Impact of clinical characteristics and management on the prognosis of unselected heart failure patients

The prescription of beta-blockers in older patients with heart failure with reduced ejection fraction: an observational study in Vietnam

This study in older hospitalized patients with heart failure with reduced ejection fraction (HFrEF) aimed to examine the prevalence of beta-blocker prescription and its associated factors. A total of 190 participants were recruited from July 2019 to July 2020. The inclusion criteria included: (1) aged ≥ 60 years, (2) having a diagnosis of chronic HFrEF in the medical records, (3) hospitalized for at least 48 h. The participants had a mean age of 75.5 ± 9.1, and 46.8% were female. Of these, 55.3% were prescribed beta-blockers during admission. To explore the factors associated with beta-blocker prescription, multivariable logistic regression analysis was applied and the results were presented as odds ratios (OR) and 95% confidence intervals (CI). On multivariate logistic regression models, higher NYHA classes (OR 0.49, 95%CI 0.26-0.94), chronic obstructive pulmonary disease (OR 0.17, 95% CI 0.04-0.85), chronic kidney disease (OR 0.40, 95% CI 0.19-0.83), and heart rate under 65 (OR 0.34, 95% CI 0.12-0.98) were associated with a reduced likelihood of prescription. In this study, we found a low rate of beta-blocker prescriptions, with only around half of the participants being prescribed beta-blockers. Further studies are needed to examine the reasons for the under-prescription of beta-blockers, and to evaluate the long-term benefits of beta-blockers in elderly patients with HFrEF in this population.

Global Comparison of Readmission Rates for Patients With Heart Failure

BACKGROUND

Heart failure (HF) readmission rates are low in some jurisdictions. However, international comparisons are lacking and could serve as a foundation for identifying regional patient management strategies that could be shared to improve outcomes.

OBJECTIVES

This study sought to summarize 30-day and 1-year all-cause readmission and mortality rates of hospitalized HF patients across countries and to explore potential differences in rates globally.

METHODS

We performed a systematic review and meta-analysis using MEDLINE, Embase, and CENTRAL for observational reports on hospitalized adult HF patients at risk for readmission or mortality published between January 2010 and March 2021. We conducted a meta-analysis of proportions using a random-effects model, and sources of heterogeneity were evaluated with meta-regression.

RESULTS

In total, 24 papers reporting on 30-day and 23 papers on 1-year readmission were included. Of the 1.5 million individuals at risk, 13.2% (95% CI: 10.5%-16.1%) were readmitted within 30 days and 35.7% (95% CI: 27.1%-44.9%) within 1 year. A total of 33 papers reported on 30-day and 45 papers on 1-year mortality. Of the 1.5 million individuals hospitalized for HF, 7.6% (95% CI: 6.1%-9.3%) died within 30 days and 23.3% (95% CI: 20.8%-25.9%) died within 1 year. Substantial variation in risk across countries was unexplained by countries' gross domestic product, proportion of gross domestic product spent on health care, and Gini coefficient.

CONCLUSIONS

Globally, hospitalized HF patients exhibit high rates of readmission and mortality, and the variability in readmission rates was not explained by health care expenditure, risk of mortality, or comorbidities.

Impact of nutritional status on heart failure mortality: a retrospective cohort study

Background

Chronic heart failure (CHF) is one of the most common causes of mortality in industrialized countries despite regular therapeutic advances. Numerous factors influence mortality in CHF patients, including nutritional status. It is known that malnutrition is a risk factor for mortality, whereas obesity may play a protective role, a phenomenon dubbed the “obesity paradox”. However, the effect of the obesity-malnutrition association on mortality has not been previously studied for CHF. Our aim was to study the effect of nutritional status on overall mortality in CHF patients.

Methods

This retrospective, multicenter study was based on a French nationwide database (PMSI). We included all CHF patients aged ≥18 years admitted to all public and private hospitals between 2012 and 2016 and performed a survival analysis over 1 to 4 years of follow-up.

