Changes in cardiovascular hospitalization and comorbidity of heart failure in the United States: findings from the National Hospital Discharge Surveys 1980-2006

National trends in metabolic risk of psychiatric inpatients in the United States during the atypical antipsychotic era

Although the cardiometabolic effects of atypical antipsychotics have been well-described in clinical samples, less is known about the longer-term impacts of these treatments. We report rates of metabolic syndrome in a nationally representative sample of U.S. adult inpatients 1993-2018 admitted for schizophrenia-spectrum disorders (n = 1,785,314), any mental health disorder (n = 8,378,773), or neither (n = 14,458,616) during a period of widespread atypical antipsychotic use. Metabolic syndrome, derived from additional diagnoses, was defined as three or more of hypertension, dyslipidemia, type II diabetes, hyperglycemia, and overweight or obese. Using an ecological age and period design, a 4-level period variable was constructed to proxy for atypical antipsychotic exposure as the minimum of age minus 20 years or the calendar year minus 1997 in accord with the disease course for schizophrenia-spectrum illness and the market share of atypical antipsychotics in the U.S. Logistic regression models, adjusted for age, year, and exposure main effects, estimated odds ratios (ORs) of metabolic syndrome. Relative to other mental health or other discharges, schizophrenia-spectrum discharges had an elevated risk for metabolic syndrome regardless of potential atypical antipsychotic exposure (OR = 1.46; 95 % CI, 1.30-1.64). For schizophrenia-spectrum discharges, periods of potential atypical antipsychotic exposure conferred additional metabolic syndrome risk OR = 1.21; 95 % CI, 1.04-1.41 for exposures of 1-2 years, OR = 1.29; 95 % CI, 1.13-1.46 for 3-7 years, OR = 1.27; 95 % CI, 1.12-1.44 for 8-12 years, and OR = 1.10; 95 % CI 0.98-1.24 for >12 years. In summary, cardiometabolic disease and related risks were elevated among a nationally representative sample of adult inpatients with schizophrenia-spectrum disorders during a period of pervasive atypical antipsychotic use.

Sex-difference in air pollution-related acute circulatory and respiratory mortality and hospitalization

BACKGROUND

Numerous studies have estimated adverse effects of short-term exposure to ambient air pollution on public health. Few have focused on sex-differences, and results have been inconsistent. The purpose of this study was three-fold: to identify sex-differences in air pollution-related health outcomes; to examine sex-differences by cause and season; and to examine time trends in sex-differences.

METHODS

Daily data were collected on circulatory- and respiratory-related mortality (for 29 years) and cause-specific hospitalization (for 17 years) with hourly concentrations of ozone (O3), nitrogen dioxide (NO2), and fine particulate matter (PM2.5). For hospitalization, more specific causes were examined: ischemic heart disease (IHD), other heart disease (OHD), cerebrovascular disease (CEV), chronic lower respiratory diseases (CLRD), and Influenza/Pneumonia (InfPn). Generalized Poisson models were applied to 24 Canadian cities, and the city-specific estimates were combined for nationwide estimates for each sex using Bayesian hierarchical models. Finally, sex-differences were tested statistically based on their interval estimates, considering the correlation between sex-specific national estimates.

RESULTS

Sex-differences were more frequently observed for hospitalization than mortality, respiratory than circulatory health outcomes, and warm than cold season. For hospitalization, males were at higher risk (M > F) for warm season (OHD and InfPn from O3; IHD from NO2; and InfPn from PM2.5), but F > M for cold season (CEV from O3 and OHD from NO2). For mortality, we found F > M only for circulatory diseases from ozone during the warm season. Among the above-mentioned sex-differences, three cases showed consistent time trends over the years: while M > F for OHD from O3 and IHD from NO2, F > M for OHD from NO2.

CONCLUSIONS

We found that sex-differences in effect of ambient air pollution varied over health outcome, cause, season and time. In particular, the consistent trends (either F > M or M > F) across 17 years provide stronger evidence of sex-differences in hospitalizations, and warrant investigation in other populations.

Changing Spatiotemporal Trends in County-Level Heart Failure Death Rates in the United States, 1999 to 2018

Background

Amid recently rising heart failure (HF) death rates in the United States, we describe county‐level trends in HF mortality from 1999 to 2018 by racial/ethnic group and sex for ages 35 to 64 years and 65 years and older.

Methods and Results

Applying a hierarchical Bayesian model to National Vital Statistics data representing all US deaths, ages 35 years and older, we estimated annual age‐standardized county‐level HF death rates and percent change by age group, racial/ethnic group, and sex from 1999 through 2018. During 1999 to 2011, ~30% of counties experienced increasing HF death rates among adults ages 35 to 64 years. However, during 2011 to 2018, 86.9% (95% CI, 85.2–88.2) of counties experienced increasing mortality. Likewise, for ages 65 years and older, during 1999 to 2005 and 2005 to 2011, 27.8% (95% CI, 25.8–29.8) and 12.6% (95% CI, 11.2–13.9) of counties, respectively, experienced increasing mortality. However, during 2011 to 2018, most counties (67.4% [95% CI, 65.4–69.5]) experienced increasing mortality. These temporal patterns by age group held across racial/ethnic group and sex.

Conclusions

These results provide local context to previously documented recent national increases in HF death rates. Although county‐level declines were most common before 2011, some counties and demographic groups experienced increasing HF death rates during this period of national declines. However, recent county‐level increases were pervasive, occurring across counties, racial/ethnic group, and sex, particularly among ages 35 to 64 years. These spatiotemporal patterns highlight the need to identify and address underlying clinical risk factors and social determinants of health contributing to these increasing trends.

Comparison of hospitalization and mortality associated with short-term exposure to ambient ozone and PM2.5 in Canada

BACKGROUND

Hospitalization and mortality (H-M) have been linked to air pollution separately. However, previous studies have not adequately compared whether air pollution is a stronger risk factor for hospitalization or mortality. This study aimed to investigate differences in H-M risk from short-term ozone and PM_2.5 exposures, and determine whether differences are modified by season, age, and sex.

METHODS

Daily ozone, PM_2.5, temperature, and all-cause H-M counts (ICD-10, A00-R99) were collected for 22-24 Canadian cities for up to 29 years. Generalized additive Poisson models were employed to estimate associations between each pollutant and health outcome, which were compared across season (warm, cold, or year-round), age (all ages or seniors > 65), and sex.

