The comorbidity conundrum: a focus on the role of noncardiovascular chronic conditions in the heart failure patient

Admission prioritization of heart failure patients with multiple comorbidities

The primary objective of this study was to enhance the operational efficiency of the current healthcare system by proposing a quicker and more effective approach for healthcare providers to deliver services to individuals facing acute heart failure (HF) and concurrent medical conditions. The aim was to support healthcare staff in providing urgent services more efficiently by developing an automated decision-support Patient Prioritization (PP) Tool that utilizes a tailored machine learning (ML) model to prioritize HF patients with chronic heart conditions and concurrent comorbidities during Urgent Care Unit admission. The study applies key ML models to the PhysioNet dataset, encompassing hospital admissions and mortality records of heart failure patients at Zigong Fourth People's Hospital in Sichuan, China, between 2016 and 2019. In addition, the model outcomes for the PhysioNet dataset are compared with the Healthcare Cost and Utilization Project (HCUP) Maryland (MD) State Inpatient Data (SID) for 2014, a secondary dataset containing heart failure patients, to assess the generalizability of results across diverse healthcare settings and patient demographics. The ML models in this project demonstrate efficiencies surpassing 97.8% and specificities exceeding 95% in identifying HF patients at a higher risk and ranking them based on their mortality risk level. Utilizing this machine learning for the PP approach underscores risk assessment, supporting healthcare professionals in managing HF patients more effectively and allocating resources to those in immediate need, whether in hospital or telehealth settings.

A large, multi-center survey assessing health, social support, literacy, and self-management resources in patients with heart failure

BACKGROUND

Most patients with heart failure (HF) have multimorbidity which may cause difficulties with self-management. Understanding the resources patients draw upon to effectively manage their health is fundamental to designing new practice models to improve outcomes in HF. We describe the rationale, conceptual framework, and implementation of a multi-center survey of HF patients, characterize differences between responders and non-responders, and summarize patient characteristics and responses to the survey constructs among responders.

METHODS

This was a multi-center cross-sectional survey study with linked electronic health record (EHR) data. Our survey was guided by the Chronic Care Model to understand the distribution of patient-centric factors, including health literacy, social support, self-management, and functional and mental status in patients with HF. Most questions were from existing validated questionnaires. The survey was administered to HF patients aged ≥ 30 years from 4 health systems in PCORnet® (the National Patient-Centered Clinical Research Network): Essentia Health, Intermountain Health, Mayo Clinic, and The Ohio State University. Each health system mapped their EHR data to a standardized PCORnet Common Data Model, which was used to extract demographic and clinical data on survey responders and non-responders.

RESULTS

Across the 4 sites, 10,662 patients with HF were invited to participate, and 3330 completed the survey (response rate: 31%). Responders were older (74 vs. 71 years; standardized difference (95% CI): 0.18 (0.13, 0.22)), less racially diverse (3% vs. 12% non-White; standardized difference (95% CI): -0.32 (-0.36, -0.28)), and had higher prevalence of many chronic conditions than non-responders, and thus may not be representative of all HF patients. The internal reliability of the validated questionnaires in our survey was good (range of Cronbach's alpha: 0.50-0.96). Responders reported their health was generally good or fair, they frequently had cardiovascular comorbidities, > 50% had difficulty climbing stairs, and > 10% reported difficulties with bathing, preparing meals, and using transportation. Nearly 80% of patients had family or friends sit with them during a doctor visit, and 54% managed their health by themselves. Patients reported generally low perceived support for self-management related to exercise and diet.

CONCLUSIONS

More than half of patients with HF managed their health by themselves. Increased understanding of self-management resources may guide the development of interventions to improve HF outcomes.

Scoping Review of Measures of Comorbidities in Heart Failure

BACKGROUND

Comorbidities are risk factors for poor clinical outcomes in patients with heart failure. However, no consensus has been reached on how to assess comorbidities related to clinical outcomes in patients with heart failure.

OBJECTIVE

The aims of this study were to review (1) how comorbidities have been assessed, (2) what chronic conditions have been identified as comorbidities and (3) the rationale for choosing the comorbidity instruments and/or specific comorbidities when exploring clinical outcomes in patients with heart failure.

METHODS

The clinical outcomes of interest were mortality, hospitalization, quality of life, and self-care. Three electronic databases and reference list searches were used in the search.

RESULTS

In this review, we included 39 articles using 3 different ways to assess comorbidities in the relationship with clinical outcomes: using an instrument (ie, Charlson Comorbidity Index), disease count, and including individual comorbidities. A total of 90 comorbidities were investigated in the 39 articles; however, definitions and labels for the diseases were inconsistent across the studies. More than half of the studies (n = 22) did not provide a rationale for selecting the comorbidity instruments and/or all of the specific comorbidities. Some of the rationale for choosing the instruments and/or specific comorbidities was inappropriate.