Results

Malnutrition led to a significant decrease in life expectancy in CHF patients when compared with normal nutritional status (aHR=1.16 [1.14-1.18] at one year and aHR=1.04 [1.004-1.08] at four years), obese, and obese-malnutrition groups. In contrast, obesity led to a significant increase in life expectancy compared with normal nutritional status (aHR=0.75 [0.73-0.78] at one year and aHR=0.85 [0.81-0.90] at four years), malnutrition, and obese-malnutrition groups. The mortality rate was similar in patients presenting both malnutrition and obesity and patients with normal nutritional status.

Conclusions

Our results indicate that the protective effect on mortality observed in obese CHF patients seems to be linked to fat massincrease. Furthermore, malnourished obese and normal nutritional status patients had similar mortality rates. Further studies should be conducted to confirm our results and to explore the physiopathological mechanisms behind these effects.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12937-021-00753-x.

Temporal Relationship between Atrial Fibrillation and Heart Failure Development Analysis from a Nationwide Database

Background Atrial fibrillation (AF) and heart failure (HF) often co-exist and are closely intertwined, each condition worsening the other. The temporal relationships between these two disorders have not yet been fully explored. We aimed to address the outcomes of patients hospitalized with HF and AF based on the chronology of the onset of the two disorders. Methods From the administrative database for the whole French population, we identified 1,349,638 patients diagnosed with both AF and HF between 2010 and 2018; 956,086 of these AF patients developed HF first (prevalent HF), and 393,552 developed HF after AF (incident HF). The outcome analysis (all-cause death, cardiovascular (CV) death, ischemic stroke or hospitalization for HF) was performed with follow-up starting at the time of last event between AF or HF in the whole cohort and in 427,848 propensity score-matched patients. Results During follow-up (mean follow-up 1.6 ± 1.9 year), matched patients with prevalent HF had a higher risk of all-cause death (21.6 vs. 19.3%/year, hazard ratio (HR) 1.10, 95% CI 1.08–1.11), CV death (7.7 vs. 6.5%/year, HR 1.14, 95% CI 1.12–1.16) as well as re-hospitalization for HF (19.4 vs. 13.2%/year, HR 1.44, 95% CI 1.41–1.46) than those with incident HF. The risk for ischemic stroke was lower in prevalent HF than in incident HF (1.2 vs. 2.4%/year, HR 0.50, 95% CI 0.48–0.52). Conclusions We identified two distinct clinical entities: patients in whom HF preceded AF (prevalent HF) had higher mortality and higher risk of re-hospitalization for HF.

Heart failure medication after a first hospital admission and risk of heart failure readmission, focus on beta-blockers and renin-angiotensin-aldosterone system medication: A retrospective cohort study in linked databases

BACKGROUND

This study assessed the association between heart failure (HF) medication (angiotensin-converting-enzyme inhibitors (ACEI)/angiotensin-receptor blockers (ARB), beta-blockers (BB), mineralocorticoid-receptor antagonists (MRA) and diuretics) and HF readmissions in a real-world unselected group of patients after a first hospital admission for HF. Furthermore we analysed readmission rates for ACEI versus ARB and for carvedilol versus β1-selective BB and we investigated the effect of HF medication in relation to time since discharge.

METHODS AND FINDINGS

Medication at discharge was determined with dispensing data from the Dutch PHARMO Database Network including 22,476 patients with HF between 2001 and 2015. After adjustment for age, gender, number of medications and year of admission no associations were found for users versus non-users of ACEI/ARB (hazard ratio, HR = 1.01; 95%CI 0.96-1.06), BB (HR = 1.00; 95%CI 0.95-1.05) and readmissions. The risk of readmission for patients prescribed MRA (HR = 1.11; 95%CI 1.05-1.16) or diuretics (HR = 1.17; 95%CI 1.09-1.25) was higher than for non-users. The HR for ARB relative to ACEI was 1.04 (95%CI 0.97-1.12) and for carvedilol relative to β1-selective BB 1.33 (95%CI 1.20-1.46). Post-hoc analyses showed a protective effect shortly after discharge for most medications. For example one month post discharge the HR for ACEI/ARB was 0.77 (95%CI 0.69-0.86). Although we did try to adjust for confounding by indication, probably residual confounding is still present.

