Heart failure mortality in Southeast Asian patients with left ventricular systolic dysfunction

On variable selection in a semiparametric AFT mixture cure model

In clinical studies, one often encounters time-to-event data that are subject to right censoring and for which a fraction of the patients under study never experience the event of interest. Such data can be modeled using cure models in survival analysis. In the presence of cure fraction, the mixture cure model is popular, since it allows to model probability to be cured (called the incidence) and the survival function of the uncured individuals (called the latency). In this paper, we develop a variable selection procedure for the incidence and latency parts of a mixture cure model, consisting of a logistic model for the incidence and a semiparametric accelerated failure time model for the latency. We use a penalized likelihood approach, based on adaptive LASSO penalties for each part of the model, and we consider two algorithms for optimizing the criterion function. Extensive simulations are carried out to assess the accuracy of the proposed selection procedure. Finally, we employ the proposed method to a real dataset regarding heart failure patients with left ventricular systolic dysfunction.

Dementia and in-hospital mortality: retrospective analysis of a nationwide administrative database of elderly subjects in Italy

AIMS

 To evaluate the relationship between comorbidity and in-hospital mortality in elderly patients affected by dementia.

METHODS

Data were obtained from the Italian Ministry of Health and included all discharge records from Italian hospitals concerning subjects aged ≥ 65 years admitted to acute Internal Medicine or Geriatrics wards between January 2015 and December 2016 (3.695.278 admissions). The variables analyzed included age, sex, and in-hospital death. Twenty-five homogeneous clusters of diseases were identified in discharge codes according to the ICD-9-CM classification.

RESULTS

Patients with dementia represented 7.5% of the sample (n. 278.149); they were older, more often males (51.9%), and had a higher in-hospital mortality (24.3%) compared to patients without dementia (9.7%). Dementia per se doubled the odds of death (OR 1.98; 95% CI 1.95-2.00), independent of age, sex, and comorbidities. Seven clusters of disease (pneumonia, heart failure, kidneys disease, cancer, infectious diseases, diseases of fluids/electrolytes and general symptoms) were associated with increased in-hospital mortality, independent of the presence/absence of dementia. Among patients with dementia, heart failure, pneumonia and kidney disease on their own substantially doubled/tripled mortality risk. The risk increased from 10.1% (none of selected conditions), up to 28.9% when only one of selected comorbidities was present, rising to 52.3% (OR: 9.34; p < 0.001) when two or more comorbidities were simultaneously diagnosed, besides general symptoms.

CONCLUSIONS

Our study confirmed an important increase of in-hospital mortality in older subjects with dementia. Despite a different comorbidity, the conditions associated with in-hospital mortality were substantially the same in patients with or without dementia. Heart failure, pneumonia, and kidney disease identified a high risk of in-hospital mortality among subjects with dementia.

Can early initiation of continuous renal replacement therapy improve patient survival with septic acute kidney injury when enrolled in early goal-directed therapy?

PURPOSE

The purpose of our study was to investigate the timing of continuous renal replacement therapy (CRRT) application, based on the interval between the start of early goal-directed therapy (EGDT) and CRRT initiation, to ascertain whether the timing was an independent predictor of mortality in patients with septic acute kidney injury (AKI).

MATERIALS AND METHODS

An observational retrospective cohort study was conducted of 60 patients (>18 years old) who had been admitted to the emergency department and received resuscitation according to the standard EGDT algorithm for severe sepsis and septic shock, and who were treated with CRRT due to septic AKI, between June 2008 and February 2013 at a tertiary hospital in Seoul, Korea. The patients were divided into 2 groups based on the median interval between the start of EGDT and the commencement of CRRT. The main outcome was 28-day all-cause mortality, and a multivariate Cox analysis for mortality was used to evaluate the independent impact of the early CRRT treatment.

RESULTS

The mean patient age was 66.3 years, and 52 (86.7%) were male. The most common comorbid disease was diabetes mellitus (35.0%) followed by malignancy (26.7%). The median interval between the start of EGDT and commencement of CRRT was 26.4 hours. During the study period, 28-day mortality was 43.3% (26 of 60 patients). The 28-day all-cause mortality rate was significantly higher in the late CRRT group than in the early CRRT group (56.7 vs 30.0%, P= .037). Furthermore, the higher mortality risk in the late group remained significant even after adjusting for diabetes mellitus, liver failure, and Acute Physiology and Chronic Health Evaluation II scores (hazard ratio, 2.461; 95% confidence interval, 1.044-5.800; P= .026).