RESULTS

Overall, ozone and PM_2.5 showed higher season-specific risk of mortality than hospitalization: warm-season ozone: 0.54% (95% credible interval, 0.20, 0.85) vs. 0.14% (0.02, 0.27) per 10 ppb; and year-round PM_2.5: 0.90% (0.33, 1.41) vs. 0.29% (0.03, 0.56) per 10 μg/m³. While age showed little H-M difference, sex appeared to be a modifier of H-M risk. While females had higher mortality risk, males had higher hospitalization risk: for females, ozone 0.87% (0.36, 1.35) vs. -0.03% (-0.18, 0.11) and PM_2.5 1.19% (0.40, 1.90) vs. 0.19% (-0.10, 0.47); and for males ozone 0.20% (-0.28, 0.65) vs. 0.35% (0.18, 0.51).

CONCLUSION

This study found H-M differences attributable to ozone and PM_2.5, suggesting that both are stronger risk factors for mortality than hospitalization. In addition, there were clear H-M differences by sex: specifically, females showed higher mortality risk and males showed higher hospitalization risk.

Heart Failure and Cognitive Impairment: Clinical Relevance and Therapeutic Considerations

Heart failure (HF) is a devastating condition characterized by poor quality of life, numerous complications, high rate of readmission and increased mortality. HF is the most common cause of hospitalization in the United States especially among people over the age of 64 years. The number of people grappling with the ill effects of HF is on the rise as the number of people living to an old age is also on the increase.

Several factors have been attributed to these high readmission and mortality rates among which are; poor adherence with therapy, inability to keep up with clinic appointments and even failure to recognize early symptoms of HF deterioration which may be a result of cognitive impairment.

Therefore, this review seeks to compile the most recent information about the links between HF and dementia or cognitive impairment. We also assessed the prognostic consequences of cognitive impairment complicating HF, therapeutic strategies among patients with HF and focus on future areas of research that would reduce the prevalence of cognitive impairment, reduce its severity and also ameliorate the effect of cognitive impairment coexisting with HF.

The impact of sex on risk of cardiovascular disease and all-cause mortality in adults with or without diabetes mellitus: A comparison between the U.S. and Japan

AIMS

To test a hypothesis that women with diabetes mellitus (DM) versus those without DM had a significantly higher risk of heart disease (HD), stroke and all-cause mortality than their male counterparts in the U.S. as well as in Japan.

METHODS

We analyzed two nationally representative datasets, one from the U.S. NHANES III cohort (n = 13,169), and the other from the Japan NIPPON DATA90 cohort (n = 7445). Hazard ratios (HRs) of DM for risk of mortality and sex-DM interaction effect on mortality were analyzed prospectively using Cox's proportional hazards regression models.

RESULTS

Patients with DM had significantly higher mortality from HD, stroke and all-cause mortality in the U.S. and in Japan. However, the HRs of DM versus non-DM for HD and all-cause mortality were significantly higher in women compared to men in the U.S. (sex-DM interaction: HR = 1.59, p = 0.01, and 1.24, p = 0.045 for HD and all-cause mortality), but the sex-DM interaction effect was not statistically significant in the Japanese cohort.

DISCUSSION

Patients with DM had a significantly higher risk of mortality than those without DM in the U.S. and Japan. However, women with DM versus those without DM had a higher relative risk of HD and all-cause mortality than their counterparts in men in the U.S, but this sex difference by DM status was not observed in the Japanese cohort. Whether the sex-difference effect of DM on HD and all-cause mortality is due to a difference in metabolic disorders between the two populations warrants consideration and further studies.

Burden of heart failure in Flemish general practices: a registry-based study in the Intego database

OBJECTIVES

To assess the prevalence and incidence of heart failure (HF) stages A to C/D and their evolution over a 16-year period. Additionally, trends in comorbidities and cardiovascular (CV) treatment in patients with HF were studied in the same period.

DESIGN

Registry-based study.

SETTING

Primary care, Flanders, Belgium.

PARTICIPANTS

Data were obtained from Intego, a morbidity registration network in which 111 general practitioners of 48 practices collaborate. In the study period between 2000 and 2015, data from 165 796 unique patients aged 45 years and older were available.

OUTCOME MEASURES

Prevalence and incidence were calculated for HF stage A, B and C/D by gender. Additionally, the trend in age-standardised prevalence and incidence rates between 2000 and 2015 was analysed with joint-point regression. The same model was used to study trends in comorbidity profiles in incident HF cases and trends in cardiovascular medication in prevalent HF cases.

RESULTS

We found a downward trend in the incidence and prevalence of HF stage C/D in Flemish general practice between 2000 and 2015, whereas the prevalence and incidence of stage A and B increased. The burden of comorbidities in incident HF cases increased during the study period, as shown by an increasing disease count (p<0.001). The prescription of cardiovascular medication such as renin-angiotensin-aldosterone system blockade, β-blockers and statins showed a sharp increase in the first part of the study period (2000-2008).

CONCLUSION

Age-standardised incidence and prevalence of HF stage C/D showed a slightly downward trend over the past 16 years, probably due to the sharp increase in cardiovascular treatment. However, the increasing age-standardised incidence and prevalence of stage A and B, as precursors of symptomatic HF, together with a rising comorbid burden, highlights the challenges we are still facing.

Naive Expectations to Resignation: A Comparison of Life Descriptions of Newly Diagnosed Versus Chronic Persons Living With Stage D HF

Purpose

This study examined life descriptions of persons with stage D heart failure (HF) comparing those newly diagnosed to those with chronic HF.

Methods

A secondary analysis of interviews from 75 participants followed in a longitudinal study of persons with stage D HF was thematically analyzed. There were 24 participants who were recently diagnosed with stage D HF (less than 2 years) and 51 participants with HF longer than 2 years.

Results

Both groups shared life descriptions along a continuum, where recently diagnosed participants described naive expectations with hope for improvement, while the chronic group appeared resigned to their fate and the reality of the limitations of living with HF. Four themes illustrated differences between the groups: outlook on life, activity adjustments, understanding of HF, and mood.

