Factors Associated With Natriuretic Peptide Testing in Patients Presenting to Emergency Departments With Suspected Heart Failure

Access to Heart Failure Services in Canada: Findings of the Heart and Stroke National Heart Failure Resources and Services Inventory

BACKGROUND

The rising incidence of heart failure (HF) in Canada necessitates commensurate resources dedicated to its management. Several health system partners launched an HF Action Plan to understand the current state of HF care in Canada and address inequities in access and resources.

METHODS

A national Heart Failure Resources and Services Inventory (HF-RaSI) was conducted from 2020 to 2021 of all 629 acute care hospitals and 20 urgent care centres in Canada. The HF-RaSI consisted of 44 questions on available resources, service,s and processes across acute care hospitals and related ambulatory settings.

RESULTS

HF-RaSIs were completed by 501 acute care hospitals and urgent care centres, representing 94.7% of all HF hospitalisations across Canada. Only 12.2% of HF care was provided by hospitals with HF expertise and resources, and 50.9% of HF admissions were in centres with minimal outpatient or inpatient HF capabilities. Across all Canadian hospitals, 28.7% did not have access to B-type natriuretic peptide testing, and only 48.1% had access to on-site echocardiography. Designated HF medical directors were present at 21.6% of sites (108), and 16.2% sites (81) had dedicated inpatient interdisciplinary HF teams. Among all of the sites, 28.1% (141) were HF clinics, and of those, 40.4% (57) had average wait times from referral to first appointment of more than 2 weeks.

CONCLUSIONS

Significant gaps and geographic variation in delivery and access to HF services exist in Canada. This study highlights the need for provincial and national health systems changes and quality improvement initiatives to ensure equitable access to the appropriate evidence-based HF care.

Epidemiology of worsening heart failure in a population-based cohort from Alberta, Canada: Evaluating eligibility for treatment with vericiguat

BACKGROUND

Patients with heart failure (HF) and a reduced ejection fraction (HFrEF) who experience worsening heart failure (WHF) events are at increased risk of adverse outcomes and experience significant morbidity and mortality. We herein describe the epidemiology of these patients and identify those potentially eligible for vericiguat therapy in this population-based study.

METHODS

This retrospective cohort study included hospitalized or emergency department (ED) patients with a primary diagnosis of HF and left ventricular ejection fraction (LVEF) <45% diagnosed between April 1^st, 2009 and March 31^st, 2019 in Alberta, Canada, with follow-up to March 31^st 2020. Inclusion criteria from the VICTORIA trial were applied to explore eligibility for vericiguat.

RESULTS

Among 25,629 patients with HF and LVEF data, 9,948 (38.8%) had HFrEF, of which 5,259 (52.8%) experienced WHF at some point during a median 5.8 years of follow-up, and 38.3% of those met the vericiguat trial eligibility criteria. Compared to HFrEF patients without WHF, those with WHF were older, with more comorbidities, worse renal function, similar LVEF status, but more use of HF medications, at baseline. At the time of WHF, 27% of those with HFrEF and WHF were on triple therapy, 50.6% were on dual therapy, and 15.4% were on monotherapy. All-cause mortality and the composite outcome of all-cause mortality or cardiovascular hospitalization at 1-year of follow-up were higher in the HFrEF with WHF cohort compared to HFrEF without WHF (adjusted hazard ratios of 1.92 and 1.51, respectively, both p<.0001).

CONCLUSION

Approximately, one-half of patients with HFrEF experienced WHF over long-term follow-up. Most were not on triple therapy, highlighting the underutilization of the existing standard-of-care treatments and opportunities for application of newer therapies; more than one-third of patients with HFrEF may be eligible for vericiguat.

LAY SUMMARY

Among patients with heart failure (HF), those who experience worsening HF are at increased risk of adverse outcomes. A few new therapies, including vericiguat, have emerged recently for patients with HF and reduced ejection fraction. However, the epidemiology, treatment patterns, and outcomes of patients with worsening HF in large representative populations is unclear. In current study, roughly, half of the patients with HF and reduced ejection fraction experienced worsening HF and 38.3% were potentially eligible for vericiguat therapy. The guideline-recommended therapies were under-utilized among patients with worsening HF, which highlights the need for initiatives to address this care gap.

The Incidence and Prevalence of Cardiac Amyloidosis in a Large Community-Based Cohort in Alberta, Canada

BACKGROUND

Despite the improved awareness of cardiac amyloidosis among clinicians, its incidence and prevalence is not well-described in a community setting. We sought to investigate the incidence and prevalence of cardiac amyloidosis in the community.