CONCLUSIONS

Patients who were prescribed carvedilol have a higher or at least a similar risk of HF readmission compared to β1-selective BB. This study showed that all groups of HF medication -some more pronounced than others- were more effective immediately following discharge.

Effectiveness by gender and age of renin-angiotensin system blockade in heart failure-A national register-based cohort study

Purpose

Investigate effectiveness by gender and age and equity implications of treatment with renin‐angiotensin system blockade (RASb) in heart failure (HF) patients.

Methods

In this population‐based register study, we used inpatient data from 2006 to 2010 for patients age 20 years or older with no HF hospitalisation for minimum of 1 year before an index hospitalisation. A wash‐out period for RASb of 6 months preceding admission was used.

Hospital data were linked with drug dispensation data and cause of death data. The associations between time‐dependent RASb exposure and all‐cause death and HF death, respectively, were examined by Cox regression models. Interactions by gender and age were also investigated on the multiplicative and additive scales.

Results

Thirty thousand seven hundred twenty‐one patients were analysed. Fifty‐one percent were women. Median age was 83. Fifty‐three percent of women and 64% of men received RASb after the index hospitalisation. Younger patients were more likely to receive RASb than older ones. One‐year mortality was 28%. RASb was associated with an overall hazard ratio (HR) for all‐cause death of 0.72 (95% confidence interval 0.69‐0.75), and an HR of 0.85 (0.77‐0.93) for HF death. Interaction analyses showed HRs for all‐cause death associated with RASb between 0.12 (0.10‐0.13) in the youngest, and 0.80 (0.76‐0.84) in the oldest patients.

Conclusions

RASb appeared effective for women and men and for patients of all ages in this hospitalised HF cohort. No gender difference in effectiveness was found. RASb exposure was low overall, indicating a need for improved adherence to treatment guidelines. Treatment with RASb may be inequitable for women and older patients.

Effect of Optimization of Medical Treatment on Long-Term Survival of Patients With Heart Failure After Implantable Cardioverter Defibrillator and Cardiac Resynchronization Device Implantation (from the French National EGB Database)

Prognosis of heart failure with reduced ejection fraction (HFrEF) is improved by drug optimization according to guidelines; however, little is known regarding such optimization in HFrEF patients with an implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT). This study aimed to describe implementation of this optimized strategy and its impact in patients implanted with an ICD/CRT. Using a 1/97th representative sample of the French national health-care insurance system claims database, a retrospective cohort study was conducted including HFrEF patients implanted with ICD or CRT between January 2009 and December 2014. HFrEF treatments were analyzed before and after ICD/CRT implantation. Heart failure (HF) hospitalization and survival were examined at 1, 3, and 5 years: 378 patients (135 CRT, 243 ICD) with a mean age of 68 ± 13 years were included. Mean follow-up was 23 months [11-42]. At baseline, 36% of patients had no or only 1 HFrEF drug among β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and mineralocorticoid receptor antagonists, whereas 26% of patients received an optimal treatment (all 3 classes). At 3 months after ICD/CRT implantation, the prescription rate of HFrEF drugs was higher than baseline but returned to preimplantation levels at the end of follow-up. HF hospitalization rate was higher in the nonoptimized patient group (28% vs 14%, p = 0.001). Optimal HFrEF treatment was associated with better survival (hazard ratio = 0.59 [0.4-0.86], p = 0.006). In conclusion, HFrEF drugs are underprescribed before and after ICD/CRT implantation despite the demonstration that HFrEF drug optimization also reduces death and HF hospitalization in this population.