Conclusions

Although persons with stage D HF share the same life descriptions, they have differing perspectives of life with HF. Findings from this study can help health-care providers tailor interventions based on the length of time from diagnosis.

Predictors of Hospice Enrollment for Patients With Advanced Heart Failure and Effects on Health Care Use

OBJECTIVES

This study sought to: 1) identify the predictors of hospice enrollment for patients with heart failure (HF); and 2) determine the impact of hospice enrollment on health care use.

BACKGROUND

Patients with HF rarely enroll in hospice. Little is known about how hospice affects this group's health care use.

METHODS

Using a propensity score-matched sample of Medicare decedents with ≥2 HF discharges within 6 months, an Outcome and Assessment Information Set (OASIS) assessment, and subsequent death, we used Medicare administrative, claims, and patient assessment data to compare hospitalizations, intensive care unit stays, and emergency department visits for those beneficiaries who enrolled in hospice and those who did not.

RESULTS

The propensity score-matched sample included 3,067 beneficiaries in each group with a mean age of 82 years; 53% were female, and 15% were Black, Asian, or Hispanic. For objective 1, there were no differences in the characteristics, symptom burden, or functional status between groups that were associated with hospice enrollment. For objective 2, in the 6 months after the second HF discharge, the hospice group had significantly fewer emergency department visits (2.64 vs. 2.82; p = 0.04), hospital days (3.90 vs. 4.67; p < 0.001), and intensive care unit stays (1.25 vs. 1.51; p < 0.001); they were less likely to die in the hospital (3% vs. 56%; p < 0.001), and they had longer median survival (80 days vs. 71 days; log-rank test p = 0.004).

CONCLUSIONS

Beneficiaries' characteristics, including symptom burden and functional status, do not predict hospice enrollment. Those patients who enrolled in hospice used less health care, survived longer, and were less likely to die in the hospital. A tailored hospice model may be needed to increase enrollment and offer benefits to patients with HF.

Geographic Variation in Heart Failure Mortality and Its Association With Hypertension, Diabetes, and Behavioral-Related Risk Factors in 1,723 Counties of the United States

Background and objectives

Studies that examined geographic variation in heart failure (HF) and its association with risk factors at county and state levels were limited. This study aimed to test a hypothesis that HF mortality is disproportionately distributed across the United States, and this variation is significantly associated with the county- and state-level prevalence of high blood pressure (HBP), diabetes, obesity and physical inactivity.

Methods

Data from 1,723 counties in 51 states (including District of Columbia as a state) on the age-adjusted prevalence of obesity, physical inactivity, HBP and diabetes in 2010, and age-adjusted HF mortality in 2013–2015 are examined. Geographic variations in risk factors and HF mortality are analyzed using spatial autocorrelation analysis and mapped using Geographic Information System techniques. The associations between county-level HF mortality and risk factors (level 1) are examined using multilevel hierarchical regression models, taking into consideration of their variations accounted for by states (level 2).

Results

There are significant variations in HF mortality, ranging from the lowest 11.7 (the state of Vermont) to highest 85.0 (Mississippi) per 100,000 population among the 51 states. Age-adjusted prevalence of obesity, physical inactivity, HBP, and diabetes are positively and significantly associated with HF mortality. Multilevel analysis indicates that county-level HF mortality rates remain significantly associated with diabetes (β = 2.7, 95% CI: 1.7–3.7, p < 0.0001), HBP (β = 3.6, 2.1–5.0, p < 0.0001), obesity (β = 0.9, 0.6–1.3, p < 0.0001), and physical inactivity (β = 1.2, 0.8–1.5, p < 0.0001) after controlling for gender, race/ethnicity, and poverty index. After further controlling obesity and physical inactivity in diabetes and HBP models, the effects of diabetes (β = 1.0, −0.3 to 2.3, p = 0.12) and HBP (β = 2.4, 0.9–3.9, p = 0.003) on HF mortality had a considerable reduction.

Conclusion

HF mortality disproportionately affects the counties and states across the nation. The geographic variations in HF morality are significantly explained by the variations in the prevalence of obesity, physical inactivity, diabetes, and HBP.

Caregiver Well-being and Patient Outcomes in Heart Failure: A Meta-analysis

BACKGROUND

Despite evidence from the broader caregiving literature about the interdependent nature of the caregiving dyad, few studies in heart failure (HF) have examined associations between caregiver and patient characteristics.

OBJECTIVE

The aim of this study is to quantitatively synthesize the relationships between caregiver well-being and patient outcomes.

METHODS

The MEDLINE, PsycINFO, and CINAHL databases were searched for studies of adult HF patients and informal caregivers that tested the relationship between caregiver well-being (perceived strain and psychological distress) and patient outcomes of interest. Summary effects across studies were estimated using random effects meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

A total of 15 articles meeting inclusion criteria were included in the meta-analysis. Taking into account differences across studies, higher caregiver strain was associated significantly with greater patient symptoms (Fisher z = 0.22, P < .001) and higher caregiver strain was associated significantly with lower patient quality of life (Fisher z = -0.36, P < .001). Relationships between caregiver psychological distress and both patient symptoms and quality of life were not significant. Although individual studies largely found significant relationships between worse caregiver well-being and higher patient clinical event-risk, these studies were not amenable to meta-analysis because of substantial variation in event-risk measures.

CONCLUSIONS

Clinical management and research approaches that acknowledge the interdependent nature of the caregiving dyad hold great potential to benefit both patients and caregivers.

Leading causes of cardiovascular hospitalization in 8.45 million US veterans

Background

We sought to determine the leading causes of cardiovascular (CV) hospitalization, and to describe and compare national rates of CV hospitalization by age, gender, race, ethnicity, region, and year, among U.S. veterans.

Methods

We evaluated the electronic health records of all veterans aged ≥18 years who had accessed any healthcare services at either a VA healthcare facility or a non-VA healthcare facility that was reimbursed by the VA, between January 1 2010 and December 31 2014. Among these 8,452,912 patients, we identified the 5 leading causes of CV hospitalization and compared rates of hospitalization by age, gender, race, ethnicity, region, year and type of VA healthcare user.