CONCLUSION

Early initiation of CRRT may be of benefit. Given the complex nature of this intervention and the ongoing controversy regarding early vs late initiation of therapy in acute and chronic situations, it is vital to develop accurate clinical trials to find definitive answers.

Transitional Care to Reduce Heart Failure Readmission Rates in South East Asia

Heart failure (HF) is an emerging public health problem due to increasing hospitalisations, readmissions and direct healthcare costs. Transitional care (TC) aims to improve multidisciplinary care coordination in HF and provides a streamlined strategy to ensure discharge success. This article reviews the different TC models and interventions in HF, and compares their strengths, weaknesses and efficacies. Notably, a nurse-led TC model under the direct administration of a dedicated multidisciplinary team appears to be the superior model of care. The emerging use of remote technology to track patient progress adds value, as human resources are scarce. Several knowledge gaps are highlighted in this article. The authors share their local institutional TC experience and discuss its early impact on HF care.

The Singapore Heart Failure Outcomes and Phenotypes (SHOP) study and Prospective Evaluation of Outcome in Patients with Heart Failure with Preserved Left Ventricular Ejection Fraction (PEOPLE) study: rationale and design

BACKGROUND

Heart failure (HF) with preserved ejection fraction (EF) accounts for a substantial proportion of cases of HF, and to date no treatments have clearly improved outcome. There are also little data comparing HF cohorts of differing ethnicity within the Asia-Pacific region.

METHODS

The Singapore Heart Failure Outcomes and Phenotypes (SHOP) study and Prospective Evaluation of Outcome in Patients with Heart Failure with Preserved Left Ventricular Ejection Fraction (PEOPLE) study are parallel prospective studies using identical protocols to enroll patients with HF across 6 centers in Singapore and 4 in New Zealand. The objectives are to determine the relative prevalence, characteristics, and outcomes of patients with HF and preserved EF (EF ≥50%) compared with those with HF and reduced EF, and to determine initial data on ethnic differences within and between New Zealand and Singapore. Case subjects (n = 2,500) are patients hospitalized with a primary diagnosis of HF or attending outpatient clinics for management of HF within 6 months of HF decompensation. Control subjects are age- and gender-matched community-based adults without HF from Singapore (n = 1,250) and New Zealand (n = 1,073). All participants undergo detailed clinical assessment, echocardiography, and blood biomarker measurements at baseline, 6 weeks, and 6 months, and are followed over 2 years for death or hospitalization. Substudies include vascular assessment, cardiopulmonary exercise testing, retinal imaging, and cardiac magnetic resonance imaging.

CONCLUSIONS

The SHOP and PEOPLE studies are the first prospective multicenter studies defining the epidemiology and interethnic differences among patients with HF in the Asia-Oceanic region, and will provide unique insights into the pathophysiology and outcomes for these patients.

Home-Based Advance Care Programme is Effective in Reducing Hospitalisations of Advanced Heart Failure Patients: A Clinical and Healthcare Cost Study

Introduction: In end-stage heart failure (HF) that is not eligible for mechanical assist device or heart transplant, palliative care serves to maximise symptom control and quality of life. We sought to evaluate the impact of home-based advance care programme (ACP) on healthcare utilisation in end-stage HF patients. Materials and Methods: Prospectively collected registry data on all end-stage HF recruited into ACP between July 2008 and July 2010 were analysed. Chart reviews were conducted on HF database and hospital electronic records. Phone interview and home visit details by ACP team were extracted to complete data entry. HF and all-cause hospitalisations 1 year before, and any time after ACP inception were defined as events. For the latter analysis, follow-up duration adjustment to event episodes was performed to account for death less than a year. Results: Forty-four patients (mean age 79 years, 39% men) were followed up for 15±8 months. Fifty-seven percent had diabetes, 80% ischaemic heart disease, and 60% chronic kidney disease. All reported functional class III/IV at enrolment. Mean serum sodium was 136±6 mmol/L, and creatinine 186±126 mmol/L. Thirty (68%) died within the programme. Mean time to death was 5.5 months. Mean all-cause and HF hospitalisations were 3.6 and 2.0 per patient before enrolment, but improved to 1.0 and 0.6 respectively after ACP. Thirty-six (71%) patients had fewer HF hospitalisations. When only those who survived more than a year were considered (n = 14), 10 (71%) and 9 (64%) experienced reduced HF (mean: 1.4 episodes per patient) and all-cause hospitalisations (mean: 2.2 episodes per patient) respectively. Conclusion: Home-based advance care programme is potentially effective in reducing healthcare utilisation of end-stage HF patients, primarily by reducing HF rehospitalisations, and in probably saving costs as well. Key words: Palliative care, End-stage heart failure