CONCLUSIONS

We found several issues related to measuring comorbidities when examining clinical outcomes in patients with heart failure. Researchers need to consider these methodological issues when measuring comorbidities in patients with heart failure. Further efforts are needed to develop guidelines on how to choose proper measures for comorbidities.

Activities of Daily Living and Outcomes in Patients with Advanced Heart Failure

BACKGROUND

Functional debility is associated with worse outcomes in the general heart failure population, but the prevalence of difficulty with activities of daily living and clinical significance once patients develop advanced heart failure requires further examination.

METHODS

This was a population-based, retrospective cohort study of Olmsted County, Minnesota adults with advanced heart failure from 2007-2018. Difficulty with 9 activities of daily living was assessed by questionnaire. Predictors of difficulty were assessed by a proportional odds model. Associations of difficulty with activities of daily living with mortality and hospitalization were examined using Cox and Andersen-Gill models.

RESULTS

Among 765 patients with advanced heart failure, 565 (73.9%) reported difficulty with activities of daily living at diagnosis. Of those, 257 (45%) had moderate and 148 (26%) had severe difficulty. Independent predictors of difficulty included female sex (odds ratio [OR] 1.73; 95% confidence interval [CI], 1.26-2.36; P = .001), older age (OR per 10-year increase 1.17; 95% CI, 1.05-1.31; P = .005), dementia (OR 1.85; 95% CI, 1.06-3.24; P = .031), depression (OR 1.75; 95% CI, 1.28-2.40; P = .001), and morbid obesity (OR 1.49; 95% CI, 1.04-2.13; P = .031). Estimated 2-year mortality was 61.5%, 64.2%, and 67.6% in patients with no/minimal, moderate, and severe difficulty, respectively. The adjusted hazard ratios (95% CI) for death were 1.08 (0.90-1.28) and 1.17 (0.95-1.43) for moderate and severe difficulty, respectively, vs no/minimal difficulty (P = .33). There were no statistically significant associations of difficulty with activities of daily living and hospitalization risks.

CONCLUSIONS

Most patients with advanced heart failure have difficulty completing activities of daily living and are at high risk of mortality regardless of impairment in activities of daily living.

Potentially inappropriate medications for patients with heart failure and risk of hospitalization from heart failure: A case-control study from Thailand

Background

Thailand have developed a list of potentially inappropriate medications for patients with heart failure (PIMHF). However, its association with clinical outcomes has not been evaluated in real-world clinical practice.

Objective

To examine the association between the prescription of any PIMHF and hospitalization from heart failure (HF).

Methods

A 1:1 matched case-control study was conducted. Data on HF patients visiting the study hospitals during 2017-2019 were obtained from the electronic medical record database. Patients with a history of first hospitalization due to HF and those with a history of outpatient department visits or non-HF hospitalization were defined as cases and controls, respectively. The association of hospitalization from HF with the prescription of any PIMHF was expressed as the adjusted odds ratio (aOR) and 95% confidence interval (95%CI), calculated using a conditional logistic regression (CLR) model.

Results

After matching, 1,603 pairs of case and control were generated for the analysis. In total, 21 of 47 PIMHF were found to have been prescribed. Compared with the reference group of patients not prescribed any of the 21 PIMHF, those who had been prescribed a PIMHF had an aOR of 1.47 [95%CI 1.02:2.13]. NSAIDs/COX-2 inhibitors, oral short-acting beta-2 agonists, medications that promote fluid overload, and medications that elevate blood pressure were the four medication classes associated with the increased risk of hospitalization from HF (aOR = 2.64, [95%CI 1.30:5.38], aOR = 4.87, [95%CI 1.17:20.29], aOR = 1.50, [95%CI 1.01:2.22], and aOR = 2.51, [95%CI 1.26:4.99], respectively).

Conclusions

The prescription of any of the 21 PIMHF found to have been prescribed in this study may increase the risk of hospitalization from HF. The Thai PIMHF list may be used in pharmacy practice as an assessment tool for the appropriate use of medication in HF patients.

Prevalence and associated factors of potentially inappropriate medications among Thai patients with heart failure

BACKGROUND

Several medications may worsen heart failure (HF), and they are considered as potentially inappropriate medications for patients with heart failure (PIMHF). No studies reported the prevalence of PIMHF use and its associated factors in Thai HF patients.

OBJECTIVE

To determine the prevalence of PIMHF use and identify factors associated with PIMHF use.

MATERIAL AND METHOD

A cross-sectional study was conducted using data on HF patients obtained from the electronic medical databases (EMDs) of two hospitals, including a secondary and a tertiary care hospital. Data collected included demographics, diagnoses and medications prescribed during 2016-2019. The prevalence of PIMHF use identified by the Thailand list of PIMHF was determined. Patient and clinical factors were examined whether they were associated with PIMHF use by calculating the adjusted odds ratio (aOR) and 95% confidence interval (95% CI) using a binary logistic regression analysis.

