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Wussler D, Belkin M, Shrestha S, Wernicke H, Papachristou A, Nowak A, Aliyeva F, Mork C, Strebel I, Huré GVF, Weil D, Michou E, Kozhuharov N, Gualandro DM, Puelacher C, Miró O, Rossello X, Martín-Sánchez FJ, Pocock SJ, Goudev A, Breidthardt T, Mueller C. Incremental value of C-reactive protein to the MEESSI acute heart failure risk score. Eur J Heart Fail 2024. [PMID: 38923253 DOI: 10.1002/ejhf.3349] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/27/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
AIMS We hypothesized that the current gold standard for risk stratification of patients with acute heart failure (AHF), the Multiple Estimation of risk based on the Emergency department Spanish Score In patients with AHF (MEESSI-AHF) risk score, can be further improved by adding systemic inflammation as quantified by C-reactive protein (CRP). METHODS AND RESULTS In a prospective multicentre diagnostic study (BASEL V), AHF was centrally adjudicated by two independent cardiologists. The MEESSI-AHF risk score was calculated using an established reduced and recalibrated model containing 12 independent risk factors. Model extension was performed by refitting and adding CRP in the logistic regression model with 30-day mortality as binary outcome. Discrimination, calibration and clinical usefulness were used to assess the performance of the extended Multiple Estimation of risk based on the Emergency department Spanish Score In patients (MEESSI) model. Validation was performed in an independent, retrospective and single-centre AHF cohort. Among 1208 AHF patients with complete data allowing calculation of the recalibrated MEESSI and the extended MEESSI models, the prognostic accuracy for 30-day mortality of the extended MEESSI model (c-statistic 0.83, 95% confidence interval [CI] 0.79-0.87) was significantly higher compared to the recalibrated model (c-statistic 0.79, 95% CI 0.75-0.83, p = 0.013). The extended model allowed to stratify a higher percentage of patients into the lowest risk group compared to the recalibrated model (33.1% vs. 20.3%). Demonstrating a calibration plot's slope of 1.00 (95% CI 0.81-1.19) and an intercept of 0.0 (95% CI -0.22 to 0.22), the extended MEESSI model achieved excellent and improved calibration. Results were confirmed in the independent validation cohort (n = 575). CONCLUSIONS Quantifying inflammation using CRP concentration provided incremental value in AHF risk stratification using the established MEESSI model.
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Affiliation(s)
- Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Maria Belkin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Hannah Wernicke
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Androniki Papachristou
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Albina Nowak
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Endocrinology and Clinical Nutrition, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Fatima Aliyeva
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Constantin Mork
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- University Clinic of Medicine, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Gabrielle Valerie Francoi Huré
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Dominic Weil
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Eleni Michou
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Cardiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Nikola Kozhuharov
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Oscar Miró
- Emergency Department, Hospital Clínic, University Barcelona, Barcelona, Spain
| | - Xavier Rossello
- Cardiology Department, Institut d'Investigació Sanitària Illes Balears (IdISBa), Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | | | - Stuart J Pocock
- Department of Medical Statistics, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Assen Goudev
- Department of Cardiology, Queen Ioanna University Hospital Sofia, Medical University of Sofia, Sofia, Bulgaria
| | - Tobias Breidthardt
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
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Lukoschewitz JD, Miger KC, Olesen ASO, Caidi NOE, Jørgensen CK, Nielsen OW, Hassager C, Hove JD, Seven E, Møller JE, Jakobsen JC, Grand J. Vasodilators for Acute Heart Failure - A Systematic Review with Meta-Analysis. NEJM EVIDENCE 2024; 3:EVIDoa2300335. [PMID: 38804781 DOI: 10.1056/evidoa2300335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
BACKGROUND Acute heart failure is a public health concern. This study systematically reviewed randomized clinical trials (RCTs) to evaluate vasodilators in acute heart failure. METHODS The search was conducted across the databases of Medline, Embase, Latin American and the Caribbean Literature on Health Sciences, Web of Science, and the Cochrane Central Register of Controlled Trials. Inclusion criteria consisted of RCTs that compared vasodilators versus standard care, placebo, or cointerventions. The primary outcome was all-cause mortality; secondary outcomes were serious adverse events (SAEs), tracheal intubation, and length of hospital stay. Risk of bias was assessed in all trials. RESULTS The study included 46 RCTs that enrolled 28,374 patients with acute heart failure. Vasodilators did not reduce the risk of all-cause mortality (risk ratio, 0.95; 95% confidence interval [CI], 0.87 to 1.04; I2=9.51%; P=0.26). No evidence of a difference was seen in the risk of SAEs (risk ratio, 1.01; 95% CI, 0.97 to 1.05; I2=0.94%) or length of hospital stay (mean difference, -0.10; 95% CI, -0.28 to 0.08; I2=69.84%). Vasodilator use was associated with a lower risk of tracheal intubation (risk ratio, 0.54; 95% CI, 0.30 to 0.99; I2=51.96%) compared with no receipt of vasodilators. CONCLUSIONS In this systematic review with meta-analysis of patients with acute heart failure, vasodilators did not reduce all-cause mortality.
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Affiliation(s)
- Jasmin D Lukoschewitz
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen
| | - Kristina C Miger
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen
| | - Anne Sophie O Olesen
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen
| | - Nora O E Caidi
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen
| | - Caroline K Jørgensen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Olav W Nielsen
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen
| | - Christian Hassager
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen
| | - Jens D Hove
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen
| | - Ekim Seven
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen
| | - Jacob E Møller
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen
- Department of Clinical Medicine, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, University of Southern Denmark, Odense, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Johannes Grand
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen
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Casey SD, Sax DR, Mark DG, Rana JS, Solomon MD, Huang J, Reed ME. Comparison of Short-Term Health Care Utilization Between Telemedicine-Delivered vs In-Person Care Visits for Heart Failure. JACC. ADVANCES 2024; 3:100969. [PMID: 38938856 PMCID: PMC11198545 DOI: 10.1016/j.jacadv.2024.100969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/12/2024] [Accepted: 03/11/2024] [Indexed: 06/29/2024]
Abstract
Background Patients with heart failure (HF) are a medically complex population with frequent hospitalizations. Downstream health care utilization following primary care delivered by telemedicine compared to in-person is unknown. Objectives The purpose of this study was to understand differences in return in-person visits, emergency department (ED) encounters, and hospitalizations following a telemedicine vs an in-person primary care visit for patients with HF seen for a HF-related complaint. Methods This was an observational study of all primary care visits for HF from January 1, 2022, to December 31, 2022, in an integrated health care delivery system. We compared 7-day in-person follow-up visits, ED visits, and hospitalizations (all-cause and HF-specific) by index visit type. Results We included 3,902 primary care visits with a primary diagnosis of HF. Most visits utilized telephone or video visits (58.4% total; 44.9% telephone, 13.5% video). After adjustment, telephone visits were associated with more in-person follow-up visits (6.14% vs 4.20%; adjusted OR: 1.08-2.21; P < 0.05) but fewer ED visits (6.12% vs 8.07%; adjusted OR: 0.55-0.97; P < 0.05) compared to in-person visits. Most hospitalized patients (74%) had an admitting diagnosis of HF. There was no difference between 7-day all-cause hospitalization following telephone or video visits compared to in-person visits. Conclusions Most patients used telemedicine to address HF-specific primary care concerns. Telephone visits were associated with slightly higher short-term in-person primary care follow-up but lower ED utilization. Overall, downstream ED visits and hospitalizations were low. Telephone and video visits appear to offer safe alternatives to in-person care for HF-related primary care and are a promising health care delivery strategy.
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Affiliation(s)
- Scott D. Casey
- Health Care Delivery and Policy Section, Kaiser Permanente Division of Research, Oakland, California, USA
- Health Care Delivery and Policy Section, The Kaiser Permanente CREST Network, Oakland, California, USA
- Department of Emergency Medicine, The Permanente Medical Group, Vallejo, California, USA
| | - Dana R. Sax
- Health Care Delivery and Policy Section, Kaiser Permanente Division of Research, Oakland, California, USA
- Health Care Delivery and Policy Section, The Kaiser Permanente CREST Network, Oakland, California, USA
- Department of Emergency Medicine, The Permanente Medical Group, Oakland, California, USA
| | - Dustin G. Mark
- Health Care Delivery and Policy Section, The Kaiser Permanente CREST Network, Oakland, California, USA
- Department of Emergency Medicine, The Permanente Medical Group, Oakland, California, USA
| | - Jamal S. Rana
- Health Care Delivery and Policy Section, Kaiser Permanente Division of Research, Oakland, California, USA
- Department of Cardiology, The Permanente Medical Group, Oakland, California, USA
| | - Matthew D. Solomon
- Health Care Delivery and Policy Section, Kaiser Permanente Division of Research, Oakland, California, USA
- Department of Cardiology, The Permanente Medical Group, Oakland, California, USA
| | - Jie Huang
- Health Care Delivery and Policy Section, Kaiser Permanente Division of Research, Oakland, California, USA
- Health Care Delivery and Policy Section, The Kaiser Permanente CREST Network, Oakland, California, USA
| | - Mary E. Reed
- Health Care Delivery and Policy Section, Kaiser Permanente Division of Research, Oakland, California, USA
- Health Care Delivery and Policy Section, The Kaiser Permanente CREST Network, Oakland, California, USA
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Sheehan M, Sokoloff L, Reza N. Acute Heart Failure: From The Emergency Department to the Intensive Care Unit. Cardiol Clin 2024; 42:165-186. [PMID: 38631788 PMCID: PMC11064814 DOI: 10.1016/j.ccl.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Acute heart failure (AHF) is a frequent cause of hospitalization around the world and is associated with high in-hospital and post-discharge morbidity and mortality. This review summarizes data on diagnosis and management of AHF from the emergency department to the intensive care unit. While more evidence is needed to guide risk stratification and care of patients with AHF, hospitalization is a key opportunity to optimize evidence-based medical therapy for heart failure. Close linkage to outpatient care is essential to improve post-hospitalization outcomes.
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Affiliation(s)
- Megan Sheehan
- Division of Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Maloney Building 5th Floor, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Lara Sokoloff
- Division of Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Maloney Building 5th Floor, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, 11th Floor South Pavilion, Room 11-145, Philadelphia, PA 19104, USA.
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Miró Ò, Llorens P, Aguiló S, Alquézar-Arbé A, Fernández C, Burillo-Putze G, Marcos NC, Marañón AA, Oms GS, Del Castillo JG. Epidemiological aspects, clinical management and short-term outcomes in elderly patients diagnosed with acute heart failure in the emergency department in Spain: results of the EDEN-34 study. Rev Clin Esp 2024; 224:204-216. [PMID: 38423386 DOI: 10.1016/j.rceng.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To estimate the incidence of acute heart failure (AHF) diagnosis in elderly patients in emergency departments (ED), diagnostic confirmation in hospitalized patients, and short-term adverse events. METHODS All patients aged ≥65 years attended in 52 Spanish EDs during 1 week were included and those diagnosed with AHF were selected. In hospitalized patients, those diagnosed with AHF at discharge were collected. As adverse events, in-hospital and 30-day mortality, and combined adverse event (death or hospitalization) at 30 days post-discharge were collected. Adjusted odds ratios (OR) for association of demographic variables, baseline status and constants at ED arrival with mortality and 30-day post-discharge adverse event were calculated. RESULTS We included 1,155 patients with AHF (annual incidence: 26.5 per 1000 inhabitants ≥65 years, 95% CI: 25.0-28.1). In 86% the diagnosis of AHF was known at discharge. Overall 30-day mortality was 10.7% and in-hospital mortality was 7.9%, and the combined event in 15.6%. In-hospital and 30-day mortality was associated with arterial hypotension (adjusted OR: 74.0, 95% CI: 5.39-1015. and 42.6, 3.74-485, respectively and hypoxemia (2.14, 1.27-3.61; and 1.87, 1.19-2.93) on arrival at the ED and requiring assistance with ambulation (2.24, 1.04-4.83; and 2.48, 1.27-4.86) and age (per 10-year increment; 1.54, 1.04-2.29; and 1.60, 1.13-2.28). The combined post-discharge adverse event was not associated with any characteristic. CONCLUSIONS AHF is a frequent diagnosis in elderly patients consulting in the ED. The functional impairment, age, hypotension and hypoxemia are the factors most associated with mortality.