Creation and validation of the acute heart failure risk score: AHFRS

Our aims were to create and validate a clinical decision rule to assess severity in acute heart failure. We conducted a prospective cohort study of patients with symptoms of acute heart failure who attended the emergency departments (EDs) of three hospitals between April 2011 and April 2013. The following data were collected on arrival to or during the stay in the ED: baseline severity of symptoms; presence of decompensated comorbidities; number of hospital admissions/visits to EDs for acute heart failure during the previous 24 months; triggers of the exacerbation; clinical signs and symptoms; results of ancillary tests requested in the ED; treatments prescribed; and response to the initial treatment in the ED. The main outcome was poor course during the acute phase, in-hospital for admitted patients and during the first week following the ED visit for discharged patients, this being a composite endpoint that included death, admission to an intensive care unit, need for invasive mechanical ventilation, cardiac arrest and use of non-invasive mechanical ventilation. Multivariate logistic regression models were developed. Predictors of poor course in acute heart failure were oedema on chest radiography, visits to the ED and/or admissions in the previous two years, and levels of glycemia and blood urea nitrogen (areas under the curve of 0.83 in the derivation sample, and 0.82 in the validation sample). Four clinical predictors available in the ED can be used to create a simple score to predict poor course in acute heart failure.Clinical Trials.gov ID: NCT02437058.

Acute Heart Failure in the Emergency Department: the SAFE-SIMEU Epidemiological Study

BACKGROUND

Patients with acute heart failure (AHF) have high rates of attendance to emergency departments (EDs), with significant health care costs.

OBJECTIVES

We aimed to describe the clinical characteristics of patients attending Italian EDs for AHF and their diagnostic and therapeutic work-up.

METHODS

We carried out a retrospective analysis on 2683 cases observed in six Italian EDs for AHF (January 2011 to June 2012).

RESULTS

The median age of patients was 84 years (interquartile range 12), with females accounting for 55.8% of cases (95% confidence interval [CI] 53.5-57.6%). A first episode of AHF was recorded in 55.3% (95% CI 55.4-57.2%). Respiratory disease was the main precipitating factor (approximately 30% of cases), and multiple comorbidities were recorded in > 50% of cases (history of acute coronary syndrome, chronic obstructive pulmonary disease, diabetes, chronic kidney disease, valvular heart disease). The treatment was based on oxygen (69.7%; 67.9-71.5%), diuretics (69.2%; 67.9-71.5%), nitroglycerin (19.7%; 18.3-21.4%), and noninvasive ventilation (15.2%; 13.8-16.6%). Death occurred within 6 h in 2.5% of cases (2.0-3.1%), 6.4% (5.5-7.3%) were referred to the care of their general practitioners within a few hours from ED attendance or after short-term (< 24 h) observation 13.9% (12.6-15.2%); 60.4% (58.5-62.2%) were admitted to the hospital, and 16.8% (15.4-18.3%) were cared for in intensive care units according to disease severity.

CONCLUSIONS

Our study reporting the "real-world" clinical activity indicates that subjects attending the Italian EDs for AHF are rather different from those reported in international registries. Subjects are older, with a higher proportion of females, and high prevalence of cardiac and noncardiac comorbidities.

Declining Risk of Sudden Death in Heart Failure

BACKGROUND

The risk of sudden death has changed over time among patients with symptomatic heart failure and reduced ejection fraction with the sequential introduction of medications including angiotensin-converting-enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, and mineralocorticoid-receptor antagonists. We sought to examine this trend in detail.

METHODS

We analyzed data from 40,195 patients who had heart failure with reduced ejection fraction and were enrolled in any of 12 clinical trials spanning the period from 1995 through 2014. Patients who had an implantable cardioverter-defibrillator at the time of trial enrollment were excluded. Weighted multivariable regression was used to examine trends in rates of sudden death over time. Adjusted hazard ratios for sudden death in each trial group were calculated with the use of Cox regression models. The cumulative incidence rates of sudden death were assessed at different time points after randomization and according to the length of time between the diagnosis of heart failure and randomization.