Results

The top 5 causes of CV hospitalization were: coronary atherosclerosis, heart failure, acute myocardial infarction, stroke and atrial fibrillation. Overall, 297,373 (3.5%) veterans were hospitalized for one or more of these cardiovascular conditions. The percentage of veterans hospitalized for one or more of these CV conditions decreased over time, from 1.23% in 2010 to 1.18% in 2013, followed by a slight increase to 1.20% in 2014. There was significant variation in rates of CV hospitalization by gender, race, ethnicity, geographic region, and urban vs. rural zip code. In particular, older, male, Black, non-Hispanic, urban and Continental region veterans experienced the highest rates of CV hospitalizations.

Conclusions

Among 8.5 million patients enrolled in the VA healthcare system from 2010 to 2014, there was substantial variation in rates of CV hospitalization by age, gender, race, geographical distribution, year, and use of non-VA (vs. VA only) healthcare care facilities.

Angiotensin II Overstimulation Leads to an Increased Susceptibility to Dilated Cardiomyopathy and Higher Mortality in Female Mice

Heart failure (HF) is associated with high mortality and affects men and women differently. The underlying mechanisms for these sex-related differences remain largely unexplored. Accordingly, using mice with cardiac-specific overexpression of the angiotensin II (ANGII) type 1 receptor (AT1R), we explored male-female differences in the manifestations of hypertrophy and HF. AT1R mice of both sexes feature electrical and Ca²⁺ handling alterations, systolic dysfunction, hypertrophy and develop HF. However, females had much higher mortality (21.0%) rate than males (5.5%). In females, AT1R stimulation leads to more pronounced eccentric hypertrophy (larger increase in LV mass/body weight ratio [+31%], in cell length [+27%], in LV internal end-diastolic [LVIDd, +34%] and systolic [LVIDs, +67%] diameter) and dilation (larger decrease in LV posterior wall thickness, +17%) than males. In addition, in female AT1R mice the cytosolic Ca²⁺ extrusion mechanisms were more severely compromised and were associated with a specific increased in Ca²⁺ sparks (by 187%) and evidence of SR Ca²⁺ leak. Altogether, these results suggest that female AT1R mice have more severe eccentric hypertrophy, dysfunction and compromised Ca²⁺ dynamics. These findings indicate that females are more susceptible to the adverse effects of AT1R stimulation than males favouring the development of HF and increased mortality.

Patterns of self-care and clinical events in a cohort of adults with heart failure: 1 year follow-up

BACKGROUND

Heart failure (HF) self-care is important in reducing clinical events (all-cause mortality, emergency room visits and hospitalizations). HF self-care behaviors are multidimensional and include maintenance (i.e. daily adherence behaviors), management (i.e. symptom response behaviors) and consulting behaviors (i.e. contacting a provider when appropriate). Across these dimensions, patterns of successful patient engagement in self-care have been observed (e.g. successful in one dimension but not in others), but no previous studies have linked patterns of HF self-care to clinical events.

OBJECTIVES

To identify patterns of self-care behaviors in HF patients and their association with clinical events.

METHODS

This was a prospective, non-experimental, cohort study. Community-dwelling HF patients (n = 459) were enrolled across Italy, and clinical events were collected one year after enrollment. We measured dimensions of self-care behavior with the Self-Care of HF Index (maintenance, management, and confidence) and the European HF Self-care Behavior Scale (consulting behaviors). We used latent class mixture modeling to identify patterns of HF self-care across dimensions, and Cox proportional hazards modeling to quantify event-free survival over 12 months of follow-up.

RESULTS

Patients (mean age 71.8 ± 12.1 years) were mostly males (54.9%). Three patterns of self-care behavior were identified; we labeled each by their most prominent dimensional characteristic: poor symptom response, good symptom response, and maintenance-focused behaviors. Patients with good symptom response behaviors had fewer clinical events compared with those who had poor symptom response behaviors (adjusted hazard ratio = 0.66 [0.46-0.96], p = 0.03). Patients with poor symptom response behaviors had the most frequent clinical events. Patients with poor symptom response and those with maintenance-focused behaviors had a similar frequency of clinical events.

CONCLUSIONS

Self-care is significantly associated with clinical events. Routine assessment, mitigation of barriers, and interventions targeting self-care are needed to reduce clinical events in HF patients.

Evaluation of periodic breathing in respiratory flow signal of elderly patients using SVM and linear discriminant analysis

Aging population is a major concern that is reflected in the increase of chronic diseases. Heart Failure (HF) is one of the most common chronic diseases of elderly people that is punctuated with acute episodes, which result in hospitalization. The periodic modulation of the amplitude of the breathing pattern is proved to be one of the multiple symptoms of an acute episode, and thus, the features extracted from its characterization contribute in the improvement of the first diagnosis of the clinical practice. The main objective of this study is to evaluate if the features extracted from the breathing pattern along with common clinical variables are reliable enough to detect Periodic Breathing (PB). A dataset of 44 elderly patients containing clinical information and a short record of electrocardiogram and respiratory flow signal was used to train two machine learning classification methods: Support Vector Machine (SVM) and Linear Discriminant Analysis (LDA). All the available clinical parameters within the dataset along with the parameters characterizing the respiratory pattern were used to classify the observations into two groups. SVM classification was optimized and performed using a = -8 and C = 10.04 giving an accuracy of 88.2 % sensitivity of 90 % and specificity of 85.7 % Similar results were achieved with LDA classifying with an accuracy of 82.4 %, a sensitivity of 81.8% and specificity of 83.3 % PB has been accurately detected using both classifiers.

The State of the Science on Integrating Palliative Care in Heart Failure

BACKGROUND

Heart failure (HF) is a chronic progressive illness associated with physical and psychological burdens, high morbidity, mortality, and healthcare utilization. Palliative care is interdisciplinary care that aims to relieve suffering and improve quality of life for persons with serious illness and their families. It is offered simultaneously with disease-oriented care, unlike hospice or end-of-life care. Despite the demonstrated benefits of palliative care in other populations, evidence for palliative care in the HF population is limited.

OBJECTIVE

The objective of this article is to describe the current evidence and the gaps in the evidence that will need to be improved to demonstrate the benefits of integrating palliative care into the care of patients with advanced HF and their family caregivers.

METHODS

We reviewed the literature to examine the state of the science and to identify gaps in palliative care integration for persons with HF and their families. We then convened an interdisciplinary working group at an NIH/NPCRC sponsored workshop to review the evidence base and develop a research agenda to address these gaps.