RESULTS

From the EMD, 972 and 2888 eligible HF patients from a secondary and a tertiary care hospital, respectively, were included in this study. The prevalence of PIMHF use was 45.16% and 33.07% at a secondary and a tertiary care hospital, respectively. Factors associated with PIMHF use were HFpEF (aOR = 1.68, 95% CI = 1.39-2.03), diabetes mellitus (DM) (aOR = 1.66, 95% CI = 1.35-2.05), renal failure (RF) (aOR = 1.49, 95% CI = 1.21-1.84), chronic pulmonary diseases (CPD) (aOR = 2.41, 95% CI = 1.74-3.34), connective tissue diseases (CTD) (aOR = 5.21, 95% CI = 2.17-12.49), and cancer (aOR = 2.57, 95% CI = 1.36-4.86).

CONCLUSION

PIMHF use according to the Thailand list of PIMHF was prevalent in Thai HF patients and associated with HFpEF, DM, RF, CPD, CTD and cancer.

Factors associated with in-hospital mortality and adverse outcomes during the vulnerable post-discharge phase after the first episode of acute heart failure: results of the NOVICA-2 study

OBJECTIVE

To identify patients at risk of in-hospital mortality and adverse outcomes during the vulnerable post-discharge period after the first acute heart failure episode (de novo AHF) attended at the emergency department.

METHODS

This is a secondary review of de novo AHF patients included in the prospective, multicentre EAHFE (Epidemiology of Acute Heart Failure in Emergency Department) Registry. We included consecutive patients with de novo AHF, for whom 29 independent variables were recorded. The outcomes were in-hospital all-cause mortality and all-cause mortality and readmission due to AHF within 90 days post-discharge. A follow-up check was made by reviewing the hospital medical records and/or by phone.

RESULTS

We included 3422 patients. The mean age was 80 years, 52.1% were women. The in-hospital mortality was 6.9% and was independently associated with dementia (OR = 2.25, 95% CI = 1.62-3.14), active neoplasia (1.97, 1.41-2.76), functional dependence (1.58, 1.02-2.43), chronic treatment with beta-blockers (0.62, 0.44-0.86) and severity of decompensation (6.38, 2.86-14.26 for high-/very high-risk patients). The 90-day post-discharge combined endpoint was observed in 19.3% of patients and was independently associated with hypertension (HR = 1.40, 1.11-1.76), chronic renal insufficiency (1.23, 1.01-1.49), heart valve disease (1.24, 1.01-1.51), chronic obstructive pulmonary disease (1.22, 1.01-1.48), NYHA 3-4 at baseline (1.40, 1.12-1.74) and severity of decompensation (1.23, 1.01-1.50; and 1.64, 1.20-2.25; for intermediate and high-/very high-risk patients, respectively), with different risk factors for 90-day post-discharge mortality or rehospitalisation.

CONCLUSIONS

The severity of decompensation and some baseline characteristics identified de novo AHF patients at increased risk of developing adverse outcomes during hospitalisation and the vulnerable post-discharge phase, without significant differences in these risk factors according to patient age at de novo AHF presentation.

Spironolactone metabolite concentrations in decompensated heart failure: insights from the ATHENA-HF trial

AIMS

In Aldosterone Targeted Neurohormonal Combined with Natriuresis Therapy in Heart Failure (ATHENA-HF), high-dose spironolactone (100 mg daily) did not improve efficacy endpoints over usual care [placebo or continued low-dose spironolactone (25 mg daily) in patients already receiving spironolactone] in the treatment of acute heart failure (HF). We hypothesized that low concentrations of the long-acting active metabolites of spironolactone [canrenone and 7α-thiomethylspironolactone (7α-TMS)] in the high-dose group could have contributed to these neutral results.

METHODS AND RESULTS

In patients randomized to high-dose spironolactone not previously treated with spironolactone (high-dose-naïve, n = 112), concentrations of canrenone and 7α-TMS increased at 48 and 96 h compared to baseline, and between 48 and 96 h (all P < 0.005), indicating that steady-state concentrations had not been reached by 48 h. In patients previously on low-dose, high-dose spironolactone (high-dose-previous, n = 37), concentrations of canrenone increased at 48 and 96 h compared to baseline (both P < 0.0005), with a marginal increase between 48 and 96 h (P = 0.0507). At 48 h, both high-dose groups had higher concentrations of both metabolites than the low-dose spironolactone group (P < 0.0001). Moreover, concentrations of both metabolites were higher in high-dose-previous vs. high-dose-naïve patients (P < 0.01), indicating that previous spironolactone use was significant, and that steady-state has not been reached in high-dose-naïve patients at 48 h. We found limited and inconsistent evidence of correlation between metabolite concentrations and endpoints.