RESULTS

Sudden death was reported in 3583 patients. Such patients were older and were more often male, with an ischemic cause of heart failure and worse cardiac function, than those in whom sudden death did not occur. There was a 44% decline in the rate of sudden death across the trials (P=0.03). The cumulative incidence of sudden death at 90 days after randomization was 2.4% in the earliest trial and 1.0% in the most recent trial. The rate of sudden death was not higher among patients with a recent diagnosis of heart failure than among those with a longer-standing diagnosis.

CONCLUSIONS

Rates of sudden death declined substantially over time among ambulatory patients with heart failure with reduced ejection fraction who were enrolled in clinical trials, a finding that is consistent with a cumulative benefit of evidence-based medications on this cause of death. (Funded by the China Scholarship Council and the University of Glasgow.).

Evaluation of mortality and readmissions following hospitalization with heart failure

OBJECTIVE

To examine the association of patient/clinical characteristics with mortality and readmission following a heart failure (HF)-related hospitalization.

RESEARCH DESIGN AND METHODS

Claims data, linked to laboratory, race/ethnicity, and mortality data, from a large US health plan were utilized to identify individuals with ≥1 inpatient claim with a diagnosis code for HF (1 January 2008-30 September 2012). Study variables were analyzed using descriptive and multivariable approaches to identify patient/clinical characteristics associated with post-discharge outcomes.

MAIN OUTCOME MEASURES

Primary outcomes included post-discharge mortality and readmission.

RESULTS

A total of 126,214 individuals were identified with a HF-related hospitalization; 19.1% with data to calculate chronic kidney disease (CKD) stage. For the overall sample, mortality probability was 4.9% and 13.4% at 1 and 6 months post-discharge, respectively (4.5% and 12.4% for subset with calculated CKD stage), while readmission (all-cause) probability was 14.8% and 39.6% at 1 and 6 months post-discharge, respectively (18.4% and 44.5% for subset with calculated CKD stage). Within the subset with calculated CKD stage, mortality and readmission probabilities differed by CKD stage (p < 0.001), with decreased renal function corresponding with increased risk of mortality and readmission. After multivariable adjustment, increasing age was associated with increased risk of mortality, while advancing CKD stage, various index hospitalization variables (i.e., pre-admission emergency room visit, intensive care unit during hospitalization), and baseline all-cause hospitalization were associated with both increased risk of mortality and all-cause 1 month readmission.

CONCLUSIONS

Calculated CKD, various index hospitalization variables, and baseline all-cause hospitalization were associated with increased risk of mortality and all-cause 1 month readmission among patients hospitalized with HF. Risk of post-discharge readmission and mortality increased with worse renal function, suggesting that improved management of this subset may reduce the burden and cost of this disease. Key study limitations include those related to retrospective claims-based studies and that renal function data were available for a subset of study patients.

Incidence of tramadol shopping behavior in a retrospective cohort of chronic non-cancer pain patients in France

PURPOSE

Opioid analgesic use in chronic non-cancer pain (CNCP) is increasingly prevalent, but the benefits and risks are inadequately understood. In France, tramadol is one of the most used prescription opioids, but studies on its misuse liability in CNCP are still lacking. The aim was to assess the incidence of tramadol shopping behavior in CNCP patients and to identify the associated risk factors.

METHODS

A retrospective cohort of CNCP patients aged 18 years and older treated by tramadol for at least six consecutive months between 2005 and 2013 from a sample of the French Health Insurance database was established. Doctor shopping was defined as at least 1 day of overlapping prescriptions written by two or more different prescribers and filled in at least three different pharmacies.

RESULTS

A total of 3505 CNCP patients were included with a majority of women (66.4%) and a mean age of 66.4 ± 14.7 years. The median tramadol treatment duration was 260 [interquartile range: 211-356] days. The 1-year incidence rate of tramadol shopping behavior was 1.0% [95%CI: 0.7-1.5]. On multivariate analysis, risk factors associated with tramadol shopping behavior were age (hazard ratio [HR] = 7.4 [95%CI: 2.8-19.7] for age <40, HR = 2.8 [95%CI: 1.0-7.7] for 40 ≤ age < 50, versus age ≥50), low-income status (HR = 8.5 [95%CI: 3.6-20.5]), and prior use of strong opioids (HR = 5.7 [95%CI: 1.9-17.0]).