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Affiliation(s)
- Ò Miró
- Área de Urgencias, Hospital Clínico, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - P Llorens
- Servicio de Urgencias, Corta Estancia y Hospitalización a Domicilio, Hospital General Dr. Balmis, Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Universidad Miguel Hernández, Alicante, Spain.
| | - S Aguiló
- Área de Urgencias, Hospital Clínico, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - A Alquézar-Arbé
- Servicio de Urgencias, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - C Fernández
- Servicio de Urgencias, Hospital Clínico San Carlos, IDISSC, Universidad Complutense, Madrid, Spain
| | - G Burillo-Putze
- Servicio de Urgencias, Hospital Universitario de Canarias, Tenerife, Spain
| | - N C Marcos
- Área de Urgencias, Hospital Clínico, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - A A Marañón
- Área de Urgencias, Hospital Clínico, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - G S Oms
- Área de Urgencias, Hospital Clínico, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - J G Del Castillo
- Servicio de Urgencias, Hospital Clínico San Carlos, IDISSC, Universidad Complutense, Madrid, Spain
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6
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Smith AB, Jung M, Pressler SJ. Pain and Heart Failure During Transport by Emergency Medical Services and Its Associated Outcomes: Hospitalization, Mortality, and Length of Stay. West J Nurs Res 2024; 46:172-182. [PMID: 38230416 PMCID: PMC10922995 DOI: 10.1177/01939459231223128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND Over 22% of patients with heart failure (HF) are transported by emergency medical services (EMSs) for a primary complaint of pain. The relationship between a primary complaint of pain on hospitalization status, mortality, or length of stay following transport by EMS is understudied. OBJECTIVES The objective of this study was to determine whether a primary complaint of pain during EMS transport predicted hospitalization status, mortality, or inpatient length of stay. METHODS In this retrospective longitudinal cohort study, data were analyzed from electronic health records of 3539 patients with HF. Descriptive statistics and multivariate logistic and linear regression analyses were used to achieve study objectives. RESULTS Demographics were mean age 64.83 years (standard deviation [SD] = 14.58); gender 57.3% women, 42.7% men; self-reported race 56.2% black, 43.2% white, and 0.7% other. Of 3539 patients, 2346 (66.3%) were hospitalized, 149 (4.2%) died, and the mean length of stay was 6.02 (SD = 7.55) days. A primary complaint of pain did not predict increased odds of in-hospital mortality but did predict 39% lower odds of hospitalization (p < .001), and 26.7% shorter length of stay (p < .001). Chest pain predicted 49% lower odds of hospitalization (p < .001) and 34.1% (p < .001) shorter length of stay, whereas generalized pain predicted 45% lower odds of hospitalization (p = .044) following post-hoc analysis. CONCLUSIONS A primary complaint of chest pain predicted lower odds of hospitalization and shorter length of stay, possibly due to established treatment regimens. Additional research is needed to examine chronic pain rather than a primary complaint of pain.
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Affiliation(s)
- Asa B. Smith
- School of Nursing, Indiana University, Indiana USA
| | - Miyeon Jung
- School of Nursing, Indiana University, Indiana USA
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7
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Phipps G, Sowden N, Mikkelsen K, Fincher G, Ranasinghe I, Atkins L, Jordan F, Chan W. Contemporary management of acute heart failure in the emergency department and the potential impact of early diuretic therapy on outcomes. Emerg Med Australas 2024; 36:71-77. [PMID: 37666655 DOI: 10.1111/1742-6723.14301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 08/06/2023] [Accepted: 08/10/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVE Acute heart failure (AHF) is one of the most common conditions presenting to the ED and patients often require hospitalisation. Emerging evidence suggests early diagnosis and administration of diuretics are associated with improved patient outcomes. Currently, there is limited literature on the management of AHF in the Australian ED context. METHODS A retrospective review of consecutive AHF presentations to the ED in a metropolitan hospital. Patient demographics, clinical status and management were assessed including timeliness of diuretics administration and association with outcomes including ED length of stay (LOS) and inpatient mortality using linear regression. RESULTS One hundred and ninety-one presentations (median age 81 years, 50.8% male) were identified. Common cardiovascular comorbidities were prevalent. Fifty-four patients (28.3%) had ≥1 clinical high-risk feature at presentation. The median time from presentation to furosemide administration was 187 min (interquartile range 97-279 min); only 35 patients received diuretics within 60 min of presentation. Early diuretics was associated with shorter ED LOS (246 min vs 275 min, P = 0.03) and a lower but non-significant inpatient mortality (4.9% vs 6.3%, P = 0.21) and a non-significant increased rate of discharge home from ED (8.6% vs 4.7%, P = 0.15). The likelihood of discharge home was significantly more pronounced in patients receiving early diuretics without clinical high-risk features (16.7% vs 4.3%, P = 0.028). CONCLUSION Despite symptoms and signs being well recognised at presentation, time to diuretics was relatively long. Early diuretics administration was associated with improved patient outcomes, particularly in clinically more stable patients. Due to the limitations of the study design, results should be interpreted with caution and warrant further research to identify factors that delay timely administration of diuretics.
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Affiliation(s)
- Genevieve Phipps
- School of Medicine, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Nicholas Sowden
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Kellie Mikkelsen
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Gavin Fincher
- School of Medicine, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Emergency Medicine, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Isuru Ranasinghe
- School of Medicine, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Lauren Atkins
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Faye Jordan
- School of Medicine, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Emergency Medicine, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Wandy Chan
- School of Medicine, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Queensland, Australia
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8
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Pang PS, Berger DA, Mahler SA, Li X, Pressler SJ, Lane KA, Bischof JJ, Char D, Diercks D, Jones AE, Hess EP, Levy P, Miller JB, Venkat A, Harrison NE, Collins SP. Short-Stay Units vs Routine Admission From the Emergency Department in Patients With Acute Heart Failure: The SSU-AHF Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2350511. [PMID: 38198141 PMCID: PMC10782263 DOI: 10.1001/jamanetworkopen.2023.50511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/15/2023] [Indexed: 01/11/2024] Open
Abstract
Importance More than 80% of patients who present to the emergency department (ED) with acute heart failure (AHF) are hospitalized. With more than 1 million annual hospitalizations for AHF in the US, safe and effective alternatives are needed. Care for AHF in short-stay units (SSUs) may be safe and more efficient than hospitalization, especially for lower-risk patients, but randomized clinical trial data are lacking. Objective To compare the effectiveness of SSU care vs hospitalization in lower-risk patients with AHF. Design, Setting, and Participants This multicenter randomized clinical trial randomly assigned low-risk patients with AHF 1:1 to SSU or hospital admission from the ED. Patients received follow-up at 30 and 90 days post discharge. The study began December 6, 2017, and was completed on July 22, 2021. The data were analyzed between March 27, 2020, and November 11, 2023. Intervention Randomized post-ED disposition to less than 24 hours of SSU care vs hospitalization. Main Outcomes and Measures The study was designed to detect at least 1-day superiority for a primary outcome of days alive and out of hospital (DAOOH) at 30-day follow-up for 534 participants, with an allowance of 10% participant attrition. Due to the COVID-19 pandemic, enrollment was truncated at 194 participants. Before unmasking, the primary outcome was changed from DAOOH to an outcome with adequate statistical power: quality of life as measured by the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12). The KCCQ-12 scores range from 0 to 100, with higher scores indicating better quality of life. Results Of the 193 patients enrolled (1 was found ineligible after randomization), the mean (SD) age was 64.8 (14.8) years, 79 (40.9%) were women, and 114 (59.1%) were men. Baseline characteristics were balanced between arms. The mean (SD) KCCQ-12 summary score between the SSU and hospitalization arms at 30 days was 51.3 (25.7) vs 45.8 (23.8) points, respectively (P = .19). Participants in the SSU arm had 1.6 more DAOOH at 30-day follow-up than those in the hospitalization arm (median [IQR], 26.9 [24.4-28.8] vs 25.4 [22.0-27.7] days; P = .02). Adverse events were uncommon and similar in both arms. Conclusions and Relevance The findings show that the SSU strategy was no different than hospitalization with regard to KCCQ-12 score, superior for more DAOOH, and safe for lower-risk patients with AHF. These findings of lower health care utilization with the SSU strategy need to be definitively tested in an adequately powered study. Trial Registration ClinicalTrials.gov Identifier: NCT03302910.
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Affiliation(s)
- Peter S. Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - David A. Berger
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - Simon A. Mahler
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Xiaochun Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis
| | | | - Kathleen A. Lane
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis
| | - Jason J. Bischof
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - Douglas Char
- Department of Emergency Medicine, Washington University in St Louis, St Louis, Missouri
| | - Deborah Diercks
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Alan E. Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson
| | - Erik P. Hess
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Phillip Levy
- Wayne State University School of Medicine and Integrative Biosciences Center, Detroit, Michigan
| | - Joseph B. Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Nicholas E. Harrison
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Sean P. Collins
- Department of Emergency Medicine, Vanderbilt University School of Medicine and Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center, Nashville, Tennessee
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Gustafson SE, Hamilton SA, Ambrosy AP. In Search of a Timely, Safe, and Effective Alternative to Hospitalization for Heart Failure. JAMA Netw Open 2024; 7:e2350454. [PMID: 38198144 DOI: 10.1001/jamanetworkopen.2023.50454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Affiliation(s)
- Shanshan E Gustafson
- Department of Medicine, Kaiser Permanente Mid-Atlantic Medical Group, Gaithersburg, Maryland
| | - Steven A Hamilton
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
- Division of Research, Kaiser Permanente Northern California, Oakland, California
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
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10
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Pokhrel Bhattarai S, Block RC, Xue Y, Rodriguez DH, Tucker RG, Carey MG. Integrative review of electrocardiographic characteristics in patients with reduced, mildly reduced, and preserved heart failure. Heart Lung 2024; 63:142-158. [PMID: 37913557 DOI: 10.1016/j.hrtlng.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/09/2023] [Accepted: 10/23/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION Electrocardiographic (ECG) changes in heart failure with reduced, mildly reduced, and preserved ejection fractions can be critical in clinical assessment while waiting to perform echocardiograms or when it is unavailable. This integrative review aimed to identify ECG characteristics among hospitalized patients demonstrating three types of heart failure during acute decompensation. METHODS We searched an electronic database of PubMed, Web of Science, EMBASE, Scopus, Google Scholar, and ClinicalTrials.gov using medical subject headings (MeSH) terms and keywords. Sixteen studies were synthesized and reported. RESULTS Heart failure with reduced ejection fraction (HFrEF) was more common in men, comorbid with coronary artery diseases and diabetes mellitus, higher BNP/Pro-BNP, wide QRS, and left bundle branch block on ECG. On average, clients with heart failure with preserved ejection fraction (HFpEF) were older and more likely to have a history of atrial fibrillation, valvular heart diseases, hypertension, chronic obstructive pulmonary, and atrial fibrillation (AF) on ECG. Patients with mildly reduced (HFmrEF) were more similar to HFpEF in older patients, comorbid with hypertension, AF and valvular diseases, and AF on ECG. CONCLUSIONS ECG characteristics might be related to left ventricular ejection fraction. Demographics, BNP/Pro-BNP, and ECG changes might help differentiate different heart failure types. Therefore, ECG might be a prognostic tool while caring for heart failure patients when highly skilled resources are unavailable. These identified ECG characteristics help generate research hypotheses and warrant validation in future research.
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Affiliation(s)
- Sunita Pokhrel Bhattarai
- University of Rochester School of Nursing, 255 Crittenden Boulevard, Box SON, Rochester, NY 14642, United States.
| | | | - Ying Xue
- University of Rochester School of Nursing, 255 Crittenden Boulevard, Box SON, Rochester, NY 14642, United States
| | - Darcey H Rodriguez
- University of Rochester School of Nursing, 255 Crittenden Boulevard, Box SON, Rochester, NY 14642, United States; University of Rochester Medical Center, United States
| | - Rebecca G Tucker
- University of Rochester School of Nursing, 255 Crittenden Boulevard, Box SON, Rochester, NY 14642, United States
| | - Mary G Carey
- University of Rochester School of Nursing, 255 Crittenden Boulevard, Box SON, Rochester, NY 14642, United States; University of Rochester Medical Center, United States
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Long B, Keim SM, Gottlieb M, Collins SP. What are the Data for Current Prognostic Tools Used to Determine the Risk of Short-Term Adverse Events in Patients with Acute Heart Failure? J Emerg Med 2023; 65:e600-e613. [PMID: 38856703 DOI: 10.1016/j.jemermed.2023.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 04/29/2023] [Accepted: 05/27/2023] [Indexed: 06/11/2024]
Abstract
BACKGROUND Acute heart failure (AHF) is a common condition evaluated in the emergency department (ED). Patients may present with a wide range of signs and symptoms, comorbidities, exacerbating factors, and ability to follow-up. Having a decision tool to objectively assess the risk of near-term events would help guide disposition decisions in these patients. CLINICAL QUESTION What are the data for current tools used to determine the short-term risk of adverse events of patients with AHF in the ED setting? EVIDENCE REVIEW Studies retrieved included six prospective studies and three retrospective cohort studies that evaluated the following five different risk scores that may predict the risk of serious adverse events in those with AHF: Ottawa Heart Failure Risk Score (OHFRS), Emergency Heart Failure Mortality Risk Grade (EHMRG), EHMRG at 30 days with addition of an ST depression variable (EHMRG30-ST), Multiple Estimation of Risk Based on the Emergency Department Spanish 40 Score in Patients with AHF Score (MEESSI-AHF), and the Improving Heart Failure Risk Stratification in the ED (STRATIFY) tool. CONCLUSIONS Based on the available literature, risk scores, including the OHFRS; EHMRG; EHMRG30-ST; MEESSI-AHF; and STRATIFY, can help identify short-term risk of adverse events, but are insufficient in isolation. Clinicians should use these tools in conjunction with other factors, such as the patient's symptom trajectory, hemodynamics, and access to follow-up care.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Samuel M Keim
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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12
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Degefu N, Jambo A, Nigusse S, Dechasa M, Gashaw T, Getachew M. The Burden and Contributing Factors of Cardiogenic Pulmonary Edema Among Acute Heart Failure Patients Admitted to Tertiary Hospital, Eastern Ethiopia. Open Access Emerg Med 2023; 15:405-414. [PMID: 37965444 PMCID: PMC10642536 DOI: 10.2147/oaem.s436352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/01/2023] [Indexed: 11/16/2023] Open
Abstract
Background Despite cardiogenic pulmonary edema is the most common phenotype of acute heart failure (AHF), studies on its burden and associated factors are limited. This study aimed to assess the burden and contributing factors of cardiogenic pulmonary edema in patients with acute heart failure admitted to a tertiary hospital in eastern Ethiopia. Patients and Methods An institution-based cross-sectional study was conducted on the medical records (n = 276) of patients with AHF between February 01, 2018, and January 31, 2023. A simple random sampling technique was used to select participants from the study population. Bivariable and multivariable logistic regression analyses were used to assess factors associated with the development of cardiogenic pulmonary edema. A P-value ≤0.05 was considered as statistically significant. Results The prevalence of cardiogenic pulmonary edema was 47.8% in AHF patients. Rural residence (adjusted odds ratio (AOR),9.54), smoking (AOR,3.17), comorbidity (AOR,2.1), and underlying cardiovascular disease (ischemic heart disease, chronic rheumatic valvular heart disease, and hypertensive heart disease with AOR: 6.71, 8.47, and 12.07, respectively) were significantly associated with the development of cardiogenic pulmonary edema in patients with AHF. Conclusion Nearly half of the patients with AHF had cardiogenic pulmonary edema. Being a rural dweller, cigarette smoking, comorbidities, and underlying cardiac illness were significantly associated with the development of cardiogenic pulmonary edema in patients with AHF.