RESULTS

We identified four key research priorities to improve palliative care for patients with HF and their families: (1) to better understand patients' uncontrolled symptoms, (2) to better characterize and address the needs of the caregivers of advanced HF patients, (3) to improve patient and family understanding of HF disease trajectory and the importance of advance care planning, and (4) to determine the best models of palliative care, including models for those who want to continue life-prolonging therapies.

CONCLUSIONS

The goal of this research agenda is to motivate patient, provider, policy, and payor stakeholders, including funders, to identify the key research topics that have the potential to improve the quality of care for patients with HF and their families.

Changes in the prevalence of hospitalization and comorbidity in US adults with stroke: A three decade cross-sectional and birth cohort analysis

BACKGROUND AND PURPOSE

Little attention was paid to the transition of care for stroke that may partially explain the long-term trend of stroke rates. We aimed to test the trend of hospitalization attributable to stroke in US adults.

METHODS

Data from National Hospital Discharge Surveys 1980-2010 in patients aged ≥18 (n = 6,527,304) were analyzed to examine the trend of patients with first-list diagnoses of stroke. Stroke comorbidities were classified in stroke patients with second- to seven-listed diagnoses of coronary heart disease, hypertension, diabetes, arrhythmias, or hyperlipidemia. Stroke trends by survey years and birth cohorts were analyzed using univariate, multivariate, and birth cohorts methods.

RESULTS

Of the total study sample, the prevalence of hospitalization due to stroke was 22.99%, 30.00%, and 27.03% in years of 1980-1989, 1990-1999, and 2000-2010 in males, and 17.30%, 22.04%, and 19.34% in females, respectively. Overall, hospitalization rates in stroke patients significantly increased among adults aged <65, and decreased in adults aged ≥65. There was an increase in stroke hospitalization rate in the old adults aged ≥65 in recent birth cohorts. Significant increased trends of comorbid hypertension, diabetes, arrhythmias, and hyperlipidemia were observed from 1980 to 2010.

CONCLUSION

A significant increase in stroke hospitalization rate was observed in adults aged <65 in the past three decades, and in old adults in recent years. Increases in stroke comorbidity rates were observed in all age groups. Findings from the study highlight that both public health and clinical practices face a serious challenge in controlling this unwelcome increased stroke trend.

Heart Failure as a Newly Approved Diagnosis for Cardiac Rehabilitation: Challenges and Opportunities

Many see the broadened eligibility of cardiac rehabilitation (CR) to include heart failure with reduced ejection fraction (HFrEF) as a likely catalyst to high CR enrollment and improved care. However, such expectation contrasts with the reality that CR enrollment of eligible coronary heart disease patients has remained low for decades. In this review, entrenched obstacles impeding utilization of CR are considered, particularly in relation to potential HFrEF management. The strengths and limitations of the HF-ACTION (Heart Failure-A Controlled Trial Investigating Outcomes of Exercise Training) trial to advance precepts of CR are considered, as well as gaps that this trial failed to address, such as the utility of CR for patients with heart failure with preserved ejection fraction and the conundrum of poor patient adherence.

[Chronic heart failure in the elderly patient]

The prevalence and incidence of heart failure (HF) is increasing, especially in the elderly population, and is becoming a major geriatric problem. Elderly patients with HF usually show etiopathogenic, epidemiological, and even clinical characteristics significantly different from those present in younger patients. Their treatment, however, derives from clinical trials performed with only a few elderly subjects. Moreover, beyond the cardiovascular disease itself, it is essential to evaluate the patient as a whole, given the interrelationship between HF and the characteristic geriatric syndromes of the elderly patient. This review examines the peculiarities in the most prevalent "real world" HF patient.

TNF and angiotensin type 1 receptors interact in the brain control of blood pressure in heart failure

Accumulating evidence suggests that the brain renin-angiotensin system and proinflammatory cytokines, such as TNF-α, play a key role in the neurohormonal activation in chronic heart failure (HF). In this study we tested the involvement of TNF-α and angiotensin type 1 receptors (AT1Rs) in the central control of the cardiovascular system in HF rats.

METHODS

we carried out the study on male Sprague-Dawley rats subjected to the left coronary artery ligation (HF rats) or to sham surgery (sham-operated rats). The rats were pretreated for four weeks with intracerebroventricular (ICV) infusion of either saline (0.25μl/h) or TNF-α inhibitor etanercept (0.25μg/0.25μl/h). At the end of the pretreatment period, we measured mean arterial blood pressure (MABP) and heart rate (HR) at baseline and during 60min of ICV administration of either saline (5μl/h) or AT1Rs antagonist losartan (10μg/5μl/h). After the experiments, we measured the left ventricle end-diastolic pressure (LVEDP) and the size of myocardial scar.

RESULTS

MABP and HR of sham-operated and HF rats were not affected by pretreatments with etanercept or saline alone. In sham-operated rats the ICV infusion of losartan did not affect MABP either in saline or in etanercept pretreated rats. In contrast, in HF rats the ICV infusion of losartan significantly decreased MABP in rats pretreated with saline, but not in those pretreated with etanercept. LVEDP was significantly elevated in HF rats but not in sham-operated ones. Surface of the infarct scar exceeded 30% of the left ventricle in HF groups, whereas sham-operated rats did not manifest evidence of cardiac scarring.

CONCLUSIONS

our study provides evidence that in rats with post-infarction heart failure the regulation of blood pressure by AT1Rs depends on centrally acting endogenous TNF-α.

National trends in main causes of hospitalization: a multi-cohort register study of the finnish working-age population, 1976-2010

Background

The health transition theory argues that societal changes produce proportional changes in causes of disability and death. The aim of this study was to identify long-term changes in main causes of hospitalization in working-age population within a nation that has experienced considerable societal change.

Methodology

National trends in all-cause hospitalization and hospitalizations for the five main diagnostic categories were investigated in the data obtained from the Finnish Hospital Discharge Register. The seven-cohort sample covered the period from 1976 to 2010 and consisted of 3,769,356 randomly selected Finnish residents, each cohort representing 25% sample of population aged 18 to 64 years.

Principal Findings

Over the period of 35 years, the risk of hospitalization for cardiovascular diseases and respiratory diseases decreased. Hospitalization for musculoskeletal diseases increased whereas mental and behavioral hospitalizations slightly decreased. The risk of cancer hospitalization decreased marginally in men, whereas in women an upward trend was observed.