CONCLUSIONS

Lower-than-anticipated concentrations of spironolactone active metabolites were observed for at least 48 h in the high-dose spironolactone group and may have contributed to the absence of pharmacological effects of spironolactone in the ATHENA-HF trial.

Does depressed persons with non-cardiovascular morbidity have a higher risk of CVD? A population-based cohort study in Sweden

BACKGROUND

Depression often co-exists with non-cardiovascular morbid conditions. Whether this comorbidity increases the risk of cardiovascular disease has so far not been studied. Thus, the aim of this study was to determine if non-cardiovascular morbidity modifies the effect of depression on future risk of CVD.

METHODS

Data was derived from the PART study (acronym in Swedish for: Psykisk hälsa, Arbete och RelaTioner: Mental Health, Work and Relationships), a longitudinal cohort study on mental health, work and relations, including 10,443 adults (aged 20-64 years). Depression was assessed using the Major Depression Inventory (MDI) and self-reported data on non-cardiovascular morbidity was assessed in 1998-2000. Outcomes of CVD were assessed using the National Patient Register during 2001-2014.

RESULTS

Both depression (HR 1.5 (95% CI, 1.1, 2.0)) and non-cardiovascular morbidity (HR 2.0 (95% CI, 1.8, 2.6)) were associated with an increased future risk of CVD. The combined effect of depression and non-cardiovascular comorbidity on future CVD was HR 2.1 (95%, CI 1.3, 3.4) after adjusting for age, gender and socioeconomic position. Rather similar associations were seen after further adjustment for hypertension, diabetes and unhealthy lifestyle factors.

CONCLUSION

Persons affected by depression in combination with non-cardiovascular morbidity had a higher risk of CVD compared to those without non-cardiovascular morbidity or depression alone.

Medication regimen complexity in ambulatory older adults with heart failure

PURPOSE

Heart failure prevalence is increasing in older adults, and polypharmacy is a major problem in this population. We compared medication regimen complexity using the validated patient-level Medication Regimen Complexity Index (pMRCI) tool in "young-old" (60-74 years) versus "old-old" (75-89 years) patients with heart failure. We also compared pMRCI between patients with ischemic cardiomyopathy (ISCM) versus nonischemic cardiomyopathy (NISCM).

PATIENTS AND METHODS

Medication lists were retrospectively abstracted from the electronic medical records of ambulatory patients aged 60-89 years with heart failure. Medications were categorized into three types - heart failure prescription medications, other prescription medications, and over-the-counter (OTC) medications - and scored using the pMRCI tool.

RESULTS

The study evaluated 145 patients (n=80 young-old, n=65 old-old, n=85 ISCM, n=60 NISCM, mean age 73±7 years, 64% men, 81% Caucasian). Mean total pMRCI scores (32.1±14.4, range 3-84) and total medication counts (13.3±4.8, range 2-30) were high for the entire cohort, of which 72% of patients were taking eleven or more total medications. Total and subtype pMRCI scores and medication counts did not differ significantly between the young-old and old-old groups, with the exception of OTC medication pMRCI score (6.2±4 young-old versus 7.8±5.8 old-old, P=0.04). With regard to heart failure etiology, total pMRCI scores and medication counts were significantly higher in patients with ISCM versus NISCM (pMRCI score 34.5±15.2 versus 28.8±12.7, P=0.009; medication count 14.1±4.9 versus 12.2±4.5, P=0.008), which was largely driven by other prescription medications.

CONCLUSION

Medication regimen complexity is high in older adults with heart failure, and differs based on heart failure etiology. Additional work is needed to address polypharmacy and to determine if medication regimen complexity influences adherence and clinical outcomes in this population.

Evaluation of the predictors of readmission in Korean patients with heart failure

WHAT IS KNOWN AND OBJECTIVE

Various factors contribute to the high rate of readmission among patients hospitalized with heart failure (HF). Determination of these factors is fundamental to identify potential targets for intervention in hospitalized patients.

METHODS

The retrospective cohort study used a large national insurance database to identify episodes of HF. Clinical information up to 12 months from the index hospitalization was obtained. Depending on their outcome, eligible patients were classified into a 30-day readmission group after discharge or a non-readmission group. Potential predictors of 30-day readmission were categorized by patient, drug therapy and health system utilization factors.

RESULTS AND DISCUSSION

Heart failure was identified in 19 128 inpatients. Of these, 27·6% were readmitted within 30 days after discharge. The mean Charlson comorbidity index (CCI) score was 5·2 ± 2·9 for the readmission group and 4·3 ± 2·5 for the non-readmission group. The strongest predictors included paralysis [adjusted odds ratio (AOR) 2·27, 95% confidence interval (CI) 1·97-2·62], followed by metastatic cancer (AOR 2·22, 95% CI 1·81-2·72) and loop diuretic therapy (AOR 1·52, 95% CI 1·29-1·79). A prescription of ACE inhibitor or angiotensin receptor blocker at discharge was associated with a 17% decreased risk (AOR 0·83, 95% CI 0·77-0·89).