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Affiliation(s)
- Natanim Degefu
- Department of Pharmaceutics, School of Pharmacy, Haramaya University, Harar, Ethiopia
| | - Abera Jambo
- Department of Clinical Pharmacy, School of Pharmacy, Haramaya University, Harar, Ethiopia
| | - Shambel Nigusse
- Department of Clinical Pharmacy, School of Pharmacy, Haramaya University, Harar, Ethiopia
| | - Mesay Dechasa
- Department of Clinical Pharmacy, School of Pharmacy, Haramaya University, Harar, Ethiopia
| | - Tigist Gashaw
- Department of Pharmacology, School of Pharmacy, Haramaya University, Harar, Ethiopia
| | - Melaku Getachew
- Department of Emergency and Critical Care Medicine, School of Medicine, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
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Casey SD, Reed ME, LeMaster C, Mark DG, Gaskin J, Norris RP, Sax DR. Physicians' Perceptions of Clinical Decision Support to Treat Patients With Heart Failure in the ED. JAMA Netw Open 2023; 6:e2344393. [PMID: 37988076 PMCID: PMC10663967 DOI: 10.1001/jamanetworkopen.2023.44393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/12/2023] [Indexed: 11/22/2023] Open
Abstract
Importance Clinical decision support (CDS) could help emergency department (ED) physicians treat patients with heart failure (HF) by estimating risk, collating relevant history, and assisting with medication prescribing if physicians' perspectives inform its design and implementation. Objective To evaluate CDS usability and workflow integration in the hands of ED physician end users who use it in clinical practice. Design, Setting, and Participants This mixed-methods qualitative study administered semistructured interviews to ED physicians from 2 community EDs of Kaiser Permanente Northern California in 2023. The interview guide, based on the Usability Heuristics for User Interface Design and the Sociotechnical Environment models, yielded themes used to construct an electronic survey instrument sent to all ED physicians. Main Outcomes and Measures Main outcomes were physicians' perceptions of using CDS to complement clinical decision-making, usability, and integration into ED clinical workflow. Results Seven key informant physicians (5 [71.4%] female, median [IQR] 15.0 [9.5-15.0] years in practice) were interviewed and survey responses from 51 physicians (23 [45.1%] female, median [IQR] 14.0 [9.5-17.0] years in practice) were received from EDs piloting the CDS intervention. Response rate was 67.1% (51 of 76). Physicians suggested changes to CDS accessibility, functionality, and workflow integration. Most agreed that CDS would improve patient care and fewer than half of physicians expressed hesitation about their capacity to consistently comply with its recommendations, citing workload concerns. Physicians preferred a passive prompt that encouraged, but did not mandate, interaction with the CDS. Conclusions and Relevance In this qualitative study of physicians who were using a novel CDS intervention to assist with ED management of patients with acute HF, several opportunities were identified to improve usability as well as several key barriers and facilitators to CDS implementation.
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Affiliation(s)
- Scott D. Casey
- Kaiser Permanente Division of Research, Oakland, California
- The Kaiser Permanente CREST Network, Oakland, California
| | - Mary E. Reed
- Kaiser Permanente Division of Research, Oakland, California
- The Kaiser Permanente CREST Network, Oakland, California
| | | | | | - Jesse Gaskin
- The Permanente Medical Group Consulting Services, The Permanente Medical Group, Oakland, California
| | | | - Dana R. Sax
- Kaiser Permanente Division of Research, Oakland, California
- The Kaiser Permanente CREST Network, Oakland, California
- The Permanente Medical Group, Oakland, California
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Sánchez-Marcos C, Jacob J, Llorens P, López-Díez MP, Millán J, Martín-Sánchez FJ, Tost J, Aguirre A, Juan MÁ, Garrido JM, Rodríguez RC, Pérez-Llantada E, Díaz E, Sánchez-Nicolás JA, Mir M, Rodríguez-Adrada E, Herrero P, Gil V, Roset A, Peacock F, Miró Ò. Emergency department direct discharge compared to short-stay unit admission for selected patients with acute heart failure: analysis of short-term outcomes. Intern Emerg Med 2023; 18:1159-1168. [PMID: 36810965 PMCID: PMC10326134 DOI: 10.1007/s11739-023-03197-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/03/2023] [Indexed: 02/24/2023]
Abstract
Short stay unit (SSU) is an alternative to conventional hospitalization in patients with acute heart failure (AHF), but the prognosis is not known compared to direct discharge from the emergency department (ED). To determine whether direct discharge from the ED of patients diagnosed with AHF is associated with early adverse outcomes versus hospitalization in SSU. Endpoints, defined as 30-day all-cause mortality or post-discharge adverse events, were evaluated in patients diagnosed with AHF in 17 Spanish EDs with an SSU, and compared by ED discharge vs. SSU hospitalization. Endpoint risk was adjusted for baseline and AHF episode characteristics and in patients matched by propensity score (PS) for SSU hospitalization. Overall, 2358 patients were discharged home and 2003 were hospitalized in SSUs. Discharged patients were younger, more frequently men, with fewer comorbidities, had better baseline status, less infection, rapid atrial fibrillation and hypertensive emergency as the AHF trigger, and had a lower severity of AHF episode. While their 30-day mortality rate was lower than in patients hospitalized in SSU (4.4% vs. 8.1%, p < 0.001), 30-day post-discharge adverse events were similar (27.2% vs. 28.4%, p = 0.599). After adjustment, there were no differences in the 30-day risk of mortality of discharged patients (adjusted HR 0.846, 95% CI 0.637-1.107) or adverse events (1.035, 0.914-1.173). In 337 pairs of PS-matched patients, there were no differences in mortality or risk of adverse event between patients directly discharged or admitted to an SSU (0.753, 0.409-1.397; and 0.858, 0.645-1.142; respectively). Direct ED discharge of patients diagnosed with AHF provides similar outcomes compared to patients with similar characteristics and hospitalized in a SSU.
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Affiliation(s)
| | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Pere Llorens
- Emergency Department, Instituto de Investigación Sanitaria Y Biómedica de Alicante (ISABIAL), Short Stay Unit and Hospital at Home, Hospital General de Alicante, Miguel Hernández University, Alicante, Spain
| | | | - Javier Millán
- Emergency Department, Hospital Universitario La Fe, Valencia, Spain
| | | | - Josep Tost
- Emergency Department, Consorci Hospitalari de Terrassa, Barcelona, Catalonia, Spain
| | - Alfons Aguirre
- Emergency Department, Hospital del Mar, Barcelona, Catalonia, Spain
| | | | | | | | | | - Elena Díaz
- Emergency Department, Hospital Sant Joan, Alicante, Spain
| | | | - María Mir
- Emergency Department, Hospital Rey Juan Carlos, Móstoles, Madrid, Spain
| | | | - Pablo Herrero
- Emergency Department, Hospital Central Asturias, Oviedo, Spain
| | - Víctor Gil
- Digital Cultures & Societies, University of Queensland, Mianjin/Brisbane, Spain
| | - Alex Roset
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Frank Peacock
- Emergency Department, Baylor College of Medicine, Houston, TX, USA
| | - Òscar Miró
- Digital Cultures & Societies, University of Queensland, Mianjin/Brisbane, Spain.
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15
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Bensimhon D, Weintraub WS, Peacock WF, Alexy T, McLean D, Haas D, Deering KL, Millar SJ, Goodwin MM, Mohr JF. Reduced heart failure-related healthcare costs with Furoscix versus in-hospital intravenous diuresis in heart failure patients: the FREEDOM-HF study. Future Cardiol 2023; 19:385-396. [PMID: 37609913 DOI: 10.2217/fca-2023-0071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023] Open
Abstract
Aim: Compare heart failure (HF) costs of Furoscix use at home compared with inpatient intravenous (IV) diuresis. Patients & methods: Prospective, case control study of chronic HF patients presenting to emergency department (ED) with worsening congestion discharged to receive Furoscix 80 mg/10 ml 5-h subcutaneous infusion for ≤7 days. 30-day HF-related costs in Furoscix group derived from commercial claims database compared with matched historical patients hospitalized for <72 h. Results: Of 24 Furoscix patients, 1 (4.2%) was hospitalized in 30-day period. 66 control patients identified and were well-matched for age, sex, ejection fraction (EF), renal function and other comorbidities. Furoscix patients had reduced mean per patient HF-related healthcare cost of $16,995 (p < 0.001). Conclusion: Furoscix use was associated with significant reductions in 30-day HF-related healthcare costs versus matched hospitalized controls.
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Affiliation(s)
| | | | | | - Tamas Alexy
- University of Minnesota, Minneapolis, MN 55455, USA
| | | | | | | | | | | | - John F Mohr
- scPharmaceuticals, Burlington, MA 01803, USA
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16
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Nishi M, Seki T, Shikuma A, Kawamata H, Horiguchi G, Matoba S. Association between patient volume to cardiologist, process of care, and clinical outcomes in heart failure. ESC Heart Fail 2023. [PMID: 37075756 PMCID: PMC10375098 DOI: 10.1002/ehf2.14385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/07/2023] [Accepted: 04/04/2023] [Indexed: 04/21/2023] Open
Abstract
AIMS The impact of hospital volume on clinical performance has been investigated by many researchers to date and thought that it is associated with quality of care and outcome for patients with heart failure (HF). This study sought to determine whether annual admissions of HF per cardiologist are associated with process of care, mortality, and readmission. METHODS AND RESULTS Among the nationwide registry 'Japanese registry of all cardiac and vascular diseases - diagnostics procedure combination' data collected from 2012 to 2019, a total of 1 127 113 adult patients with HF and 1046 hospitals were included in the study. Primary outcome was in-hospital mortality, and secondary outcome was 30 day in-hospital mortality and readmission at 30 days and 6 months. Hospital and patient characteristics and process of care measures were also assessed. Mixed-effect logistic regression and Cox proportional-hazards model was used for multivariable analysis, and adjusted odds ratio and hazard ratio were evaluated. Process of care measures had inverse trends for annual admissions of HF per cardiologist (P < 0.01 for all measures: prescription rate of beta-blocker, angiotensin converting enzyme inhibitor or angiotensin II receptor blocker, mineralocorticoid receptor antagonist, and anticoagulant for atrial fibrillation). Adjusted odds ratio for in-hospital mortality was 1.04 (95% confidence interval (CI): 1.04-1.08, P = 0.04) and 30 day in-hospital mortality was 1.05 (95% CI: 1.01-1.09, P = 0.01) for interval of 50 annual admissions of HF per cardiologist. Adjusted hazard ratio for 30 day readmission was 1.05 (95% CI: 1.02-1.08, P < 0.01) and 6 month readmission was 1.07 (95% CI: 1.03-1.11, P < 0.01). Plots of the adjusted odds indicated 300 as the threshold of annual admissions of HF per cardiologist for substantial increase of in-hospital mortality risk. CONCLUSIONS Our findings demonstrated that annual admissions of HF per cardiologist are associated with worse process of care, mortality, and readmission with the threshold for mortality risk increased, emphasizing the optimal proportion of patients admitted with HF to cardiologist for better clinical performance.