Conclusions/Significance

A considerable health transition related to hospitalizations and a shift in the utilization of health care services of working-age men and women took place in Finland between 1976 and 2010.

Epidemiology of heart failure and scope of the problem

Heart failure (HF) is typically a chronic disease, with progressive deterioration occurring over a period of years or even decades. HF poses an especially large public health burden. It represents a new epidemic of cardiovascular disease, affecting nearly 5.8 million people in the United States, and over 23 million worldwide. In the present article, our goal is to describe the most up-to-date epidemiology of HF in the United States and worldwide, and challenges facing HF prevention and treatment.

Trends in the prevalence of hospitalization attributable to hypertensive diseases among United States adults aged 35 and older from 1980 to 2007

We aimed to examine the trend in the prevalence of hospitalization attributable to hypertensive disease and its subtypes among United States adults aged ≥35 years from 1980 to 2007. Data (n = 4,598,488,000 hospitalized cases) from the National Hospital Discharge Surveys were used to examine the trends of hospitalized patients with first (the reason for admission) and patients with any second to seventh (a co-morbid condition when admission) diagnosis of hypertensive disease (International Classification of Disease, 9th Revision, Clinical Modification: 401 to 405) by gender and geographic region. Age-adjusted rates of disease were calculated using the United States 2000 standard population. The results show that age-adjusted hospitalization rates due to first diagnosis of hypertensive disease increased from 1.74% to 2.06% in men (p <0.01), and from 2.0% to 2.09% in women (p = 0.06) from 1980 to 1981 to 2006 to 2007. Age-adjusted rates due to any second to seventh diagnosis of hypertensive disease significantly increased from 7.06% to 35.09% in men (p <0.001), and from 7.88% to 31.98% (p <0.001) in women from 1980 to 1981 to 2006 to 2007. Patients with second to seventh diagnosis of essential hypertension and hypertensive chronic kidney disease had the highest and the second highest annual percent increases. Subjects living in the Southern region of the United States had the highest prevalence of hospitalization due to any second to seventh diagnosis of hypertensive disease compared with all other regions in 2006 to 2007. In conclusion, the prevalence of hospitalization due to hypertensive disease significantly increased in the United States from 1980 to 2007.

Health Literacy Influences Heart Failure Knowledge Attainment but Not Self-Efficacy for Self-Care or Adherence to Self-Care over Time

Background. Inadequate health literacy may be a barrier to gaining knowledge about heart failure (HF) self-care expectations, strengthening self-efficacy for self-care behaviors, and adhering to self-care behaviors over time. Objective. To examine if health literacy is associated with HF knowledge, self-efficacy, and self-care adherence longitudinally. Methods. Prior to education, newly referred patients at three HF clinics (N = 51, age: 64.7 ± 13.0 years) completed assessments of health literacy, HF knowledge, self-efficacy, and adherence to self-care at baseline, 2, and 4 months. Repeated measures analysis of variance with Bonferroni-adjusted alpha levels was used to test longitudinal outcomes. Results. Health literacy was associated with HF knowledge longitudinally (P < 0.001) but was not associated with self-efficacy self-care adherence. In posthoc analyses, participants with inadequate health literacy had less HF knowledge than participants with adequate (P < 0.001) but not marginal (P = 0.073) health literacy. Conclusions. Adequate health literacy was associated with greater HF knowledge but not self-efficacy or adherence to self-care expectations over time. If nurses understand patients' health literacy level, they may educate patients using methods that promote understanding of concepts. Since interventions that promote self-efficacy and adherence to self-care were not associated with health literacy level, new approaches must be examined.

Management of type 2 diabetes in older people

The prevalence of diabetes is increasing due to aging of the population and increasing obesity. In the developed world, there is an epidemiologic shift from diabetes being a disease of middle age to being a disease of older people due to increased life expectancy. In old age, diabetes is associated with high comorbidity burden and increased prevalence of geriatric syndromes in addition to the traditional vascular complications. Therefore, comprehensive geriatric assessment should be performed on initial diagnosis of diabetes. Due to the heterogeneous nature of older people with diabetes and variations in their functional status, comorbidities, and life expectancy, therapeutic interventions, and glycemic targets should be individualized taking into consideration patients' preferences and putting quality of life at the heart of their care plans.

Serum bilirubin as a prognostic marker in patients with acute decompensated heart failure

BACKGROUND/AIMS

Several prognostic markers for heart failure (HF) have been determined but the importance of liver function tests (LFTs) remains unknown. The aim of this study was to determine the prognostic significance, if any, of abnormal LFTs in acute decompensated HF.

METHODS

All adult patients (> 18 years of age) who were admitted to a community hospital with a diagnosis of acute decompensated HF during the period January 2008 to December 2009 were identified. Exclusion criteria included acute coronary syndrome, active hepatobiliary disease, renal failure (serum creatinine ≥ 2 mg/dL), and malignancy. The primary end point was readmission secondary to acute exacerbation of HF. The Cox proportional hazard model was used for statistical analyses.

RESULTS

Univariate analysis showed that serum total bilirubin (TB, p < 0.01), serum B-type natriuretic peptide (p < 0.05), ejection fraction (EF, p < 0.05), and heart rate (p < 0.05) were significant predictors of hospital readmission secondary to acute decompensated HF. Multivariate analysis showed that high serum TB (> 1.3 mg/dL) on admission was an independent predictor (p < 0.05) of hospital readmission secondary to HF. The 'at-risk' group-patients with serum TB > 1.3 mg/dL and/or EF < 35% on admission-had a readmission rate that was 87% ± 20% (p < 0.05) higher than those with neither criterion.

CONCLUSIONS

In patients with acute decompensated HF, elevated serum TB on admission with or without low EF (< 35%) predicts a worse prognosis and early future readmission, secondary to HF.

Patterns of comorbidity in older adults with heart failure: the Cardiovascular Research Network PRESERVE study

OBJECTIVES

To examine whether the total burden of comorbidity and pattern of co-occurring conditions varies in individuals with heart failure (HF) with preserved left ventricular ejection fraction (LVEF) (HF-P) or HF with reduced LVEF (HF-R).

DESIGN

Cross-sectional cohort study.