METHODS AND RESULTS

In the adult population of Alberta, we examined 3 cohorts: (1) probable cases of cardiac amyloidosis: the presence of physician-assigned diagnosis of amyloidosis (International Classification of Diseases [ICD]-10 code E85; ICD-9 277.3) and 1 or more health care encounter for heart failure (HF) (ICD-10 I50; ICD-9 428); (2) possible cardiac amyloidosis: the presence of clinical phenotypes suggestive of amyloidosis; and (3) a comparator HF cohort without amyloidosis. Between 2004 and 2018, 982 of the 145,329 patients with HF were identified as probable cardiac amyloidosis. During the same period, the incidence rates of probable cardiac amyloidosis increased from 1.38 to 3.69 per 100,000 person-years and the prevalence rates increased from 3.42 to 14.85 per 100,000 person-years (P_trend < .0001). Patients with probable cardiac amyloidosis were more likely to be male, have a higher comorbidity burden, greater health care use, and poorer outcomes as compared with patients with HF without amyloidosis. A much larger group of patients was identified as possible cardiac amyloidosis (n = 46,255), with similar increase in prevalence from 2004 to 2018 (from 416 to 850 per 100,000 person-years).

CONCLUSIONS

The incidence and prevalence of cardiac amyloidosis has increased over the last decade. Given the advent of new therapies for cardiac amyloidosis and considering their high cost, it is imperative to devise strategies to screen, identify, and track patients with cardiac amyloidosis from administrative databases.

External Validation and Refinement of Emergency Heart Failure Mortality Risk Grade Risk Model in Patients With Heart Failure in the Emergency Department

Background

Emergency Heart Failure Mortality Risk Grade (EHMRG) assesses the risk of death within 7 days of emergency department (ED) presentation for patients with acute heart failure (AHF). We aimed to externally validate and refine the EHMRG model in patients who presented to the ED with AHF.

Methods

We performed a cohort study using administrative data for all ambulance-transported patients from Alberta (2012-2016) presenting to the ED with a primary diagnosis of AHF.

Results

Among 6708 patients with AHF, the 7-day mortality was 0.0%, 0.8%, 1.6%, 4.0%, 4.2%, and 12.0% across EHMRG risk categories (1-4, 5A and 5B). The EHMRG score had a c-index of 0.73 (95% confidence interval [CI], 0.71-0.76) for 7-day mortality and 0.71 (95% CI, 0.70-0.73) for 30-day mortality, but lower c-statistics for other outcomes (0.61-0.67). The inclusion of natriuretic peptides to the EHMRG model improved prediction (Net Reclassification Improvement, 0.268; 95% CI, 0.173-0.363; P < 0.01) for 7-day mortality, as did the addition of the Canadian Triage and Acuity Scale (Net Reclassification Improvement, 0.111; 95% CI, 0.005-0.218; P = 0.04).

Conclusion

The EHMRG model exhibited moderate discriminative ability in a large population-based cohort of patients with AHF in the ED. Revision of the EHMRG score through factor inclusion and exclusion could improve the model’s performance.

Prognostic factors for in-hospital mortality of patients hospitalized for acutely decompensated heart failure

Objectives Despite improved treatment during last 20 years, prognosis for patients hospitalized for acutely decompensated heart failure (ADHF) is poor and mortality rates reported for these patients are high. Laboratory results can assist clinicians in evaluation and triaging of patients on hospital admission, and are important for the medical decision-making and prognosis assessments. Recently, new guidelines for the diagnosis and treatment of acute and chronic HF patients were published introducing a new group of patients with mid-range left ventricular ejection fraction (LVEF). Methods In order to explore the prognostic value for the in-hospital mortality of ADHF patients we analyzed laboratory test results for 165 emergency hospitalized patients regarding the survival and LVEF. Results In-hospital mortality was 16%. Patients who died were older than survivals (p = 0.003). There were no differences in LVEF between survivals and non-survivals. Patients who survived had significantly lower N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hs-cTnT), uric acid, urea, creatinine, and red blood cell distribution width (RDW) than patients who died (p < 0.001). All these tests had a good discrimination power between survivals and non-survivals (p < 0.001), but their incremental addition to NT-proBNP didn't improve its overall prognostic value. There was only a very weak correlation between NT-proBNP concentrations and LVEF. Groups with different LVEF status showed significant difference in number of erythrocytes, RDW and hemoglobin concentrations. Conclusions NT-proBNP had the best discriminatory power between survivals and non-survivals. Some routine laboratory test results, like RDW, uric acid, urea, and creatinine, have potentially significant value.

2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure

Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.