WHAT IS NEW AND CONCLUSIONS

Hospitalized patients with HF have a 30-day all-cause readmission rate exceeding a quarter. Post-discharge care should focus on patients with advanced age, acuity of admission, enrolled medical aid, hospitalization exceeding 14 days, higher CCI score, more than 10 prescription drugs at discharge, presence of several comorbidities and loop diuretic therapy, which are independent predictors for 30-day readmission.

Drugs That May Cause or Exacerbate Heart Failure: A Scientific Statement From the American Heart Association

Heart failure is a common, costly, and debilitating syndrome that is associated with a highly complex drug regimen, a large number of comorbidities, and a large and often disparate number of healthcare providers. All of these factors conspire to increase the risk of heart failure exacerbation by direct myocardial toxicity, drug-drug interactions, or both. This scientific statement is designed to serve as a comprehensive and accessible source of drugs that may cause or exacerbate heart failure to assist healthcare providers in improving the quality of care for these patients.

The Prognostic Value of Peripheral Artery Disease in Heart Failure: Insights from a Meta-analysis

BACKGROUND

Peripheral artery disease (PAD) is prevalent in individuals with heart failure (HF). We therefore performed a meta-analysis to assess the prognostic impact of PAD in HF patients.

METHODS

A systematic search of PubMed and The Cochrane Library was conducted to identify publications from inception to May 2015. We also manually assessed the reference lists of relevant literature for more eligible citations. Only studies reporting the risk of PAD for prognostic endpoints in HF were included in our meta-analysis.

RESULTS

The search strategy yielded eight studies comprising a total of 20,968 subjects, of whom 19.4% had a concurrent PAD. All-cause mortality in HF patients with PAD was profoundly higher than in those without this comorbidity (hazard ratio [HR] 1.36, 95% confidence interval [CI] 1.25 to 1.49). Peripheral artery disease was also associated with significant increases in HF hospitalisation and cardiovascular mortality in individuals with HF (HR 1.15, 95% CI 1.01 to 1.32; HR 1.31, 95% CI 1.13 to 1.52, respectively). Subgroup and sensitivity analyses supported the positive relationship between PAD and HF.

CONCLUSIONS

Peripheral artery disease is associated with a worse overall prognosis in HF patients, which highlights the need to increase focus on PAD as an important comorbidity in patients with HF.

Challenges in personalised management of chronic diseases-heart failure as prominent example to advance the care process

Chronic diseases are the leading causes of morbidity and mortality in Europe, accounting for more than 2/3 of all death causes and 75 % of the healthcare costs. Heart failure is one of the most prominent, prevalent and complex chronic conditions and is accompanied with multiple other chronic diseases. The current approach to care has important shortcomings with respect to diagnosis, treatment and care processes. A critical aspect of this situation is that interaction between stakeholders is limited and chronic diseases are usually addressed in isolation.

Health care in Western countries requires an innovative approach to address chronic diseases to provide sustainability of care and to limit the excessive costs that may threaten the current systems. The increasing prevalence of chronic diseases combined with their enormous economic impact and the increasing shortage of healthcare providers are among the most critical threats. Attempts to solve these problems have failed, and future limitations in financial resources will result in much lower quality of care. Thus, changing the approach to care for chronic diseases is of utmost social importance.

Influence of Cardiovascular and Noncardiovascular Co-morbidities on Outcomes and Treatment Effect of Heart Rate Reduction With Ivabradine in Stable Heart Failure (from the SHIFT Trial)

Incidence of chronic heart failure (HF) increases with age and cardiovascular (CV) morbidity. Co-morbidities increase hospitalization and mortality in HF, and non-CV co-morbidities may lead to preventable hospitalizations. We studied the impact of co-morbidities on mortality and morbidity in Systolic Heart Failure Treatment with the I(f) Inhibitor Ivabradine Trial, and investigated whether the impact of ivabradine was affected by co-morbidities. We analyzed the Systolic Heart Failure Treatment with the I(f) Inhibitor Ivabradine Trialpopulation, with moderate-to-severe HF and left ventricular dysfunction (in sinus rhythm with heart rate at rest ≥70 beats/min), according to co-morbidity: chronic obstructive pulmonary disease, diabetes mellitus, anemia, stroke, impaired renal function, myocardial infarction, hypertension, and peripheral artery disease. Co-morbidity load was classed as 0, 1, 2, 3, 4+ or 1 to 2 co-morbidities, or 3+ co-morbidities. Co-morbidities were evenly distributed between the placebo and ivabradine groups. Patients with more co-morbidities were likely to be older, women, had more advanced HF, were less likely to be on β blockers, with an even distribution on ivabradine 2.5, 5, or 7.5 mg bid and placebo at all co-morbidity loads. Number of co-morbidities was related to outcomes. Cardiovascular death or HF hospitalization events significantly increased (p <0.0001) with co-morbidity load, with the most events in patients with >3 co-morbidities for both, ivabradine and placebo. There was no interaction between co-morbidity load and the treatment effects of ivabradine. Hospitalization rate was lower at all co-morbidity loads for ivabradine. In conclusion, cardiac and noncardiac co-morbidities significantly affect CV outcomes, particularly if there are >3 co-morbidities. The effect of heart rate reduction with ivabradine is maintained at all co-morbidity loads.