SETTING

Four participating health plans within the National Heart, Lung, and Blood Institute-sponsored Cardiovascular Research Network.

PARTICIPANTS

All members aged 65 and older with HF based on hospital discharge and ambulatory visit diagnoses.

MEASUREMENTS

Participants with a LVEF of 50% or greater were classified as having HF-P. Presence of cardiac and noncardiac comorbidities was obtained from health plan administrative databases.

RESULTS

Of 23,435 individuals identified with HF and LVEF information, 53% (12,407) had confirmed HF-P (mean age 79.6; 60% female). More than three-quarters of the sample had three or more co-occurring conditions in addition to HF, and half had five or more cooccurring conditions. Participants with HF-P had a slightly higher burden of comorbidity than those with HF-R (mean 4.5 vs 4.4, P = .002). Patterns of how specific conditions co-occurred did not vary in participants with preserved or reduced systolic function.

CONCLUSION

There is a high degree of comorbidity and multiple morbidity in individuals with HF. The burden and pattern of comorbidity varies only slightly in individuals with preserved or reduced LVEF.

Analysis of the prevalence of cardiovascular disease and associated risk factors for European-American and African-American populations in the state of Pennsylvania 2005-2009

We examined the burden of cardiovascular disease (CVD) and its associated risk factors using statewide representative data from the Pennsylvania Behavior Risk Factors Surveillance System. The data from 35,576 subjects aged ≥ 18 years participating in the Pennsylvania Behavior Risk Factors Surveillance System in 2005, 2007, and 2009 were analyzed. The age-adjusted prevalence rates of CVD were computed. Logistic regression analysis was applied to examine associations between the risk factors and CVD prevalence, with adjustment for confounding variables. The results showed that no significant changes in the prevalence of CVD, coronary heart disease, and stroke were observed in either European Americans or African Americans from 2005 to 2009 (p >0.05). African Americans had significantly greater CVD rates than European Americans. Although smoking rates significantly decreased, several other CVD risk factors (i.e., obesity, hypertension, and hypercholesterolemia) significantly increased from 2005 to 2009 in European Americans. Similar changes were observed in African Americans, although these changes did not reach statistical significance. Logistic regression analysis indicated that African Americans had a 35% greater risk of CVD. Education level less than high school, smoking, obesity, hypertension, and diabetes were significantly and positively associated with CVD. In conclusion, no significant achievements in CVD control and risk factor reduction were observed from 2005 to 2009 in Pennsylvania. Additional aggressive control of hypertension, obesity, and diabetes for both European and African Americans must be made to reduce the burden of CVD.

Precipitant profile of acute heart failure: experience of a tertiary level cardiac centre in Sri Lanka

INTRODUCTION AND OBJECTIVES

Heart failure (HF) is a common cause of hospitalisation in most countries. Data on acute precipitants of HF and hospitalisation is not available in Sri Lanka.

BACKGROUND AND METHODS

A prospective study of 100 sequential admissions with HF to the cardiology unit (National Hospital of Sri Lanka) to describe the precipitants and clinical outcome of HF.

RESULTS

Fifty-eight male and 42 female admissions were studied. Mean age was 60.66 years. Mean hospital stay was 5.5(SD 4.6) days. Sixty had de novo HF and 40 had pre-existing HF. The most common identifiable precipitants were acute ischaemia 37 (37%), anaemia 41 (41%), respiratory tract infection 10 (10%), arrhythmia 11 (11%), worsening renal function 11 (11%) and alcohol 5 (5.7%). Non-adherence to medication 4 (4.6%), smoking 3 (3.9%), exposure to environmental stress 3 (3.4%) and uncontrolled hypertension 1 (1%) were also observed as precipitants. The most common arrhythmia was atrial fibrillation. Out of 34 patients in whom angiotensin-converting enzyme inhibitors or angiotensin-converting enzyme receptor blockers were indicated, 11% were not on the drug. Among 29 patients in whom spironolactone was indicated, seven patients were not on the drug.

CONCLUSIONS

Most precipitating factors of HF are preventable. Early identification and prevention of anaemia, preventing respiratory tract infection by vaccination, aggressive revascularisation for patients with ischaemia, monitoring of renal functions, and patient education regarding drug and diet compliance, would reduce the number of admissions.

Serum 25-hydroxyvitamin D concentration and mortality from heart failure and cardiovascular disease, and premature mortality from all-cause in United States adults

We aimed to examine associations between serum 25-hydroxyvitamin D (25[OH]D) concentration and mortality from heart failure (HF) and cardiovascular disease (CVD) and premature death from all causes using data from the Third National Health and Nutrition Examination Survey, which included 13,131 participants (6,130 men, 7,001 women) ≥35 years old at baseline (1988 to 1994) and followed through December 2000. Premature death was defined all-cause death at <75 years of age. Results indicated that during an average 8-year follow-up, there were 3,266 deaths (24.9%) including 101 deaths from HF, 1,451 from CVD, and 1,066 premature all-cause deaths. Among HF deaths, 37% of decedents had serum 25(OH)D levels <20 ng/ml, whereas only 26% of those with non-HF deaths had such levels (p <0.001). Multivariate-adjusted Cox model indicated that subjects with serum 25(OH)D levels <20 ng/ml had 2.06 times higher risk (95% confidence interval 1.01 to 4.25) of HF death than those with serum 25(OH)D levels ≥30 ng/ml (p <0.001). In addition, hazard ratios (95% confidence intervals) for premature death from all causes were 1.40 (1.17 to 1.68) in subjects with serum 25(OH)D levels <20 ng/ml and 1.11 (0.93 to 1.33) in those with serum 25(OH)D levels of 20 to 29 ng/ml compared to those with serum 25(OH)D levels ≥30 ng/ml (p <0.001, test for trend). In conclusion, adults with inadequate serum 25(OH)D levels have significantly higher risk of death from HF and all CVDs and all-cause premature death.

Global variability in diabetes mellitus and its association with body weight and primary healthcare support in 49 low- and middle-income developing countries

AIMS

In the absence of any previous global comparison, we examined the variability in prevalence of diabetes mellitus across 49 developing countries, and the associations of diabetes with body weight and primary healthcare support using data from the World Health Survey.

