decreased potential for mortality benefit and increased risk of side effects, why the risk/benefit tradeoff may be different in this population.ObjectiveWe aimed to determine the association between receipt of a beta-blocker after heart failure discharge and early mortality and readmission rates among patients with heart failure and reduced ejection fraction (HFrEF), specifically patients aged 75+.Design and ParticipantsWe used 100% Medicare Parts A and B and a random 40% sample of Part D to create a cohort of beneficiaries with ≥ 1 hospitalization for HFrEF between 2008 and 2016 to run an instrumental variable analysis.Main MeasureThe primary measure was 90-day, all-cause mortality; the secondary measure was 90-day, all-cause readmission.Key ResultsUsing the two-stage least squared methodology, among all HFrEF patients, receipt of a beta-blocker within 30-day of discharge was associated with a − 4.35% (95% CI − 6.27 to − 2.42%, p < 0.001) decrease in 90-day mortality and a − 4.66% (95% CI − 7.40 to − 1.91%, p = 0.001) decrease in 90-day readmission rates. Even among patients ≥ 75 years old, receipt of a beta-blocker at discharge was also associated with a significant decrease in 90-day mortality, − 4.78% (95% CI − 7.19 to − 2.40%, p < 0.001) and 90-day readmissions, − 4.67% (95% CI − 7.89 to − 1.45%, p < 0.001).ConclusionPatients aged ≥ 75 years who receive a beta-blocker after HFrEF hospitalization have significantly lower 90-day mortality and readmission rates. The magnitude of benefit does not appear to wane with age. Absent a strong contraindication, all patients with HFrEF should attempt beta-blocker therapy at/after hospital discharge, regardless of age.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06901-7KEY WORDS: heart failure, beta-blockers, geriatrics, cardiology, instrumental variable analysis     

The Impact of Pre-existing Heart Failure on Pneumonia Prognosis: Population-based Cohort Study

Background  There are limited data describing how pre-existing heart failure affects mortality following pneumonia. Objective  To examine the association between history and severity of heart failure and mortality among patients hospitalized for pneumonia. Design  Population-based cohort study in Western Denmark between 1994 and 2003. Patients  33,736 adults with a first-time hospitalization for pneumonia. Heart failure was identified and categorized based on data linked from population-based health care databases. Measurements  We compared 30-day mortality between patients with pre-existing heart failure and other pneumonia patients, while adjusting for age, gender, comorbidity, and medication use. Results  The 30-day mortality was 24.4% among heart-failure patients and 14.4% among other patients, with an adjusted 30-day mortality rate ratio (MRR) of 1.40 (95% CI: 1.29–1.51). Adjusted MRRs increased according to severity of pre-existing heart failure, as indicated by medication regimen: thiazide-based, MRR = 1.09 (95% CI: 0.79–1.50); loop-diuretics, MRR = 1.25 (95% CI: 1.10–1.43); loop-diuretics and digoxin, MRR = 1.35 (95% CI: 1.18–1.55); loop-diuretics and spironolactone, MRR = 1.72 (95% CI: 1.49–2.00). Pre-existing heart valve disease and atrial fibrillation substantially increased mortality. Conclusion  History and severity of heart failure are associated with a poor outcome for patients hospitalized with pneumonia.     

Role of Internal Jugular Venous Ultrasound in suspected or confirmed Heart Failure: A Systematic Review

BackgroundFew data are available on the use of internal jugular vein (IJV) ultrasound parameters to assess central venous pressure and clinical outcomes among patients with suspected or confirmed heart failure (HF).MethodsWe performed electronic searches on PubMed, The Cochrane Library, EMBASE, EBSCO, Web of Science, and CINAHL databases from the inception through January 9, 2021, to identify studies evaluating the accuracy and reliability of the IJV ultrasound parameters and exploring its correlation with central venous pressure and clinical outcomes in adult patients with suspected or confirmed acutely decompensated HF. The studies’ report quality was assessed by Quality Assessment of Diagnostic Accuracy Studies-2 scale.ResultsA total of 11 studies were eligible for final analysis (n = 1481 patients with HF). The studies were segregated into 3 groups: (1) the evaluation of patients presenting to the emergency department with dyspnea, (2) the evaluation of patients presenting to the HF clinic for follow-up, and (3) the evaluation of hospitalized patients with acutely decompensated HF or undergoing right heart catheterization. US parameters included IJV height, IJV diameter, IJV diameter ratio, IJV cross-sectional area, respiratory compressibility index, and compression compressibility index.ConclusionsThe findings of this systematic review suggest a significant role for ultrasound interrogation of the IJV in evaluation of patients in the emergency department presenting with dyspnea, in the outpatient clinic for poor clinical outcomes in HF, and in determining the timing of discharge for patients admitted with acutely decompensated HF. Further studies are warranted for testing the reliability of the reported ultrasound indices.     