Worldwide risk factors for heart failure: a systematic review and pooled analysis

BACKGROUND

Heart failure risk factors are diverse and likely to vary among world regions. Systematic review and pooled analysis were used to describe contributions of major underlying risk factors for heart failure in six world regions.

METHODS

Electronic databases were systematically searched, and 37 clinic-based studies representing 40 countries published in 1980-2008 and reporting underlying risk factors for heart failure were included. Risk factors were classified as ischemic heart disease (IHD), hypertension, rheumatic/other valvular heart disease, cardiopulmonary disease, cardiomyopathy, and "other". Crude and age- and sex-adjusted risk factor prevalences were estimated for each region using a regression analysis, under specifications of overlapping as well as additive contributions.

RESULTS

Many heart failure cases were assigned multiple underlying risk factors, leading to a considerable overlap. Crude IHD prevalence among heart failure patients was >50% in Europe and North America, approximately 30-40% in East Asia and Latin America and the Caribbean, and <10% in Sub-Saharan Africa. Age and sex adjustment attenuated regional differences in IHD-as-risk factor but IHD remained rare in Sub-Saharan Africa. Hypertension prevalence was high in heart failure patients of all regions but the highest in Eastern and Central Europe and Sub-Saharan Africa (age- and sex-adjusted, 35.0% and 32.6%, respectively). Cardiomyopathy was most common in Latin America, the Caribbean and Sub-Saharan Africa (age- and sex-adjusted, 19.8% and 25.7%).

CONCLUSIONS

Heart failure risk factors vary substantially among world regions. More detailed regional heart failure epidemiology studies are needed in order to quantify the global burden of heart failure and identify regional prevention and treatment strategies.

The diversity of heart failure in a hospitalized population: the role of age

BACKGROUND

The prevalence of heart failure (HF) among hospitalized elderly patients is high and steadily growing. However, because most studies have focused mostly on young patients, little is known about the clinical characteristics, echocardiographic measures, prognostic factors, and outcome of hospitalized elderly HF patients.

METHODS AND RESULTS

We identified all HF patients aged ≥50 years who had undergone ≥1 echocardiography study and had been hospitalized during January 2000 to December 2009. A comparative analysis was performed between 3,897 "young" patients (aged 50-75 years) and 5,438 "elderly" patients (aged >75 years), followed for a mean 2.8 ± 2.6 years. Elderly HF patients were more often female (50% vs 35%; P < .0001) and had a higher prevalence of HF with preserved ejection fraction (64.8% vs 53%; P < .0001), more significant valvular disease (35.7% vs 32.5%; P < .0001), and lower rates of ischemic heart disease (65.5% vs 70.9%; P < .0001) and diabetes (34.4% vs 53.9%; P < .0001). Thirty-day and 1-year mortality rates were significantly higher among the elderly population (12.2% vs 6.9% [P < .0001] and 34.3% vs 21.2% [P < .0001], respectively). Prognostic markers differed significantly between age groups. Young-specific predictors were chronic renal failure, diastolic dysfunction, malignancy, and tricuspid regurgitation, whereas elderly-specific predictors were HF with reduced ejection fraction, chronic obstructive pulmonary disease, pulmonary hypertension, and mitral regurgitation.

CONCLUSIONS

Hospitalized elderly, compared with young, HF patients differed in prevalence of cardiac and noncardiac comorbid conditions, echocardiographic parameters, and predictors of short- and intermediate-term mortality. Identifying unique features in the elderly population may render age-tailored therapeutics.