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Affiliation(s)
- Masahiro Nishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomotsugu Seki
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akira Shikuma
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hirofumi Kawamata
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Go Horiguchi
- Department of Biostatistics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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17
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Stolldorf DP, Jones AB, Miller KF, Paz HH, Mumma BE, Danesh VC, Collins SP, Dietrich MS, Storrow AB. Medication Discussions With Patients With Cardiovascular Disease in the Emergency Department: An Opportunity for Emergency Nurses to Engage Patients to Support Medication Reconciliation. J Emerg Nurs 2023; 49:275-286. [PMID: 36623969 PMCID: PMC9992264 DOI: 10.1016/j.jen.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 01/09/2023]
Abstract
INTRODUCTION This study aimed to investigate the level of patient involvement in medication reconciliation processes and factors associated with that involvement in patients with cardiovascular disease presenting to the emergency department. METHODS An observational and cross-sectional design was used. Patients with cardiovascular disease presenting to the adult emergency department of an academic medical center completed a structured survey inclusive of patient demographics and measures related to the study concepts. Data abstracted from the electronic health record included the patient's medical history and emergency department visit data. Our multivariable model adjusted for age, gender, education, difficulty paying bills, health status, numeracy, health literacy, and medication knowledge and evaluated patient involvement in medication discussions as an outcome. RESULTS Participants' (N = 93) median age was 59 years (interquartile range 51-67), 80.6% were white, 96.8% were not Hispanic, and 49.5% were married or living with a partner. Approximately 41% reported being employed and 36.9% reported an annual household income of <$25,000. Almost half (n = 44, 47.3%) reported difficulty paying monthly bills. Patients reported moderate medication knowledge (median 3.8, interquartile range 3.4-4.2) and perceived involvement in their care (41.8 [SD = 9.1]). After controlling for patient characteristics, only difficulty paying monthly bills (b = 0.36, P = .005) and medication knowledge (b = 0.30, P = .009) were associated with involvement in medication discussions. DISCUSSION Some patients presenting to the emergency department demonstrated moderate medication knowledge and involvement in medication discussions, but more work is needed to engage patients.
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Kaplinsky E, Perrone S, Barbagelata A. Emerging concepts in heart failure management and treatment: focus on vericiguat. Drugs Context 2023; 12:dic-2022-5-5. [PMID: 36660012 PMCID: PMC9828868 DOI: 10.7573/dic.2022-5-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/26/2022] [Indexed: 01/04/2023] Open
Abstract
The nitric oxide (NO)-soluble guanylate cyclase (sGC)-cyclic guanosine monophosphate (cGMP) pathway is dysregulated in patients with heart failure (HF) resulting in myocardial and vascular dysfunction that contributes to its progression. Vericiguat is a novel direct sGC stimulator that targets in at least two ways the NO-sGC-cGMP pathway with the subsequent restoration of cGMP activity. The VICTORIA trial assessed the effects of vericiguat (versus placebo) in 5050 patients with chronic HF (NYHA class II-IV), left ventricular ejection fraction (LVEF) <45%, elevated natriuretic peptide levels and a recent HF decompensation (hospitalized or outpatient intravenous diuretics). After a median follow-up of 10.8 months, a lower risk (10% reduction) of the primary combined outcome (cardiovascular death or HF hospitalization) was achieved (HR 0.90, 95% CI 0.83-0.98; p=0.02). The composite endpoint was driven by HF hospitalizations (HR 0.9, 95% CI 0.81-1.00; p=0.048) whilst CV death reduction was not statistically significant on its own. The target dose was achieved in 89% of patients treated with vericiguat, and no significant differences were observed in the rates of syncope or hypotension. The VICTORIA trial showed that vericiguat was safe, well tolerated and without need of laboratory testing. The aim of this review is to provide comprehensive information about vericiguat in terms of its differential mechanism of action and clinical data particularly focused on the VICTORIA trial. A comparison is also made with DAPA-HF and EMPEROR-Reduced considering that, in all these contemporary trials, a new study medication was added to the standard triple HF therapy. This is a relevant issue because the VICTORIA trial had a significant but less powerful effect than DAPA-HF and EMPEROR-Reduced on HF outcomes in a setting of more severe disease, higher event rate and shorter follow-up. In addition, relevant data on other previous studies are also provided in both HF with reduced LVEF (SOCRATES-Reduced) and HF with preserved LVEF (SOCRATES-Preserved and VITALITY-Preserved). This article is part of the Emerging concepts in heart failure management and treatment Special Issue: https://www.drugsincontext.com/special_issues/emerging-concepts-in-heart-failure-management-and-treatment.
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Affiliation(s)
- Edgardo Kaplinsky
- Cardiology Unit, Medicine Department, Hospital Municipal de Badalona, Spain
| | - Sergio Perrone
- Catholic University Argentina/Fleni Institute, Buenos Aires, Argentina
| | - Alejandro Barbagelata
- Catholic University Argentina/Fleni Institute, Buenos Aires, Argentina,Duke University School of Medicine, Durham, NC, USA
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19
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Nelson DM, Madsen BE, Kopecky SL, Jenson CE, Loth AR, Mullan AF, Clements CM, Lin G. Retrospective validation of acute heart failure risk stratification in the emergency department. Heart Lung 2023; 57:31-40. [PMID: 36007429 DOI: 10.1016/j.hrtlng.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 07/21/2022] [Accepted: 08/08/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Heart Failure (HF) is a primary diagnosis for hospital admission from the Emergency Department (ED), although not all patients require hospitalization. The Emergency Heart Failure Mortality Risk Grade (EHMRG) estimates 7-day mortality in patients with acute HF in ED settings, but further validation is needed in the United States (US). OBJECTIVES To validate EHMRG scores by risk-stratifying patients with acute HF in a large tertiary healthcare center in the US and analyze outcome measures to determine if EHMRG risk scores safely identify low-risk groups that may be discharged or managed in ED observation units (EDOUs). METHODS A retrospective cohort analysis of 304 patients with acute HF presenting to an ED at a large, tertiary healthcare center was completed. EHMRG scores were calculated to stratify patients according to published thresholds. Mortality and major adverse cardiac event (MACE) rates were analyzed. RESULTS No deaths occurred in very low and low-risk EHMRG groups at 7 days post discharge. 30-day mortality was significantly less in the lower risk groups (3.1%) when compared to all other patients (11.1%). MACE rates at 30 days in the very low risk group (15%) were significantly less when compared to all other patients (31.3%). Hospitalizations occurred in 23.4% of patients in lower risk groups. CONCLUSIONS ED risk stratification with EHMRG differentiates high-risk patients requiring hospitalization from lower risk patients who can be safely managed in alternative settings with good outcomes. Data supports improved pathways for patients with acute HF during a time of high hospital volumes.
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Affiliation(s)
- Danika M Nelson
- Mayo Clinic, Department of Cardiovascular Diseases, 200 1st Street SW Rochester, MN 55905, United States; Department of Graduate Nursing, Winona State University-Rochester, 400 South Broadway SE, Rochester, MN 55904, United States.
| | - Bo E Madsen
- Mayo Clinic, Department of Emergency Medicine, 200 1st Street SW Rochester, MN 55905, United States
| | - Stephen L Kopecky
- Mayo Clinic, Department of Cardiovascular Diseases, 200 1st Street SW Rochester, MN 55905, United States
| | - Carole E Jenson
- Department of Graduate Nursing, Winona State University-Rochester, 400 South Broadway SE, Rochester, MN 55904, United States
| | - Ann R Loth
- Department of Graduate Nursing, Winona State University-Rochester, 400 South Broadway SE, Rochester, MN 55904, United States
| | - Aidan F Mullan
- Mayo Clinic, Department of Quantitative Health Sciences, 200 1st Street SW Rochester, MN 55905, United States
| | - Casey M Clements
- Mayo Clinic, Department of Emergency Medicine, 200 1st Street SW Rochester, MN 55905, United States
| | - Grace Lin
- Mayo Clinic, Department of Cardiovascular Diseases, 200 1st Street SW Rochester, MN 55905, United States
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Solnick RE, Vijayasiri G, Li Y, Kocher KE, Jenq G, Bozaan D. Emergency department returns and early follow-up visits after heart failure hospitalization: Cohort study examining the role of race. PLoS One 2022; 17:e0279394. [PMID: 36548344 PMCID: PMC9778499 DOI: 10.1371/journal.pone.0279394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
Health disparities in heart failure (HF) show that Black patients face greater ED utilization and worse clinical outcomes. Transitional care post-HF hospitalization, such as 7-day early follow-up visits, may prevent ED returns. We examine whether early follow-up is associated with lower ED returns visits within 30 days and whether Black race is associated with receiving early follow-up after HF hospitalization. This was a retrospective cohort analysis of all Black and White adult patients at 13 hospitals in Michigan hospitalized for HF from October 1, 2017, to September 30, 2020. Adjusted risk ratios (aRR) were estimated from multivariable logistic regressions. The analytic sample comprised 6,493 patients (mean age = 71 years (SD 15), 50% female, 37% Black, 9% Medicaid). Ten percent had an ED return within 30 days and almost half (43%) of patients had 7-day early follow-up. Patients with early follow-up had lower risk of ED returns (aRR 0.85 [95%CI, 0.71-0.98]). Regarding rates of early follow-up, there was no overall adjusted association with Black race, but the following variables were related to lower follow-up: Medicaid insurance (aRR 0.90 [95%CI, 0.80-1.00]), dialysis (aRR 0.86 [95%CI, 0.77-0.96]), depression (aRR 0.92 [95%CI, 0.86-0.98]), and discharged with opioids (aRR 0.94 [95%CI, 0.88-1.00]). When considering a hospital-level interaction, three of the 13 sites with the lowest percentage of Black patients had lower rates of early follow-up in Black patients (ranging from 15% to 55% reduced likelihood). Early follow-up visits were associated with a lower likelihood of ED returns for HF patients. Despite this potentially protective association, certain patient factors were associated with being less likely to receive scheduled follow-up visits. Hospitals with lower percentages of Black patients had lower rates of early follow-up for Black patients. Together, these may represent missed opportunities to intervene in high-risk groups to prevent ED returns in patients with HF.
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Affiliation(s)
- Rachel E. Solnick
- Department of Emergency Medicine, School of Medicine, University of Michigan, Ann Arbor, MI, United States of America
- Now at Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States of America
- * E-mail:
| | - Ganga Vijayasiri
- Integrated Michigan Patient-Centered Alliance in Care Transitions (I-MPACT), Michigan Medicine, Ann Arbor, MI, United States of America
| | - Yiting Li
- Integrated Michigan Patient-Centered Alliance in Care Transitions (I-MPACT), Michigan Medicine, Ann Arbor, MI, United States of America
| | - Keith E. Kocher
- Department of Emergency Medicine, School of Medicine, University of Michigan, Ann Arbor, MI, United States of America
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States of America
- Department of Learning Health Sciences, School of Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Grace Jenq
- Integrated Michigan Patient-Centered Alliance in Care Transitions (I-MPACT), Michigan Medicine, Ann Arbor, MI, United States of America
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - David Bozaan
- Integrated Michigan Patient-Centered Alliance in Care Transitions (I-MPACT), Michigan Medicine, Ann Arbor, MI, United States of America
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, United States of America
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
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Sax DR, Sturmer LR, Mark DG, Rana JS, Reed ME. Barriers and Opportunities Regarding Implementation of a Machine Learning-Based Acute Heart Failure Risk Stratification Tool in the Emergency Department. Diagnostics (Basel) 2022; 12:diagnostics12102463. [PMID: 36292152 PMCID: PMC9600201 DOI: 10.3390/diagnostics12102463] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/26/2022] [Accepted: 10/01/2022] [Indexed: 11/16/2022] Open
Abstract
Hospital admissions for patients with acute heart failure (AHF) remain high. There is an opportunity to improve alignment between patient risk and admission decision. We recently developed a machine learning (ML)-based model that stratifies emergency department (ED) patients with AHF based on predicted risk of a 30-day severe adverse event. Prior to deploying the algorithm and paired clinical decision support, we sought to understand barriers and opportunities regarding successful implementation. We conducted semi-structured interviews with eight front-line ED providers and surveyed 67 ED providers. Audio-recorded interviews were transcribed and analyzed using thematic analysis, and we had a 65% response rate to the survey. Providers wanted decision support to be streamlined into workflows with minimal disruptions. Most providers wanted assistance primarily with ED disposition decisions, and secondarily with medical management and post-discharge follow-up care. Receiving feedback on patient outcomes after risk tool use was seen as an opportunity to increase acceptance, and few providers (<10%) had significant hesitations with using an ML-based tool after education on its use. Engagement with key front-line users on optimal design of the algorithm and decision support may contribute to broader uptake, acceptance, and adoption of recommendations for clinical decisions.