METHODS

Diabetes mellitus was defined by individuals' self-report of a physician diagnosis of diabetes. BMI is the weight (kg)/the square of the height (m). Healthcare support was assessed using clinical treatment status and whether patients with diabetes followed prescribed behaviour changes to control diabetes. Associations of diabetes with BMI and diabetes treatment status were analysed cross-sectionally.

RESULTS

A total of 215898 participants were included in the analysis. Age-adjusted prevalence of diabetes ranged from 0.27% (Mali) to 15.54% (Mauritius). Participants who were underweight (BMI <18.5 kg/m(2) ), overweight (BMI 25-29.9 kg/m(2) ) and obese (BMI ≥ 30 kg/m(2) ) were significantly associated with odds of having diabetes as compared with those who were of normal weight (BMI 18.5-24.9 k/m(2) ), with corresponding values of multivariate adjusted odds ratios (95% CI) of 1.15 (1.07-1.24), 1.56 (1.44-1.68) and 2.35 (2.17-2.61), respectively. The overall untreated rate of those with diabetes mellitus was 9.6% in the total sample. Patients with underweight had the highest diabetes untreated rate, followed by those with normal weight, overweight and obesity.

CONCLUSION

There are significant variations in prevalence of diabetes and primary healthcare support for diabetes across low- and middle-income countries. Aggressively preventing abnormal body weight and improving healthcare support may play a pivotal role in ameliorating the unfavourable epidemic of diabetes in developing countries.

Public health options for improving cardiovascular health among older Americans

Life expectancy at birth has increased from 74 years in 1980 to 78 years in 2006. Older adults (aged 65 years and older) are living longer with cardiovascular conditions, which are leading causes of death and disability and thus an important public health concern. We describe several major issues, including the impact of comorbidities, the role of cognitive health, prevention and intervention approaches, and opportunities for collaboration to strengthen the public health system. Prevention can be effective at any age, including for older adults. Public health models focusing on policy, systems, and environmental change approaches have the goal of providing social and physical environments and promoting healthy choices.

Adherence of heart failure patients to exercise: barriers and possible solutions: a position statement of the Study Group on Exercise Training in Heart Failure of the Heart Failure Association of the European Society of Cardiology

The practical management of heart failure remains a challenge. Not only are heart failure patients expected to adhere to a complicated pharmacological regimen, they are also asked to follow salt and fluid restriction, and to cope with various procedures and devices. Furthermore, physical training, whose benefits have been demonstrated, is highly recommended by the recent guidelines issued by the European Society of Cardiology, but it is still severely underutilized in this particular patient population. This position paper addresses the problem of non-adherence, currently recognized as a main obstacle to a wide implementation of physical training. Since the management of chronic heart failure and, even more, of training programmes is a multidisciplinary effort, the current manuscript intends to reach cardiologists, nurses, physiotherapists, as well as psychologists working in the field.

Health literacy and self-care of patients with heart failure

BACKGROUND AND RESEARCH OBJECTIVE

Today's complex healthcare system relies heavily on sophisticated self-care regimens. To navigate the system and follow self-care protocols, patients must be able to understand and use health information, which requires health literacy. However, nearly 90 million Americans lack the necessary health literacy skills to adequately care for themselves in the face of a complex healthcare system and self-care regimens. Understanding how to effectively care for one's self is thought to improve heart failure symptoms and patient outcomes, but little is actually known about how health literacy influences self-care in patients with heart failure. The purpose of this pilot study was to examine the relationship between health literacy and self-care of patients with heart failure.

SUBJECTS AND METHODS

Patients with a diagnosis of heart failure were recruited from a variety of community settings. Participants completed the Short-Form Test of Functional Health Literacy (measured health literacy), the Self-care Index of Heart Failure (measured self-care maintenance, management, and confidence), and a demographic questionnaire. Spearman ρ correlations were used to assess the strength of the relationship between health literacy level and self-care scores.

RESULTS AND CONCLUSIONS

Among the 49 participants recruited, health literacy was positively related to self-care maintenance (Rs = 0.357, P = .006). Health literacy had a negative relationship with self-care management (Rs = -0.573, P = .001). There was no association between health literacy and self-care confidence (Rs = 0.201, P = .083). This project provides preliminary data regarding the association between health literacy and self-care in heart failure, showing support for higher health-literate patients performing more self-care maintenance, which has been shown to improve patient outcomes in heart failure. Patients with higher health literacy trended toward having greater self-care confidence, which can increase the likelihood of performing self-care, but this finding was not statistically significant. It was unexpected to find that lower health-literate patients performed more self-care management.

Resource utilization and costs following hospitalization of patients with chronic heart failure in the US

BACKGROUND

Despite advances in its management and the identification of preventable risk factors, heart failure (HF) is a growing health problem in the US. The objective of this study was to describe treatment patterns, medical resource utilization and costs following hospitalization for chronic HF for patients stratified by age.

METHODS

Patients with at least one hospitalization with chronic HF were identified in a US commercial insurance claims database from 2004-2008. Patients were followed from the 1st day of chronic HF hospitalization (index hospitalization) until disenrollment or end of data availability. Inpatient, outpatient and prescription drug utilization rates were calculated per person per month (PPPM). Costs included payments made by insurers and, where available, patient out-of-pocket payments and sick-leave costs were also calculated. Utilization rates and costs were stratified by patient age.

RESULTS

There were 7814 patients included in the study. Index hospitalization was the most resource intensive and expensive ($31,023 age <65, $12,426 age ≥ 65). The rate of outpatient visits was the highest within 3 months following index hospitalization (3.6/PPPM age <65, 4.1/PPPM age ≥ 65). For the older age group, rate of re-hospitalizations was highest (0.06/PPPM) within 3-6 months following index hospitalization, while the younger group had its highest rate (0.08/PPPM) during the first 3 months following index hospitalization. Prescription dispensing rates were similar between age groups; average reimbursement PPPM for cardiovascular drugs did not exceed $92 (age <65) and $221 (age ≥ 65), which represents less than 3% of hospitalization costs for both groups.

CONCLUSIONS

Treating chronic HF patients is resource intensive. The greatest burden occurs within 6 months after index hospitalization for both age groups; patients continue to be burdened after hospitalization by high inpatient and outpatient visit rates. Outpatient cardiovascular drug costs account for a small proportion of total healthcare costs.