Influence of Risk on Reduction of Readmission and Death by Disease Management Programs in Heart Failure

ObjectiveDisease management programs (DMPs) may reduce short-term readmission or death after heart failure (HF) hospitalization. We sought to determine if targeting of DMP to the highest-risk patients could improve efficiency.Methods and ResultsPatients (n = 412) admitted with HF were randomized to usual care or an intensive DMP including optimizing intravascular volume status at discharge, increased self-care education, exercise guidance, closer home surveillance, and increased intensity of HF nurse follow-up. Both treatment groups were similar in demographics, medication use, Charlson comorbidity index, ejection fraction, and left ventricular and atrial volumes. Readmission or death occurred in 74/197 (37%) usual care and 50/215 (23%) DMP patients within 30 days (relative risk [RR] 0.62, 95% confidence interval [CI] 0.46–0.84), and 113/197 (57%) usual care and 78/215 (36%) DMP patients within 90 days, (RR 0.63, 9%% CI 0.51–0.78). The predicted risk of death and readmission (estimated from our previously developed risk score) was similar between treatment groups (mean predicted risk 38.6 ± 22.2% vs 39.4 ± 21.9%; P = .73) and similar across categories of predicted risk between the treatment groups. For 30-day readmission or death, patients from the 2 highest risk quintiles showed a benefit from intervention, and there was an interaction between intervention and predicted risk (P = .02). For 90-day readmission or death, most patients—other than those in the lowest-risk quintile—benefited from the intervention.ConclusionsUse of a risk score may permit targeting of DMP to reduce HF admission. Intensive DMP may reduce short-term readmission or death, particularly in high-risk patients.     

NT-proBNP对老年慢性心力衰竭患者再住院率及生存率的影响

目的分析N-端脑利钠肽前体(NT-proBNP)水平与患者再住院率及生存率的关系,探讨NT-proBNP水平对慢性心力衰竭患者长期预后的预测价值。方法选取2010年1月—2012年5月确诊为慢性心力衰竭的老年患者(60岁以上)共192例进行研究。所有患者均给予适当的抗心力衰竭治疗,比较治疗前后不同心功能分级患者的血浆NT-proBNP水平变化情况;并根据NTproBNP水平由低至高将患者分为3组(A、B、C),随访两年,比较3组患者的再住院率及生存率,研究NT-proBNP与患者再住院率及生存率的关系。结果治疗前,心力衰竭心功能分级越高,其NT-proBNP水平越高,但经抗心力衰竭治疗后NT-proBNP水平均显著降低(P0.01);A组低NT-proBNP水平患者的再住院率最低,生存率最高,与B组、C组比较差异有统计学意义(P0.01);NTproBNP水平与患者的再住院率呈正相关(P0.05),而与患者的生存率则呈负相关(P0.05)。结论 NT-proBNP与慢性心力衰竭患者的再住院率及生存率密切相关,能为老年慢性心力衰竭患者预后评估及临床疗效评估提供客观的依据。     

Context Matters in Heart Failure Self-Care: A Qualitative Systematic Review

BackgroundThe aim of this work was to identify the main contextual factors and processes that influence patients' self-care of heart failure (HF).Methods and ResultsA systematic review was conducted with the use of qualitative meta-synthesis. Ten databases were searched up to March 19, 2012. Of the 1,421 papers identified by the systematic search, 45 studies were included in this meta-synthesis. To be included, studies had to contain a qualitative research component, data pertaining to self-care of HF from adults (≥18 y) and be published as full papers or theses since 1995. These studies involved: 1,398 patients (mean age 65.9 y), 180 caregivers, and 63 health professionals. Six main types of contextual factors were found to influence HF self-care in the studies: caregivers; social networks and social support; place; finances and financial capacity; work and occupation; and HF support groups and programs.ConclusionHF self-care is influenced by contextual elements that fall outside of traditional elements of a HF self-care program. Inclusion of these elements may help to address the current concerns about poor adherence to self-management programs.     

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.