Antecedents of self-care in adults with congenital heart defects

BACKGROUND

Adults with congenital heart defects (ACHD) face long-term complications related to prior surgery, abnormal anatomy, and acquired cardiovascular conditions. Although self-care is an important part of chronic illness management, few studies have explored self-care in the ACHD population. The purpose of this study is to describe self-care and its antecedents in the ACHD population.

METHODS

Persons with moderate or severe ACHD (N=132) were recruited from a single ACHD center. Self-care (health maintenance behaviors, monitoring and management of symptoms), and potential antecedents including sociodemographic and clinical characteristics, ACHD knowledge, behavioral characteristics (depressive symptoms and self-efficacy), and family-related factors (parental overprotection and perceived family support) were collected via self-report and chart review. Multiple regression was used to identify antecedents of self-care maintenance, monitoring, and management.

RESULTS

Only 44.7%, 27.3%, and 23.3% of participants performed adequate levels of self-care maintenance, monitoring and management, respectively. In multiple regression analysis, self-efficacy, education, gender, perceived family support, and comorbidities explained 25% of the variance in self-care maintenance (R(2)=.248, F(5, 123)=9.44, p<.001). Age, depressive symptoms, self-efficacy, and NYHA Class explained 23% of the variance in self-care monitoring (R(2)=.232, F(2, 124)=10.66, p<.001). Self-efficacy and NYHA Class explained 9% of the variance in self-care management (R(2)=.094, F(2, 80)=5.27, p=.007).

CONCLUSIONS

Low levels of self-care are common among persons with ACHD. Multiple factors, including modifiable factors of self-efficacy, depressive symptoms, and perceived family support, are associated with self-care and should be considered in designing future interventions to improve outcomes in the ACHD population.

Impact of a Telehealth and Care Management Program on All-Cause Mortality and Healthcare Utilization in Patients with Heart Failure

BACKGROUND

Telehealth has the potential to improve chronic disease management and outcomes, but data regarding direct benefit of telehealth in patients with heart failure (HF) have been mixed. The objective of this study was to determine whether the Health Buddy Program (HBP) (Bosch Healthcare, Palo Alto, CA), a content-driven telehealth system coupled with care management, is associated with improved outcomes in Medicare beneficiaries with HF.

MATERIALS AND METHODS

This was a retrospective cohort study of 623 Medicare beneficiaries with HF offered HBP enrollment compared with a propensity score-matched control group of Medicare beneficiaries with HF from the Medicare 5% sample. Associations between availability of the HBP and all-cause mortality, hospitalization, hospital days, and emergency department visits were evaluated.

RESULTS

Beneficiaries offered enrollment in the HBP had 24.9% lower risk-adjusted all-cause mortality over 3 years of follow-up (hazard ratio [HR] = 0.75; 95% confidence interval [CI], 0.63-0.89; p = 0.001). Patients who used the HBP at least once (36.9%) had 57.2% lower mortality compared with matched controls (HR = 0.43; 95% CI, 0.31-0.60; p < 0.001), whereas patients who did not use the HBP had no significant difference in survival (HR = 0.96; 95% CI, 0.78-1.19; p = 0.69). Patients offered the HBP also had fewer hospital admissions following enrollment (Δ = -0.05 admissions/quarter; p = 0.011), which was primarily observed in patients who used the HBP at least once (Δ = -0.10 admissions/quarter; p < 0.001).

CONCLUSIONS

The HBP, a content-driven telehealth system coupled with care management, was associated with significantly better survival and reduced hospitalization in Medicare beneficiaries with HF. Prospective study is warranted to determine the mechanism of this association and opportunities for optimization.

Multimorbidity in heart failure: a community perspective

BACKGROUND

Comorbidities are a major concern in heart failure, leading to adverse outcomes, increased health care utilization, and excess mortality. Nevertheless, the epidemiology of comorbid conditions and differences in their occurrence by type of heart failure and sex are not well documented.

METHODS

The prevalence of 16 chronic conditions defined by the US Department of Health and Human Services was obtained among 1382 patients from Olmsted County, Minn. diagnosed with first-ever heart failure between 2000 and 2010. Heat maps displayed the pairwise prevalences of the comorbidities and the observed-to-expected ratios for occurrence of morbidity pairs by type of heart failure (preserved or reduced ejection fraction) and sex.