Systolic heart failure in South Asians

Heart failure (HF) is a common condition leading to an unfavourable prognosis and impaired quality of life. In this review, we provide an overview of published literature on possible epidemiological and pathophysiological differences between patients with systolic HF of South Asian origin and those from other ethnic groups (mainly White). Systolic HF tends to manifest earlier among South Asians and with frequent hospital admissions. However, survival for such patients appears to be significantly better compared with the White group, which might be associated with different patterns of HF. For example, this could be attributed to a lower prevalence of left ventricular systolic dysfunction in South Asian subjects. Indeed, the high prevalence of hypertension and diabetes among South Asians may predispose to diastolic HF with preserved systolic function. In addition, because of underrepresentation of South Asians in clinical trials, there are little data on optimal management of this ethnic group.

Future of personalized pharmacotherapy in chronic heart failure patients

There is a significant amount of diversity among heart failure (HF) patients. Contemporary HF regimens often do not take into consideration many of the factors that might influence an individual’s response to treatment. Clinical recommendations based on trial data derived from mainly younger Caucasian male study populations have, in most cases, been applied equally to women and African–Americans. Subgroup analyses of randomized HF trials and results of retrospective cohort studies have been used for customizing HF regimens in women and African–Americans. Pharmacogenetics is an emerging strategy for personalizing HF therapy. Genetic biomarkers may play an important role in predicting a patient’s response to treatment and in predicting those at risk of toxicity. HF pharmacotherapy has improved over the last two decades; however, substantial work remains in order to personalize HF management and maximize the benefit of pharmacologic interventions, while limiting adverse events.

Precipitant in acute heart failure in a multiethnic Asian urban cohort study

OBJECTIVES

To identify acute heart failure (HF) precipitants in patients with a history of chronic HF, and to analyse any relationship with early outcomes.

BACKGROUND

There are limited studies on acute HF precipitants and the relationship with outcomes, and determining this will help to identify the avoidable precipitants and may lead to better outcomes.

METHODS

Patients with a history of HF and admission to the authors' hospital in 2008, with a discharge primary diagnosis of HF, were enrolled. Diagnosis of HF was prospectively defined and reviewed by two cardiology teams. Patients' case records were reviewed, or families were interviewed for 1-month follow-up outcome information.

RESULTS

242 admissions by 185 patients constituted our study cohort. Patients were older, and 36.8% were females. The ethnic Chinese, Malay and Indian composition of the cohort were 41.3%, 35.1% and 16.1% respectively. The mean left-ventricular ejection fraction was 34.0±17.5%. Preserved left ventricular ejection fraction (≥45%) constituted 35.1% of the cohort. Acute HF precipitants were identified in 62.8% of admissions and unidentified in 37.2% admissions. Non-compliance issues and infections constituted 27.2% and 13.6% of precipitants respectively. Cardiac precipitants accounted for 10.0% admissions. Multiple precipitants accounted for 8.3% admissions. There were no significant differences in patient profile, including ethnicity and gender, and outcomes between patients with identified precipitants and patients with unidentified precipitants.

CONCLUSION

Non-compliance issues were a major precipitant of acute HF in patients with chronic HF. Precipitants were not determined in 37.2% of admissions. There were no significant associations between the different types of precipitants and early 30-day outcomes.

Assessment of the clinical outcomes and cost-effectiveness of the management of systolic heart failure in Chinese patients using a home-based intervention

This study was designed to assess the clinical effect of a home-based telephone intervention in Chinese heart failure patients. A total of 550 Chinese heart failure patients were enrolled into either (i) a group that received the usual standard of care (UC group); or (ii) a group that received a home-based heart failure centre management programme using nursing specialist-led telephone consultations (HFC group). The impact of the home-based intervention on admission rate, admission length and medical costs over 6 months was measured. Although the mean left ventricular ejection fraction in HFC patients was 29.3% compared with 34.8% in UC patients, the home-based intervention resulted in a significantly lower all-cause admission rate per person (HFC 0.60 +/- 0.77 times/person; UC 0.96 +/- 0.85 times/person), a shorter all-cause hospital stay (reduced by 8 days per person) and lower total 6-month medical costs (reduced by US$2682 per patient). These results suggest that the home-based intervention with nursing specialist-led telephone consultations may improve the clinical outcome and provide cost-savings for Chinese patients with heart failure.