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Affiliation(s)
- Dana R. Sax
- Kaiser Permanente Northern California Division of Research, Oakland, CA 94612, USA
- Department of Emergency Medicine, The Permanente Medical Group, Oakland, CA 94612, USA
- Correspondence:
| | - Lillian R. Sturmer
- College of Osteopathic Medicine, Touro University, Vallejo, CA 94592, USA
| | - Dustin G. Mark
- Kaiser Permanente Northern California Division of Research, Oakland, CA 94612, USA
- Department of Emergency Medicine, The Permanente Medical Group, Oakland, CA 94612, USA
| | - Jamal S. Rana
- Kaiser Permanente Northern California Division of Research, Oakland, CA 94612, USA
- Department of Cardiology, The Permanente Medical Group, Oakland, CA 94612, USA
| | - Mary E. Reed
- Kaiser Permanente Northern California Division of Research, Oakland, CA 94612, USA
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22
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Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Heart Failure Syndromes: Approved by ACEP Board of Directors, June 23, 2022. Ann Emerg Med 2022; 80:e31-e59. [PMID: 36153055 DOI: 10.1016/j.annemergmed.2022.05.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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23
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Gil-Rodrigo A, Verdú-Rotellar JM, Gil V, Alquézar A, Llauger L, Herrero-Puente P, Jacob J, Abellana R, Muñoz MÁ, López-Díez MP, Ivars-Obermeier N, Espinosa B, Rodríguez B, Fuentes M, Tost J, López-Grima ML, Romero R, Müller C, Peacock WF, Llorens P, Miró Ò. Evaluation of the HEFESTOS scale to predict outcomes in emergency department acute heart failure patients. Intern Emerg Med 2022; 17:2129-2140. [PMID: 36031673 DOI: 10.1007/s11739-022-03068-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 07/26/2022] [Indexed: 11/29/2022]
Abstract
The HEFESTOS scale was developed in 14 Spanish primary care centres and validated in 9 primary care centres of other European countries. It showed good performance to predict death/hospitalisation during the first 30 days after an episode of acute heart failure (AHF), with c-statistics of 0.807/0.730 in the derivation/validation cohorts. We evaluated this scale in the emergency department (ED) setting, comparing it to the EHMRG and MEESSI scales in the ED and the EFFECT and GWTG scales in hospitalised patients, to predict 30-day outcomes, including death and hospitalisation. Consecutive AHF patients were enrolled in 34 Spanish EDs in January-February 2016, 2018, and 2019 with variables needed to calculate outcome scores. Thirty-day hospitalisation/death (together and separately) and post-discharge combined adverse event (ED revisit or hospitalisation for AHF or all-cause death) were determined for patients discharged home after ED care. Predictive capacity was assessed by c-statistic with 95% confidence intervals. Of 10,869 patients, 4,044 were included (median age: 83 years, 54% women). The performance of HEFESTOS was modest for 30-day hospitalisation/death, c-statistic=0.656 (0.637-0.675), hospitalisation, 0.650 (0.631-0.669), and death, 0.610 (0.576-0.644). Of 1,034 patients with scores for the 5 scales, HEFESTOS had the numerically highest c-statistic for hospitalisation/death at 30 days, 0.666 (0.627-0.704), vs. MEESSI= 0.650 (0.612-0.687, p=0.51), EFFECT=0.633 (0.595-0.672, p=0.21), GWTG=0.618 (0.578-0.657, p=0.06) and EHMRG=0.617 (0.577-0.704, p=0.07). Similar modest performances were observed for predicting hospitalisation [ranging from HEFESTOS=0.656 (0.618-0.695) to GWTG=0.603 (0.564-0.643)]. Conversely, prediction of 30-day death was good with the MEESSI=0.787 (0.728-845), EFFECT=0.754 (0.691-0.818) and GWTG=0.749 (0.689-0.809) scales, and modest with EHMRG=0.649 (0.581-0.717) and HEFESTOS=0.610 (0.538-0.683). Although the HEFESTOS scale was numerically better for predicting 30-day hospitalisation/death in ED AHF patients, its modest performance precludes routine use. Only 30-day mortality was adequately predicted by some scales, with the MEESSI achieving the best results.
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Affiliation(s)
- Adriana Gil-Rodrigo
- Emergency Department, Short Stay Unit and Hospitalization at Home Unit, Dr, Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - José María Verdú-Rotellar
- Unitat de Suport a La Recerca de Barcelona, Fundació Institut Universitari Per a La Recerca a l'Atenció Primària de Salut Jordi Gol I Gurina (IDIAPJGol), Catalan Institute of Health, Pompeu Fabra University, Barcelona, Spain
| | - Víctor Gil
- Emergency Department, Clinic Barcelona Hospital University, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, c/ Villarroel 170, 08036, Barcelona, Catalonia, Spain
| | - Aitor Alquézar
- Emergency Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalonia, Spain
| | - Lluís Llauger
- Emergency Department, Hospital Universitari de Vic, Barcelona, Catalonia, Spain
| | | | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, l'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Rosa Abellana
- Unitat de Bioestadistica del Departament de Fonaments Clínics, Medical School, University of Barcelona, Barcelona, Catalonia, Spain
| | - Miguel-Ángel Muñoz
- Unitat de Suport a La Recerca de Barcelona, Fundació Institut Universitari Per a La Recerca a l'Atenció Primària de Salut Jordi Gol I Gurina (IDIAPJGol), Catalan Institute of Health, Pompeu Fabra University, Barcelona, Spain
| | | | - Nicole Ivars-Obermeier
- Emergency Department, Short Stay Unit and Hospitalization at Home Unit, Dr, Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Begoña Espinosa
- Emergency Department, Short Stay Unit and Hospitalization at Home Unit, Dr, Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Beatriz Rodríguez
- Emergency Department, Infanta Leonor University Hospital, Madrid, Spain
| | - Marta Fuentes
- Emergency Department, University Hospital of Salamanca, Salamanca, Spain
| | - Josep Tost
- Emergency Department, Consorci Hospitalari de Terrassa, Barcelona, Catalonia, Spain
| | | | - Rodolfo Romero
- Emergency Department, University Hospital of Getafe, Universidad Europea, Madrid, Spain
| | - Christian Müller
- Cardiology Department, University Hospital of Basel, Cardiovascular Research Institute Basel, Basel, Switzerland
- The GREAT Network, Rome, Italy
| | - WFrank Peacock
- Emergency Department, Baylor School of Medicine, Houston, TX, USA
- The GREAT Network, Rome, Italy
| | - Pere Llorens
- Emergency Department, Short Stay Unit and Hospitalization at Home Unit, Dr, Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Òscar Miró
- Emergency Department, Clinic Barcelona Hospital University, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, c/ Villarroel 170, 08036, Barcelona, Catalonia, Spain.
- The GREAT Network, Rome, Italy.
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24
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Sánchez-Marcos C, Jacob J, Llorens P, Rodríguez B, Martín-Sánchez F, Herrera S, Castillero-Díaz L, Herrero P, Gil V, Miró Ò. Análisis de la efectividad y seguridad de las unidades de estancia corta en la hospitalización de pacientes con insuficiencia cardíaca aguda. Propensity Score UCE-EAHFE. Rev Clin Esp 2022. [DOI: 10.1016/j.rce.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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25
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Emergency department risk assessment and disposition of acute heart failure patients: existing evidence and ongoing challenges. Heart Fail Rev 2022:10.1007/s10741-022-10272-4. [PMID: 36123519 PMCID: PMC9485013 DOI: 10.1007/s10741-022-10272-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 12/02/2022]
Abstract
Heart failure (HF) is a global public health burden, characterized by frequent emergency department (ED) visits and hospitalizations. Identifying successful strategies to avoid admissions is crucial for the management of acutely decompensated HF, let alone resource utilization. The primary challenge for ED management of patients with acute heart failure (AHF) lies in the identification of those who can be safely discharged home instead of being admitted. This is an elaborate decision, based on limited objective evidence. Thus far, current biomarkers and risk stratification tools have had little impact on ED disposition decision-making. A reliable definition of a low-risk patient profile is warranted in order to accurately identify patients who could be appropriate for early discharge. A brief period of observation can facilitate risk stratification and allow for close monitoring, aggressive treatment, continuous assessment of response to initial therapy and patient education. Lung ultrasound may represent a valid bedside tool to monitor cardiogenic pulmonary oedema and determine the extent of achieved cardiac unloading after treatment in the observation unit setting. Safe discharge mandates multidisciplinary collaboration and thoughtful assessment of socioeconomic and behavioural factors, along with a clear post-discharge plan put forward and a close follow-up in an outpatient setting. Ongoing research to improve ED risk stratification and disposition of AHF patients may mitigate the tremendous public health challenge imposed by the HF epidemic.
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26
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Kilaru AS, Illenberger N, Meisel ZF, Groeneveld PW, Liu M, Mondal A, Mitra N, Merchant RM. Incidence of Timely Outpatient Follow-Up Care After Emergency Department Encounters for Acute Heart Failure. Circ Cardiovasc Qual Outcomes 2022; 15:e009001. [PMID: 36073354 PMCID: PMC9489651 DOI: 10.1161/circoutcomes.122.009001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients who are discharged from the emergency department (ED) after an encounter for acute heart failure are at high risk for return hospitalization. These patients may benefit from timely outpatient follow-up care to reassess volume status, adjust medications, and reinforce self-care strategies. This study examines the incidence of outpatient follow-up care after ED encounters for acute heart failure and describes patient characteristics associated with obtaining timely follow-up care. METHODS We conducted a retrospective cohort study using an administrative claims database for a large US commercial insurer, from January 1, 2012 to June 30, 2019. Participants included adult patients discharged from the ED with principal diagnosis of acute heart failure. The primary outcome was obtaining an in-person outpatient clinic visit for heart failure within 30 days. We also examined the competing risk of all-cause hospitalization within 30 days and without an intervening outpatient clinic visit. We estimated competing risk regression models to identify patient characteristics associated with obtaining outpatient follow-up and report cause-specific hazard ratios. RESULTS The cohort included 52 732 patients, with mean age of 73.9 years (95% CI, 73.8-74.0) and 27 395 (52.0% [95% CI, 51.5-52.4]) female patients. Within 30 days of the ED encounter, 12 279 (23.2%) patients attended an outpatient clinic visit for heart failure, with 8382 (15.9%) patients hospitalized before they could obtain an outpatient clinic visit. In the adjusted analysis, patients that were younger, women, reporting non-Hispanic Black race, and had fewer previous clinic visits were less likely to obtain outpatient follow-up care. CONCLUSIONS Few patients obtain timely outpatient follow-up after ED visits for heart failure, although nearly 20% require hospitalization within 30 days. Improved transitions following discharge from the ED may represent an opportunity to improve outcomes for patients with acute heart failure.
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Affiliation(s)
- Austin S Kilaru
- Center for Emergency Care Policy and Research, Department of Emergency Medicine (A.S.K., R.M.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (A.S.K., R.M.M., P.W.G.), Wharton School, University of Pennsylvania Philadelphia
- Perelman School of Medicine, and Leonard Davis Institute of Health Economics (A.S.K., R.M.M., P.W.G., A.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
| | - Nicholas Illenberger
- Department of Population Health, NYU Grossman School of Medicine (N.I.), New York, New York
| | - Zachary F Meisel
- Center for Emergency Care Policy and Research, Department of Emergency Medicine (A.S.K., R.M.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
- Perelman School of Medicine, and Leonard Davis Institute of Health Economics (A.S.K., R.M.M., P.W.G., A.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
| | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (A.S.K., R.M.M., P.W.G.), Wharton School, University of Pennsylvania Philadelphia
- Perelman School of Medicine, and Leonard Davis Institute of Health Economics (A.S.K., R.M.M., P.W.G., A.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
| | - Manqing Liu
- Department of Epidemiology, T.H. Chan School of Public Health, Harvard University Boston, Massachusetts (M.L.)
| | - Angira Mondal
- Perelman School of Medicine, and Leonard Davis Institute of Health Economics (A.S.K., R.M.M., P.W.G., A.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics (N.M.), Wharton School, University of Pennsylvania Philadelphia
| | - Raina M Merchant
- Center for Emergency Care Policy and Research, Department of Emergency Medicine (A.S.K., R.M.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (A.S.K., R.M.M., P.W.G.), Wharton School, University of Pennsylvania Philadelphia
- Perelman School of Medicine, and Leonard Davis Institute of Health Economics (A.S.K., R.M.M., P.W.G., A.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
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27
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Jain V, Minhas AMK, Morris AA, Greene SJ, Pandey A, Khan SS, Fonarow GC, Mentz RJ, Butler J, Khan MS. Demographic and Regional Trends of Heart Failure-Related Mortality in Young Adults in the US, 1999-2019. JAMA Cardiol 2022; 7:900-904. [PMID: 35895048 PMCID: PMC9330269 DOI: 10.1001/jamacardio.2022.2213] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance There are limited data on mortality trends in young adults with heart failure (HF). Objective To study the trends in HF-related mortality among young adults. Design, Setting, and Participants This retrospective cohort analysis used mortality data of young adults aged 15 to 44 years with HF listed as a contributing or underlying cause of death in the US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database from January 1999 to December 2019. Analysis took place in October 2021. Exposures Age 15 to 44 years with HF listed as a contributing or underlying cause of death. Main Outcomes and Measures HF-related age-adjusted mortality rates (AAMR) per 100 000 US population stratified by sex, race and ethnicity, and geographic areas. Results Between 1999 and 2019, a total of 61 729 HF-related deaths occurred in young adults. Of these, 38 629 (62.0%) were men and 23 460 (38.0%) were women, and 22 156 (35.9%) were Black, 6648 (10.8%) were Hispanic, and 30 145 (48.8%) were White. The overall AAMR per 100 000 persons for HF in young adults increased from 2.36 in 1999 to 3.16 in 2019. HF mortality increased in young men and women, with men having higher AAMRs throughout the study period. AAMR increased for all race and ethnicity groups, with Black adults having the highest AAMRs (6.41 in 1999 and 8.58 in 2019). AAMR for Hispanic adults and White adults increased from 1.62 to 2.04 and 1.83 to 2.45 over the same time period, respectively. Across most demographic and regional subgroups, HF-related mortality stayed stable or decreased between 1999 and 2012, followed by an increase between 2012 and 2019. There were significant regional differences in the burden of HF-related mortality, with states in the upper 90th percentile of HF-related mortality (Oklahoma, South Carolina, Louisiana, Arkansas, Alabama, and Mississippi) having a significantly higher mortality burden compared with those in the bottom tenth percentile. Conclusions and Relevance Following an initial period of stability, HF-related mortality in young adults increased from 2012 to 2019 in the United States. Black adults have a 3-fold higher AAMR compared with White adults, with significant geographic variation. Targeted health policy measures are needed to address the rising burden of HF in young adults, with a focus on prevention, early diagnosis, and reduction in disparities.