CONCLUSION

Tramadol shopping behavior incidence appears low in CNCP patients but may represent a public health concern given the widespread use of tramadol. Education and best monitoring of high-risk patients are needed to reduce doctor shopping. Copyright © 2016 John Wiley & Sons, Ltd.

Influence of heart failure on the prognosis of patients with acute myocardial infarction in southwestern China

The impact of heart failure (HF) on acute myocardial infarction (AMI) in patients from southwestern China remains unclear. The present study aimed to compare in-hospital cardiovascular events, mortality and clinical therapies in AMI patients with or without HF in southwestern China. In total, 591 patients with AMI hospitalized between February 2009 and December 2012 were examined; those with a history of HF were excluded. The patients were divided into four groups according to AMI type (ST-elevated or non-ST-elevated AMI) and the presence of HF during hospitalization. Clinical characteristics, in-hospital cardiovascular events, mortality, coronary angiography and treatment were compared. Clinical therapies, specifically evidence-based drug use were analyzed in patients with HF during hospitalization, including angiotensin converting enzyme inhibitors (ACEIs) and β-blockers (BBs). AMI patients with HF had a higher frequency of co-morbidities, lower left ventricular ejection fraction, longer length of hospital stay and a greater risk of in-hospital mortality compared with AMI patients without HF. AMI patients with HF were less likely to be examined by cardiac angiography or treated with reperfusion therapy or recommended medications. AMI patients with HF co-treated with ACEIs and BBs had a significantly higher survival rate (94.4 vs. 67.5%; P<0.001) compared with untreated patients or patients treated with either ACEIs or BBs alone. Logistic regression analysis revealed that HF and cardiogenic shock in patients with AMI were the strongest predictors of in-hospital mortality. AMI patients with HF were at a higher risk of adverse outcomes. Cardiac angiography and timely standard recommended medications were associated with improved clinical outcomes.

Prognosis and management of myocardial infarction: Comparisons between the French FAST-MI 2010 registry and the French public health database

BACKGROUND

Multicentre registries of myocardial infarction management show a steady improvement in prognosis and greater access to myocardial revascularization in a more timely manner. While French registries are the standard references, the question arises: are data stemming solely from the activity of French cardiac intensive care units (ICUs) a true reflection of the entire French population with ST-segment elevation myocardial infarction (STEMI)?

AIM

To compare data on patients hospitalized for STEMI from two French registries: the French registry of acute ST-elevation or non-ST-elevation myocardial infarction (FAST-MI) and the Échantillon généraliste des bénéficiaires (EGB) database.

METHODS

We compared patients treated for STEMI listed in the FAST-MI 2010 registry (n=1716) with those listed in the EGB database, which comprises a sample of 1/97th of the French population, also from 2010 (n=403).

RESULTS

Compared with the FAST-MI 2010 registry, the EGB database population were older (67.2±15.3 vs 63.3±14.5 years; P<0.001), had a higher percentage of women (36.0% vs 24.7%; P<0.001), were less likely to undergo emergency coronary angiography (75.2% vs 96.3%; P<0.001) and were less often treated in university hospitals (27.1% vs 37.0%; P=0.001). There were no significant differences between the two registries in terms of cardiovascular risk factors, comorbidities and drug treatment at admission. Thirty-day mortality was higher in the EGB database (10.2% vs 4.4%; P<0.001).

CONCLUSIONS

Registries such as FAST-MI are indispensable, not only for assessing epidemiological changes over time, but also for evaluating the prognostic effect of modern STEMI management. Meanwhile, exploitation of data from general databases, such as EGB, provides additional relevant information, as they include a broader population not routinely admitted to cardiac ICUs.