RESULTS

Most heart failure patients had 2 or more additional chronic conditions (86%); the most prevalent were hypertension, hyperlipidemia, and arrhythmias. The co-occurrence of other cardiovascular diseases was common, with higher prevalences of co-occurring cardiovascular diseases in men compared with women. Patients with preserved ejection fraction had one additional condition compared with those with reduced ejection fraction (mean 4.5 vs 3.7). The patterns of co-occurring conditions were similar between preserved and reduced ejection fraction; however, differences in the ratios of observed-to-expected co-occurrence were apparent by type of heart failure and sex. In addition, some psychological and neurological conditions co-occurred more frequently than expected.

CONCLUSION

Multimorbidity is common in heart failure, and differences in co-occurrence of conditions exist by type of heart failure and sex, highlighting the need for a better understanding of the clinical consequences of multiple chronic conditions in heart failure patients.

The journey of the frail older adult with heart failure: implications for management and health care systems

The heart failure epidemic predominantly affects older people, particularly those with concurrent co-morbid conditions and geriatric syndromes. Mortality and heath service utilization associated with heart failure are significant, and extend beyond the costs associated with acute care utilization. Over time, older people with heart failure experience a journey characterized by gradual functional decline, accelerated by unpredictable disease exacerbations, requiring greater support to remain in the community, and often ultimately leading to institutionalization. In this narrative review, we posit that the rate of functional decline and associated health care resource utilization can be attenuated by optimizing the management of heart failure and associated co-morbidities. However, to realize this objective, the manner in which care is delivered to frail older people with heart failure must be restructured, from the bedside to the level of the health care system, in order to optimally anticipate, diagnose and manage co-morbidities.

Differences in clinical characteristics, management and short-term outcome between acute heart failure patients chronic obstructive pulmonary disease and those without this co-morbidity

AIM-METHODS

ALARM-HF was a retrospective, observational registry that included 4,953 patients admitted for acute heart failure (AHF) in six European countries, Turkey, Mexico and Australia. Data about respiratory disorders and related medications were available for 4,616 patients with AHF.

RESULTS

Chronic obstructive pulmonary disease (COPD) patients (n = 1,143, 24.8%) were older and more frequently men (p < 0.001) when compared to non-COPD patients. Despite the equivalent left ventricular ejection fraction (38.6 ± 13.7 vs. 38.2 ± 14.5%, p > 0.05), COPD patients more frequently presented with acutely decompensated heart failure (p < 0.001). Moreover, a worse cardiovascular profile was observed in the COPD group, including more atrial fibrillation/flutter, diabetes, hypertension, obesity, peripheral vascular disease (p < 0.001). Before admission, a higher percentage of COPD patients had experienced infections (25.0 vs. 14.0 %, p < 0.001), and were more likely to receive diuretics (p = 0.006), ACE inhibitors (p = 0.042), nitrates (p = 0.003), and digoxin (p = 0.034). With the exception of ACE inhibitors, those differences maintained at discharge, with concomitant increase in ARBs prescription (p = 0.01). Notably, β-blockers were less prescribed before admission (21.1 vs. 23.8%, p = 0.055) in COPD patients, and remained underutilized at discharge (p < 0.001). Correcting for baseline differences, all-cause in-hospital mortality did not differ between COPD and non-COPD groups (10.1 vs. 10.9%, p = 0.085).

CONCLUSION

A large proportion of AHF patients presented with concomitant COPD, had different clinical characteristics/co-morbidities, and less frequently received evidence-based pharmacological therapy compared to non-COPD patients. However, the in-hospital mortality was not higher in COPD group.

Multidrug and optimal heart failure therapy prescribing in older general practice populations: a clinical data linkage study

OBJECTIVE

To investigate multidrug therapy in the cardiovascular disease (CVD) population and whether it was associated with suboptimal drug prescribing in heart failure (HF).

DESIGN

A population-based cross-sectional clinical data linkage study.

SETTING

The clinical database populations were registered with three general practices in North Staffordshire that are part of a research network.

PARTICIPANTS

3155 patients aged 50 years and over were selected on the basis of a CVD-related prescription and a CVD consultation code applied to their electronic medical record in a 2-year time period. All available diagnostic data were linked to all drugs prescribed data during this time period. Two study groups were: (1) HF and (2) non-HF CVD (reference group).

EXPOSURE

A standard drug formulary system was used to define four multidrug count categories based on the number of different British National Formulary drug chapters prescribed at the same time.

PRIMARY AND SECONDARY OUTCOME MEASURES

Optimal HF therapy was defined as the prescribing of ACE inhibitor (ACEi) or a combination of ACEi and β-blocker in the 2-year time window. An additional three specific CVD drug categories that are indicated in HF were also measured.