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Affiliation(s)
- Vardhman Jain
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Alanna A Morris
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Sadiya S Khan
- Division of Cardiology, Northwestern University, Chicago, Illinois.,Web Editor, JAMA Cardiology
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center, Los Angeles.,Section Editor, JAMA Cardiology
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson.,Baylor Scott and White Research Institute, Dallas, Texas
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28
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911 Calls for Emergency Medical Services in Heart Failure: A Descriptive Qualitative Study. J Cardiovasc Nurs 2022; 37:418-426. [PMID: 34935743 DOI: 10.1097/jcn.0000000000000861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Heart failure (HF) is a common condition leading to activation of emergency medical services (EMS). OBJECTIVE The aim of this study was to describe reasons given by persons with HF, family members, or other caregivers for requesting EMS activation during 911 calls. METHODS In this descriptive qualitative study, a content analysis was performed on transcribed audio files of 383 EMS requests involving 383 persons with HF in the community. RESULTS One hundred forty-seven calls (38.4%) were placed by the family members, 75 (19.6%) were placed by the patients, 56 (14.6%) were placed by healthcare workers or personnel from living facilities, and the remaining calls (n = 105, 27.4%) were placed by others (eg, friends, neighbors, officers). Three broad categories of symptoms, signs, and events were identified as the reasons for an EMS request. Frequently reported symptoms were breathing problems (55.4%), chest pain (18.3%), and other pain (eg, head, extremities) (16.7%). Signs included decreased consciousness (15.4%), swelling (5.7%), and bleeding (5.0%). The reported events involved falls (8.1%), heart attack (6.3%), hypoxic episodes (6.0%), stroke (5.2%), and post-hospital-discharge complications (4.7%). In most calls (74.9%), multiple reasons were reported and a combination of symptoms, signs, and events were identified. Heart failure diagnosis was mentioned in fewer than 10% of the calls. CONCLUSIONS Overall, symptoms and signs of HF exacerbation were common reasons to activate 911 calls. Falls were frequently reported. Under the duress of the emergent situations surrounding the 911 call, callers rarely mentioned the existence of HF. Interventions are needed to guide patients with HF and their family members to promote the management of HF to reduce EMS activation as well as to activate EMS quickly for acute changes in HF conditions.
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29
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Dzikowicz DJ, Pokhrel Bhattarai S, Ng J, Zemanek AL, Carey MG. Delays in Door-to-Diuretic Time and 1-Year Mortality Among Patients With Heart Failure. J Cardiovasc Nurs 2022; 37:410-417. [PMID: 35713596 DOI: 10.1097/jcn.0000000000000932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Achieving prompt euvolemic state in heart failure (HF) is associated with reduced mortality. Time-sensitive metrics such as door-to-diuretic time , or the time between presentation and administration of intravenous diuretics, may be an important facilitator of achieving a faster euvolemic state and reducing mortality. OBJECTIVE The aim of this study was to investigate whether reduced door-to-diuretic time was associated with lower odds of death among hospitalized patients with HF. METHODS A retrospective chart review of patients with HF admitted to a medical center was performed between 2020 and 2021. Inclusion criteria were an International Classification of Diseases, 10th Revision code for HF with positive Framingham Criteria and the use of intravenous bolus furosemide. Exclusion criteria included ventricular assist devices, dialysis, and ultrafiltration therapy. Data collected from the medical records included demographics, echocardiography, staff notes, and medications. The end point was 1-year all-cause mortality. Descriptive statistics, t tests or median test, and multivariate logistic regression were used to describe the sample, evaluate group differences, and determine odds of mortality, respectively. RESULTS Among 160 charts from patients with HF (age, 70 ± 14.4 years; 52%, n = 83, male; 53%, n = 85, ischemic cardiomyopathy; 83%, n = 134, New York Heart Association classes III-IV), 30% (n = 48) died within 1 year. The median diuretic dose was 40 mg (interquartile range, 20 mg), with a median time of administration of 247 minutes (4.12 hours) (interquartile range, 294 minutes to 4.9 hours). After covariate adjustment, prolonged door-to-diuretic time more than doubled (2.22; 95% confidence interval, 1.03-4.8; P = .04) the odds of 1-year mortality. CONCLUSIONS On the basis of this sample of charts from older highly symptomatic patients with HF, delayed door-to-diuretic time was associated with significantly greater odds of 1-year all-cause mortality.
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30
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Grand J, Nielsen OW, Møller JE, Hassager C, Jakobsen JC. Vasodilators for acute heart failure – a protocol for a systematic review of randomized clinical trials with meta‐analysis and Trial Sequential Analysis. Acta Anaesthesiol Scand 2022; 66:1156-1164. [PMID: 36054782 PMCID: PMC9542024 DOI: 10.1111/aas.14130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/30/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Johannes Grand
- Department of Cardiology Copenhagen University Hospital Hvidovre and Amager‐Hospital, Kettegård Alle 30 Copenhagen Denmark
| | - Olav W. Nielsen
- Department of Cardiology Bispebjerg Hospital Copenhagen University Hospital, Rigshospitalet Bispebjerg Bakke 23 Copenhagen
- University of Copenhagen, Department of Clinical Medicine Copenhagen Denmark
| | - Jacob Eifer Møller
- The Heart Center, Copenhagen University Hospital Rigshospitalet, Department of Cardiology Copenhagen Denmark
- Odense University Hospital, Department of Cardiology, University of Southern Denmark, Department of Clinical Medicine Odense Denmark
| | - Christian Hassager
- The Heart Center, Copenhagen University Hospital Rigshospitalet, Department of Cardiology Copenhagen Denmark
- University of Copenhagen, Department of Clinical Medicine Copenhagen Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Department of Regional Health Research, Faculty of Health Sciences University of Southern Denmark Odense Denmark
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Bhatnagar R, Fonarow GC, Heidenreich PA, Ziaeian B. Expenditure on Heart Failure in the United States: The Medical Expenditure Panel Survey 2009-2018. JACC. HEART FAILURE 2022; 10:571-580. [PMID: 35902161 PMCID: PMC9680004 DOI: 10.1016/j.jchf.2022.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 05/02/2023]
Abstract
BACKGROUND With rising United States health care expenditure, estimating current spending for patients with heart failure (HF) informs the value of preventative health interventions. OBJECTIVES The purpose of this study was to estimate current health care expenditure growth for patients with HF in the United States. METHODS The authors pooled MEPS (Medical Expenditure Panel Survey) data from 2009-2018 to calculate total HF-related expenditure across clinical settings in the United States. A 2-part model adjusted for demographics, comorbidities, and year was used to estimate annual mean and incremental expenditures associated with HF. RESULTS In the United States, an average of $28,950 (2018 inflation-adjusted dollars) is spent per year for health care-related expenditure for individuals with HF compared with $5,727 for individuals without HF. After adjusting for demographics and comorbidities, a diagnosis of HF was associated with $3,594 in annual incremental expenditure compared with those without HF. HF-related expenditure increased from $26,864 annual per person in 2009-2010 to $32,955 in 2017-2018, representing a 23% rise over 10 years. In comparison, expenditure on myocardial infarction, type 2 diabetes mellitus, and cancer grew by 16%, 28%, and 16%, respectively. Most of the cost was related to hospitalization: $12,569 per year. Outpatient office-based care and prescription medications saw the greatest growth in cost over the period, 41% and 24%, respectively. Estimated incremental national expenditure for HF per year was $22.3 billion; total annual expenditure for adults with HF was $179.5 billion. CONCLUSIONS HF is a costly condition for which expenditure is growing faster than that of other chronic conditions.
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Affiliation(s)
- Roshni Bhatnagar
- Division of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Paul A Heidenreich
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA; Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Boback Ziaeian
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA; Division of Cardiology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA.
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Sánchez-Marco C, Jacob J, Llorens P, Rodríguez B, Martín-Sánchez FJ, Herrera S, Castillero-Díaz LE, Herrero P, Gil V, Miró Ò. Original articleAnalysis of the effectiveness and safety of short-stay units in the hospitalization of patients with acute heart failure. Propensity Score SSU-EAHFE. Rev Clin Esp 2022; 222:443-457. [PMID: 35842410 DOI: 10.1016/j.rceng.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/27/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVES This work aims to analyze if hospitalization in short-stay units (SSU) of patients diagnosed in the emergency department with acute heart failure (AHF) is effective in terms of the length of hospital stay and if it is associated with differences in short-term progress. METHOD Patients from the EAHFE registry diagnosed with AHF who were admitted to the SSU (SSU group) were included and compared to those hospitalized in other departments (non-SSU group) from all hospitals (comparison A) and, separately, those from hospitals with an SSU (comparison B) and without an SSU (comparison C). For each comparison, patients in the SSU/non-SSU groups were matched by propensity score. The length of hospital stay (efficacy), 30-day mortality, and post-discharge adverse events at 30 days (safety) were compared. RESULTS A total of 2,003 SSU patients and 12,193 non-SSU patients were identified. Of them, 674 pairs of patients were matched for comparison A, 634 for comparison B, and 588 for comparison C. The hospital stay was significantly shorter in the SSU group in all comparisons (A: median 4 days (IQR = 2-5) versus 8 (5-12) days, p < 0.001; B: 4 (2-5) versus 8 (5-12), p < 0.001; C: 4 (2-5) versus 8 (6-12), p < 0.001). Admission to the SSU was not associated with differences in mortality (A: HR = 1.027, 95%CI = 0.681-1.549; B: 0.976, 0.647-1.472; C: 0.818, 0.662-1.010) or post-discharge adverse events (A: HR = 1.002, 95%CI = 0.816-1.232; B: 0.983, 0.796-1.215; C: 1.135, 0.905-1.424). CONCLUSION The hospitalization of patients with AHF in the SSU is associated with shorter hospital stays but there were no differences in short-term progress.
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Affiliation(s)
- C Sánchez-Marco
- Área de Urgencias, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - J Jacob
- Servicio de Urgencias, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - P Llorens
- Servicio de Urgencias, Corta Estancia y Hospitalización a Domicilio, Hospital General de Alicante, Instituto de Investigación Sanitaria y Biómedica de Alicante (ISABIAL), Universidad Miguel Hernández, Alicante, Spain
| | - B Rodríguez
- Servicio de Urgencias, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - F J Martín-Sánchez
- Servicio de Urgencias, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | - S Herrera
- Servicio de Urgencias, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - P Herrero
- Servicio de Urgencias, Hospital Central de Asturias, Oviedo, Spain
| | - V Gil
- Área de Urgencias, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Ò Miró
- Área de Urgencias, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain.
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Reinhardt SW, Clark KA, Xin X, Parzynski CS, Riello RJ, Sarocco P, Ahmad T, Desai NR. Thirty-Day and 90-Day Episode of Care Spending Following Heart Failure Hospitalization Among Medicare Beneficiaries. Circ Cardiovasc Qual Outcomes 2022; 15:e008069. [DOI: 10.1161/circoutcomes.121.008069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND:
Despite growing interest in value-based models, utilization patterns and costs for heart failure (HF) admissions are not well understood. We sought to characterize Medicare spending for patients with HF for 30- and 90-day episodes of care (which include an index hospitalization and 30 or 90 days following discharge) and to describe the patterns of post-acute care spending.
METHODS:
Using Medicare fee-for-service administrative claims data from 2016 to 2018, we performed a retrospective analysis of patients discharged after hospitalization with primary discharge diagnoses of systolic HF, diastolic HF, hypertensive heart disease (HHD) with HF, and HHD with HF and chronic kidney disease. We analyzed coding patterns across these groups over time, median 30- and 90-day payments, and costs allocated to index hospitalization and postacute care.
RESULTS:
The study included 935 962 patients discharged following hospitalization for HF (systolic HF: 178 603; diastolic HF: 165 156; HHD with HF: 226 929; HHD with HF and chronic kidney disease: 365 274). The proportion of HHD codes increased from 26% of HF hospitalizations in 2016 to 91% in 2018. There was substantial spending on 30-day (median $13 330, interquartile range $9912–$22 489) and 90-day episodes (median $21 658, interquartile range $12 423–$37 630) for HF with significant variation, such that the third quartile of patients incurred costs 3 times the amount of the first quartile. Across all codes, the index hospitalization accounted for ≈70% of 30-day and 45% of 90-day spending. Sixty-one percent of postacute care spending occurred 31 to 90 days following discharge, with readmissions and observation stays (36%) and skilled nursing facilities (27%) comprising the largest categories.
CONCLUSIONS:
This patient episode-level analysis of contemporary Medicare beneficiaries is the first to examine 90-day spending, which will become an increasingly important pasyment benchmark with the expansion of the Medicare Bundled Payments for Care Improvement Program. Further investigation into the drivers of costs will be essential to provide high-value HF care.
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Affiliation(s)
- Samuel W. Reinhardt
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (S.W.R., K.A.A.C., T.A., N.R.D.)
| | - Katherine A.A. Clark
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (S.W.R., K.A.A.C., T.A., N.R.D.)
| | - Xin Xin
- Center for Outcomes Research & Evaluationm Yale-New Haven Hospital, New Haven‚ CT. (X.X., C.S.P., T.A., N.R.D.)
| | - Craig S. Parzynski
- Center for Outcomes Research & Evaluationm Yale-New Haven Hospital, New Haven‚ CT. (X.X., C.S.P., T.A., N.R.D.)
| | - Ralph J. Riello
- Department of Pharmacy, Yale-New Haven Hospital, New Haven‚ CT. (R.J.R.)
| | - Phil Sarocco
- Cytokinetics, Incorporated, South San Francisco, CA (P.S.)
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (S.W.R., K.A.A.C., T.A., N.R.D.)
- Center for Outcomes Research & Evaluationm Yale-New Haven Hospital, New Haven‚ CT. (X.X., C.S.P., T.A., N.R.D.)
| | - Nihar R. Desai
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (S.W.R., K.A.A.C., T.A., N.R.D.)
- Center for Outcomes Research & Evaluationm Yale-New Haven Hospital, New Haven‚ CT. (X.X., C.S.P., T.A., N.R.D.)
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Chandramouli C, Stewart S, Almahmeed W, Lam CSP. Clinical implications of the universal definition for the prevention and treatment of heart failure. Clin Cardiol 2022; 45 Suppl 1:S2-S12. [PMID: 35789016 PMCID: PMC9254673 DOI: 10.1002/clc.23842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022] Open
Abstract
The diagnosis of heart failure (HF) primarily relies on signs and symptoms that are neither sensitive nor specific. This impedes timely diagnosis and delays effective therapies or interventions, despite the availability of several evidence-based treatments for HF. Through monumental collaborative efforts from representatives of HF societies worldwide, the universal definition of HF was published in 2021, to provide the necessary standardized framework required for clinical management, clinical trials, and research. This review elaborates the key concepts of the new universal definition of HF, highlighting the key merits and potential avenues, which can be nuanced further in future iterations. We also discuss the key implications of the universal definition document from the perspectives of various stakeholders within the healthcare framework, including patients, care providers, system/payers and policymakers.
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Affiliation(s)
- Chanchal Chandramouli
- National Heart Centre SingaporeSingaporeSingapore
- Duke‐National University of SingaporeSingaporeSingapore
| | - Simon Stewart
- Torrens University AustraliaAdelaideSouth AustraliaAustralia
- University of GlasgowGlasgowUK
- Institute of Health ResearchUniversity of Notre Dame AustraliaFremantleNew South WalesAustralia
| | - Wael Almahmeed
- Institute of Cardiac Science, Sheikh Khalifa Medical CityAbu DhabiUnited Arab Emirates
- Heart and Vascular Institute, Cleveland ClinicAbu DhabiUnited Arab Emirates
| | - Carolyn Su Ping Lam
- National Heart Centre SingaporeSingaporeSingapore
- Duke‐National University of SingaporeSingaporeSingapore
- University Medical Centre GroningenGroningenThe Netherlands
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Sax DR, Mark DG, Rana JS, Collins SP, Huang J, Reed ME. Risk adjusted 30‐day mortality and serious adverse event rates among a large, multi‐center cohort of emergency department patients with acute heart failure. J Am Coll Emerg Physicians Open 2022; 3:e12742. [PMID: 35706908 PMCID: PMC9182626 DOI: 10.1002/emp2.12742] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/18/2022] [Accepted: 04/27/2022] [Indexed: 12/02/2022] Open
Abstract
Background Admission rates for emergency department (ED) patients with acute heart failure (AHF) remain elevated. Use of a risk stratification tool could improve disposition decision making by identifying low‐risk patients who may be safe for outpatient management. Methods We performed a secondary analysis of a retrospective, multi‐center cohort of 26,189 ED patients treated for AHF from January 1, 2017 to December 31, 2018. We applied a 30‐day risk model we previously developed and grouped patients into 4 categories (low, low/moderate, moderate, and high) of predicted 30‐day risk of a serious adverse event (SAE). SAE consisted of death or cardiopulmonary resuscitation (CPR), intra‐aorta balloon pump, endotracheal intubation, renal failure requiring dialysis, or acute coronary syndrome. We measured the 30‐day mortality and composite SAE rates among patients by risk category according to ED disposition: direct discharge, discharge after observation, and hospital admission. Results The observed 30‐day mortality and total SAE rates were less than 1% and 2%, respectively, among 25% of patients in the low and low/moderate risk groups. These rates did not vary significantly by ED disposition. An additional 23% of patients were moderate risk and experienced an approximate 2% 30‐day mortality rate. Conclusion Use of a risk stratification tool could help identify lower risk AHF patients who may be appropriate for ED discharge. These findings will help inform prospective testing to determine how this risk tool can augment ED decision making.
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Affiliation(s)
- Dana R. Sax
- Department of Emergency Medicine Kaiser Permanente Northern California Oakland and Richmond Medical Centers Oakland California USA
- Division of Research Kaiser Permanente Northern California Oakland California USA
| | - Dustin G. Mark
- Department of Emergency Medicine Kaiser Permanente Northern California Oakland and Richmond Medical Centers Oakland California USA
- Division of Research Kaiser Permanente Northern California Oakland California USA
| | - Jamal S. Rana
- Division of Research Kaiser Permanente Northern California Oakland California USA
- Department of Cardiology Kaiser Permanente Northern California Oakland and Richmond Medical Centers Oakland California USA
| | - Sean P. Collins
- Department of Emergency Medicine Vanderbilt University Medical Center Vanderbilt Tennessee USA
| | - Jie Huang
- Division of Research Kaiser Permanente Northern California Oakland California USA
| | - Mary E. Reed
- Division of Research Kaiser Permanente Northern California Oakland California USA
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Sax DR, Mark DG, Rana JS, Reed ME, Lindenfeld J, Stevenson LW, Storrow AB, Butler J, Pang PS, Collins SP. Current Emergency Department Disposition of Patients with Acute Heart Failure: An Opportunity for Improvement. J Card Fail 2022; 28:1545-1559. [DOI: 10.1016/j.cardfail.2022.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/06/2022] [Accepted: 05/12/2022] [Indexed: 12/26/2022]
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Fermann GJ, Schrock JW, Levy PD, Pang P, Butler J, Chang AM, Char D, Diercks D, Han JH, Hiestand B, Hogan C, Jenkins CA, Kampe C, Khan Y, Kumar VA, Lee S, Lindenfeld J, Liu D, Miller KF, Peacock WF, Reilly CM, Robichaux C, Rothman RL, Self WH, Singer AJ, Sterling SA, Storrow AB, Stubblefield WB, Walsh C, Wilburn J, Collins SP. Troponin is unrelated to outcomes in heart failure patients discharged from the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12695. [PMID: 35434709 PMCID: PMC8994616 DOI: 10.1002/emp2.12695] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/03/2022] [Accepted: 02/10/2022] [Indexed: 11/26/2022] Open
Abstract
Background Prior data has demonstrated increased mortality in hospitalized patients with acute heart failure (AHF) and troponin elevation. No data has specifically examined the prognostic significance of troponin elevation in patients with AHF discharged after emergency department (ED) management. Objective Evaluate the relationship between troponin elevation and outcomes in patients with AHF who are treated and released from the ED. Methods This was a secondary analysis of the Get with the Guidelines to Reduce Disparities in AHF Patients Discharged from the ED (GUIDED‐HF) trial, a randomized, controlled trial of ED patients with AHF who were discharged. Patients with elevated conventional troponin not due to acute coronary syndrome (ACS) were included. Our primary outcome was a composite endpoint: time to 30‐day cardiovascular death and/or heart failure‐related events. Results Of the 491 subjects included in the GUIDED‐HF trial, 418 had troponin measured during the ED evaluation and 66 (16%) had troponin values above the 99th percentile. Median age was 63 years (interquartile range, 54‐70), 62% (n = 261) were male, 63% (n = 265) were Black, and 16% (n = 67) experienced our primary outcome. There were no differences in our primary outcome between those with and without troponin elevation (12/66, 18.1% vs 55/352, 15.6%; P = 0.60). This effect was maintained regardless of assignment to usual care or the intervention arm. In multivariable regression analysis, there was no association between our primary outcome and elevated troponin (hazard ratio, 1.00; 95% confidence interval, 0.49–2.01, P = 0.994) Conclusion If confirmed in a larger cohort, these findings may facilitate safe ED discharge for a group of patients with AHF without ACS when an elevated troponin is the primary reason for admission.
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Affiliation(s)
- Gregory J. Fermann
- Department of Emergency Medicine University of Cincinnati Cincinnati Ohio USA
| | - Jon W. Schrock
- Department of Emergency Medicine Metro Health Cleveland Ohio USA
| | - Phillip D. Levy
- Department of Emergency Medicine Wayne State University Detroit Michigan USA
| | - Peter Pang
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis Indiana USA
| | - Javed Butler
- Division of Cardiovascular Medicine Stony Brook University Stony Brook New York USA
| | - Anna Marie Chang
- Department of Emergency Medicine Thomas Jefferson University Philadelphia Pennsylvania USA
| | - Douglas Char
- Division of Emergency Medicine Washington University St. Louis Missouri USA
| | - Deborah Diercks
- Department of Emergency Medicine University of Texas‐Southwestern Dallas Texas USA
| | - Jin H. Han
- Department of Emergency Medicine Metro Health Cleveland Ohio USA
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis Indiana USA
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Brian Hiestand
- Department of Emergency Medicine Wake Forest University Winston‐Salem North Carolina USA
| | - Chris Hogan
- Department of Emergency Medicine Virginia Commonwealth University Richmond Virginia USA
| | - Cathy A. Jenkins
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Christy Kampe
- Department of Biostatistics Vanderbilt University Nashville Tennessee USA
| | - Yosef Khan
- American Heart Association/American Stroke Association Dallas Texas USA
| | - Vijaya A. Kumar
- Department of Emergency Medicine Wayne State University Detroit Michigan USA
| | - Sangil Lee
- Department of Emergency Medicine University of Iowa Iowa City Iowa USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Disease Vanderbilt University Medical Center Nashville Tennessee USA
| | - Dandan Liu
- Department of Biostatistics Vanderbilt University Nashville Tennessee USA
| | - Karen F. Miller
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - W. Frank Peacock
- Department of Emergency Medicine Baylor College of Medicine Houston Texas USA
| | - Carolyn M. Reilly
- Department of Emergency Medicine Emory University Atlanta Georgia USA
| | - Chad Robichaux
- Department of Medicine Emory University School of Medicine Atlanta Georgia USA
| | - Russell L. Rothman
- Department of Internal Medicine Pediatrics & Health Policy Vanderbilt University Nashville Tennessee USA
| | - Wesley H. Self
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Adam J. Singer
- Department of Emergency Medicine Renaissance School of Medicine at Stony Brook University Stony Brook New York USA
| | - Sarah A. Sterling
- Department of Emergency Medicine University of Mississippi Medical Center Jackson Mississippi USA
| | - Alan B. Storrow
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - William B. Stubblefield
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Cheryl Walsh
- Geriatric Research Education and Clinical Center Tennessee Valley Healthcare System Nashville Tennessee USA
| | - John Wilburn
- Department of Emergency Medicine Wayne State University Detroit Michigan USA
| | - Sean P. Collins
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
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Ledwoch J, Schneider A, Leidgschwendner K, Kraxenberger J, Krauth A, Schneider V, Martens E, Müller A, Laugwitz KL, Kupatt C. Diagnostic Accuracy of High-Sensitive Troponin for the Identification of Myocardial Infarction in Patients Presenting with Acute Heart Failure. J Emerg Med 2022; 62:359-367. [PMID: 35065860 DOI: 10.1016/j.jemermed.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/27/2021] [Accepted: 11/27/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The differentiation of myocardial infarction (MI) in the setting of acute heart failure (AHF) can be challenging because the majority of patients presenting with AHF show elevations of high-sensitive troponin (hs-Tn). Fast identification of MI is crucial to perform timely coronary angiography and to improve clinical outcome. OBJECTIVES The aim of the present study was to assess the diagnostic accuracy of different levels of hs-Tn for the identification of type 1 MI in patients with AHF. METHODS This was a retrospective single-center analysis of admitted AHF patients with documentation of high-sensitive troponin T (hs-TnT). RESULTS A total of 649 patients were enrolled into the present study. Of them, 18% had type 1 MI, 7% had type 2 MI, 69% had myocardial injury, and 6% had no myocardial injury. The area under the curve of hs-TnT for the prediction of type 1 MI was 0.70. Sensitivity and specificity of the hs-TnT 99th percentile upper reference limit (URL) for type 1 MI was 100% and 8%, respectively. The Youden index derived cut-off of hs-TnT was 50 ng/L, showing a sensitivity and specificity for type 1 MI of 63% and 68%, respectively. No significant difference regarding 30-day mortality was found depending on the presence of type 1 MI (odds ratio 1.86; 95% confidence interval 0.91-3.81). CONCLUSIONS Hs-TnT-based identification of type 1 MI in patients with AHF requires higher cut-offs compared with the 99th percentile URL used in overall acute coronary syndrome populations. However, the adjusted cut-off provided only moderate sensitivity and specificity.