RESULTS

The HF group, compared with the reference group, had higher non-CVD multidrug therapy (26% with 7 or more counts compared with 14% in the non-HF CVD reference group). For the first-choice optimal drug treatment for HF with ACEi (64%) or ACEi and β-blocker combined therapy (23%), the multidrug-adjusted associations between the HF group and the reference group were OR 3.89; 95% CI 2.8 to 5.5 and 1.99; 1.4 to 2.9, respectively. These estimates were not influenced by adjustment for sociodemographic factors and multidrug counts.

CONCLUSIONS

Multidrug therapy prescribing is much higher in the HF group than in a comparable CVD group but did not influence optimal drug prescribing.

The impact of cardiac and noncardiac comorbidities on the short-term outcomes of patients hospitalized with acute myocardial infarction: a population-based perspective

Objectives

The objectives of our large observational study were to describe the prevalence of cardiac and noncardiac comorbidities in a community-based population of patients hospitalized with acute myocardial infarction (AMI) at all medical centers in central Massachusetts, and to examine whether multiple comorbidities were associated with in-hospital death rates and hospital length of stay.

Methods

The study sample consisted of 2,972 patients hospitalized with AMI at all eleven greater Worcester medical centers in central Massachusetts during the three study years of 2003, 2005, and 2007.

Results

The average age of this hospitalized population was 71 years, 55% were men, 93% were Caucasian, and approximately one third had developed an ST segment elevation AMI during the years under study. Hypertension (75%) was the most common cardiac condition identified in patients hospitalized with AMI whereas renal disease (22%) was the most common noncardiac comorbidity diagnosed in this study population. Approximately one in every four hospitalized patients had any four or more of the seven cardiac conditions examined, while one in 13 had any three or more of the five noncardiac conditions studied. Patients with four or more cardiac comorbidities were more than twice as likely to have died during hospitalization and have a prolonged hospital length of stay, compared to those without any cardiac comorbidities. Patients with three or more noncardiac comorbidities had markedly increased odds of dying during hospitalization and having a prolonged hospital stay compared to those with no noncardiac comorbidities previously diagnosed.

Conclusion

Our findings highlight the need for additional contemporary data to improve the short-term outcomes of patients hospitalized with AMI and multiple concurrent medical illnesses.

Management of acute heart failure in spanish emergency departments based on age

INTRODUCTION AND OBJECTIVES

To investigate possible age-related differences in the profile, clinical symptoms, management, and short-term outcomes of patients seen for acute heart failure in Spanish emergency departments.

METHODS

We performed a multipurpose, multicenter study with prospective follow-up including all patients with acute heart failure attended in 29 Spanish emergency departments. The following variables were collected: demographic, personal history, geriatric syndromes, data of acute episode, discharge destination, in-hospital and 30-day mortality and 30-day revisit. The sample was divided into 4 age groups: <65, 65-74, 75-84, and ≥85 years.

RESULTS

We included 5819 patients: 493 (8.5%) were <65 years old, 971 (16.7%) were 65-74 years old, 2407 (41.4%) were 75-84 years old, and 1948 (33.5%) were ≥85 years old; 4424 patients (76.5%) were admitted from the emergency department, 251 of whom (4.5%) died during hospitalization. Statistically significant differences were observed in relation to cardiovascular risk factors, comorbidities, geriatric syndromes, clinical presentation, and diagnostic and therapeutic procedures based on an increase in the age of the groups. A statistically significant linear trend was observed between age group and the probability of hospital admission (P<.001), and hospital (P<.001) and 30-day mortality (P<.001).

CONCLUSIONS

The management of acute heart failure in elderly patients requires a multidimensional approach which goes beyond merely cardiological aspects of treatment.

Adjusted prognostic association of depression following myocardial infarction with mortality and cardiovascular events: individual patient data meta-analysis

BACKGROUND

The association between depression after myocardial infarction and increased risk of mortality and cardiac morbidity may be due to cardiac disease severity.

AIMS

To combine original data from studies on the association between post-infarction depression and prognosis into one database, and to investigate to what extent such depression predicts prognosis independently of disease severity.

METHOD

An individual patient data meta-analysis of studies was conducted using multilevel, multivariable Cox regression analyses.

RESULTS

Sixteen studies participated, creating a database of 10 175 post-infarction cases. Hazard ratios for post-infarction depression were 1.32 (95% CI 1.26-1.38, P<0.001) for all-cause mortality and 1.19 (95% CI 1.14-1.24, P<0.001) for cardiovascular events. Hazard ratios adjusted for disease severity were attenuated by 28% and 25% respectively.

CONCLUSIONS

The association between depression following myocardial infarction and prognosis is attenuated after adjustment for cardiac disease severity. Still, depression remains independently associated with prognosis, with a 22% increased risk of all-cause mortality and a 13% increased risk of cardiovascular events per standard deviation in depression z-score.