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Affiliation(s)
- Jakob Ledwoch
- Klinik für Kardiologie, Pneumologie und Internistische Intensivmedizin, München Klinik Neuperlach, Munich, Germany
| | - Alisa Schneider
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Katharina Leidgschwendner
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Jana Kraxenberger
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Anna Krauth
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Vera Schneider
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Eimo Martens
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Alexander Müller
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Karl-Ludwig Laugwitz
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Christian Kupatt
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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Grand J, Miger K, Sajadieh A, Køber L, Torp-Pedersen C, Ertl G, López-Sendón J, Pietro Maggioni A, Teerlink JR, Sato N, Gimpelewicz C, Metra M, Holbro T, Nielsen OW. Blood Pressure Drops During Hospitalization for Acute Heart Failure Treated With Serelaxin: A Patient-Level Analysis of 4 Randomized Controlled Trials. Circ Heart Fail 2022; 15:e009199. [PMID: 35184572 DOI: 10.1161/circheartfailure.121.009199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hypotensive events and drops in systolic blood pressure (SBP-drop) are frequent in patients hospitalized with acute heart failure. We investigated whether SBP-drops are associated with outcomes in patients treated with serelaxin. METHODS Patient-level retrospective analyses of 4 prospective trials investigating serelaxin in acute heart failure. Main inclusion criteria were SBP 125 to 180 mm Hg, pulmonary congestion, and elevated NT-proBNP (N-terminal pro-B-type natriuretic peptide). SBP-drops were prospectively defined as SBP<100 mm Hg, or, if SBP remained >100 mm Hg, a drop from baseline of 40 mm Hg from baseline. Outcomes were a short-term composite outcome (worsening heart failure, hospital readmission for heart failure or all-cause mortality through 14 days) and 180-day mortality. RESULTS Overall, 2559/11 226 (23%) patients had an SBP-drop. SBP-drop, versus no SBP-drop, was associated with a worse outcome: cumulative incidence of 180-day mortality (11% versus 9%, hazard ratio [HR]. 1.21 [95% CI, 1.05-1.39]; P=0.009) and the short-term outcome (11% versus 9%, HR, 1.29 [95% CI, 1.13-1.49]; P<0.001). Of the 2 SBP-drop components, an SBP<100 mm Hg was associated with the worst outcome compared with a 40 mm Hg drop: short-term outcome (11% versus 10%) and HRs of 1.32 (95% CI, 1.13-1.55; P=0.0005) and 1.22 (95% CI, 0.97-1.56; P=0.09), for each component respectively, with a P value for interaction of 0.05. SBP-drops were associated with a worse short-term outcome in the placebo group (HR, 1.46 [95% CI, 1.19-1.79]; P=0.0003), but not in the serelaxin-group (HR, 1.18 [95% CI, 0.97-1.42]; P=0.10); P interaction=0.003. CONCLUSIONS SBP-drops in patients with acute heart failure and normal to high SBP at admission is associated with worse short- and long-term outcomes especially for SBP <100 mm Hg. However, in patients treated with the intravenous vasodilator serelaxin, SBP-drops seemed less harmful. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02064868, NCT02007720, NCT01870778, NCT00520806.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology Bispebjerg Hospital, University of Copenhagen, Denmark. (J.G., K.M., A.S., O.W.N.)
| | - Kristina Miger
- Department of Cardiology Bispebjerg Hospital, University of Copenhagen, Denmark. (J.G., K.M., A.S., O.W.N.)
| | - Ahmad Sajadieh
- Department of Cardiology Bispebjerg Hospital, University of Copenhagen, Denmark. (J.G., K.M., A.S., O.W.N.)
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Denmark. (L.K.)
| | | | - Georg Ertl
- German Comprehensive Heart Failure Center, Department of Internal Medicine I, University Hospital Würzburg (G.E.)
| | - José López-Sendón
- IdiPaz Research Institute, Hospital La Paz, Autonomous University of Madrid, Spain (J.L.-S.)
| | - Aldo Pietro Maggioni
- Associazione Nazionale Medicin Cardiologi Ospedalieri Research Center, Florence, Italy (A.P.M.).,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy (A.P.M.)
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco (J.R.T.)
| | - Naoki Sato
- Department of Cardiovascular Medicine, Kawaguchi Cardiovascular and Respiratory Hospital, Saitama, Japan (N.S.)
| | | | - Marco Metra
- ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Italy (M.M.)
| | | | - Olav W Nielsen
- Department of Cardiology Bispebjerg Hospital, University of Copenhagen, Denmark. (J.G., K.M., A.S., O.W.N.).,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark. (O.W.N.)
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Osenenko KM, Kuti E, Deighton AM, Pimple P, Szabo SM. Burden of hospitalization for heart failure in the United States: a systematic literature review. J Manag Care Spec Pharm 2022; 28:157-167. [PMID: 35098748 PMCID: PMC10373049 DOI: 10.18553/jmcp.2022.28.2.157] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Heart failure (HF) affects approximately 6 million Americans, with prevalence projected to increase by 46% and direct medical costs to reach $53 billion by 2030. Hospitalizations are the largest component of direct costs for HF; however, recent syntheses of the economic and clinical burden of hospitalization for heart failure (HHF) are lacking. OBJECTIVE: To synthesize contemporary estimates of cost and clinical outcomes of HHF in the United States. METHODS: A systematic literature review was conducted using MEDLINE and Embase to identify articles reporting cost or charge per HHF in the United States published between January 2014 and May 2019. Subgroups of interest were those with both HF and renal disease or diabetes, as well as HF with reduced or preserved ejection fraction (HFrEF or HFpEF). RESULTS: 23 studies reporting cost and/or charge per HHF were included. Sample sizes ranged from 989 to approximately 11 million (weighted), mean age from 65 to 83 years, and 39% to 74% were male. Cost per HHF ranged from $7,094 to $9,769 (median) and $10,737 to $17,830 (mean). Charge per HHF ranged from $22,162 to $40,121 (median), and $50,569 to $50,952 (mean). Among patients with renal disease, HHF mean cost ranged from $9,922 to $41,538. For those with HFrEF or HFpEF, mean cost ranged from $11,600 to $17,779 and $7,860 to $10,551, respectively. No eligible studies were identified that reported HHF costs or charges among patients with HF and diabetes. Cost and charge per HHF increased with length of stay, which ranged from 3 to 5 days (median) and 4 to 7 days (mean). CONCLUSIONS: This synthesis demonstrates the substantial economic burden of HHF and the variability in estimates of this burden. Factors contributing to variability in estimates include length of stay, age and sex of the sample, HF severity, and frequencies of comorbidities. Further research into cost drivers of HHF is warranted to understand potential mechanisms to reduce associated costs. DISCLOSURES: This study was funded by Boehringer Ingelheim Pharmaceuticals. Osenenko, Deighton, and Szabo are employees of Broadstreet HEOR, which received funds from Boehringer Ingelheim Pharmaceuticals for this work. Kuti and Pimple are employees of Boehringer Ingelheim Pharmaceuticals. This study was presented in abstract form at the 2020 American Heart Association (AHA) Quality of Care and Outcomes Research (QCOR) 2020 Scientific Sessions (May 15-16, Virtual Meeting).
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Affiliation(s)
| | - Effie Kuti
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT
| | | | - Pratik Pimple
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT
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Abstract
BACKGROUND Pharmacotherapies such as loop diuretics are the cornerstone treatment for acute heart failure (AHF), but resistance and poor response can occur. Ultrafiltration (UF) is an alternative therapy to reduce congestion, however its benefits, efficacy and safety are unclear. OBJECTIVES To assess the effects of UF compared to diuretic therapy on clinical outcomes such as mortality and rehospitalisation rates. SEARCH METHODS We undertook a systematic search in June 2021 of the following databases: CENTRAL, MEDLINE, Embase, Web of Science CPCI-S and ClinicalTrials.gov. We also searched the WHO ICTRP platform in October 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared UF to diuretics in adults with AHF. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We contacted study authors for any further information, and language interpreters to translate texts. We assessed risk of bias in included studies using Risk of Bias 2 (RoB2) tool and assessed the certainty of the evidence using GRADE. MAIN RESULTS We included 14 trials involving 1190 people. We included people who had clinical signs of acute hypervolaemia. We excluded critically unwell people such as those with ischaemia or haemodynamic instability. Mean age ranged from 57.5 to 75 years, and the setting was a mix of single and multi-centre. Two trials researched UF as a complimentary therapy to diuretics, while the remaining trials withheld diuretic use during UF. There was high risk of bias in some studies, particularly with deviations from the intended protocols from high cross-overs as well as missing outcome data for long-term follow-up. We are uncertain about the effect of UF on all-cause mortality at 30 days or less (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.13 to 2.85; 3 studies, 286 participants; very low-certainty evidence). UF may have little to no effect on all-cause mortality at the longest available follow-up (RR 1.00, 95% CI 0.73 to 1.36; 9 studies, 987 participants; low-certainty evidence). UF may reduce all-cause rehospitalisation at 30 days or less (RR 0.76, 95% CI 0.53 to 1.09; 3 studies, 337 participants; low-certainty evidence). UF may slightly reduce all-cause rehospitalisation at longest available follow-up (RR 0.91, 95% CI 0.79 to 1.05; 6 studies, 612 participants; low-certainty evidence). UF may reduce heart failure-related rehospitalisation at 30 days or less (RR 0.62, 95% CI 0.37 to 1.04; 2 studies, 395 participants; low-certainty evidence). UF probably reduces heart failure-related rehospitalisation at longest available follow-up, with a number needed to treat for an additional beneficial effect (NNTB) of 10 (RR 0.69, 95% CI 0.53 to 0.90; 4 studies, 636 participants; moderate-certainty evidence). No studies measured need for mechanical ventilation. UF may have little or no effect on serum creatinine change at 30 days since discharge (mean difference (MD) 14%, 95% CI -12% to 40%; 1 study, 221 participants; low-certainty evidence). UF may increase the risk of new initiation of renal replacement therapy at longest available follow-up (RR 1.42, 95% CI 0.42 to 4.75; 4 studies, 332 participants; low-certainty evidence). There is an uncertain effect of UF on the risk of complications from central line insertion in hospital (RR 4.16, 95% CI 1.30 to 13.30; 6 studies, 779 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS: This review summarises the latest evidence on UF in AHF. Moderate-certainty evidence shows UF probably reduces heart failure-related rehospitalisation in the long term, with an NNTB of 10. UF may reduce all-cause rehospitalisation at 30 days or less and at longest available follow-up. The effect of UF on all-cause mortality at 30 days or less is unclear, and it may have little effect on all-cause mortality in the long-term. While UF may have little or no effect on serum creatinine change at 30 days, it may increase the risk of new initiation of renal replacement therapy in the long term. The effect on complications from central line insertion is unclear. There is insufficient evidence to determine the true impact of UF on AHF. Future research should evaluate UF as an adjunct therapy, focusing on outcomes such as heart failure-related rehospitalisation, cardiac mortality and renal outcomes at medium- to long-term follow-up.
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Affiliation(s)
- Mehul Srivastava
- Institute of Health Informatics Research, University College London, London, UK
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia
| | - Nicholas Harrison
- Department of Emergency Medicine, Division of Research, Indiana University School of Medicine, Indianapolis, MI-Michigan, USA
| | | | - Audrey R Tan
- Institute of Health Informatics Research, University College London, London, UK
| | - Mandy Law
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Australia
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Esteban-Zubero E, García-Muro C, Alatorre-Jiménez MA, Johal V, López-García CA, Marín-Medina A. High Flow Nasal Cannula Therapy in the Emergency Department: Main Benefits in Adults, Pediatric Population and against COVID-19: A Narrative Review. ACTA MEDICA (HRADEC KRALOVE, CZECH REPUBLIC) 2022; 65:45-52. [DOI: 10.14712/18059694.2022.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
This review aims to summarize the literature’s main results about high flow nasal cannula therapy (HFNC) HFNC benefits in the Emergency Department (ED) in adults and pediatrics, including new Coronavirus Disease (COVID-19). HFNC has recently been established as the usual treatment in the ED to provide oxygen support. Its use has been generalized due to its advantages over traditional oxygen therapy devices, including decreased nasopharyngeal resistance, washing out of the nasopharyngeal dead space, generation of positive pressure, increasing alveolar recruitment, easy adaptation due to the humidification of the airways, increased fraction of inspired oxygen and improved mucociliary clearance. A wide range of pathologies has been studied to evaluate the potential benefits of HFNC; some examples are heart failure, pneumonia, chronic pulmonary obstructive disease, asthma, and bronchiolitis. The regular use of this oxygen treatment is not established yet due to the literature’s controversial results. However, several authors suggest that it could be useful in several pathologies that generate acute respiratory failure. Consequently, the COVID-19 irruption has generated the question of HFNC as a safety and effective treatment. Our results suggested that HFNC seems to be a useful tool in the ED, especially in patients affected by acute hypoxemic respiratory failure, acute heart failure, pneumonia, bronchiolitis, asthma and acute respiratory distress syndrome in patients affected by COVID-19. Its benefits in hypercapnic respiratory failure are more discussed, being only observed benefits in patients with mild-moderate disease. These results are based in clinical as well as cost-effectiveness outcomes. Future studies with largest populations are required to confirm these results as well as establish a practical guideline to use this device.
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Hospitalization following an emergency-department visit for worsening heart failure: The role of left ventricular ejection fraction. Med Clin (Barc) 2022; 159:157-163. [DOI: 10.1016/j.medcli.2021.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 11/18/2022]
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Feldman BA, Rivera OE, Greb CJ, Jacoby JL, Nesfeder J, Secheresiu P, Shah M, Sundlof DW. "House Calls" by Mobile Integrated Health Paramedics for Patients with Heart Failure: A Feasibility Study. PREHOSP EMERG CARE 2021; 26:747-755. [PMID: 34505798 DOI: 10.1080/10903127.2021.1977439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: Early readmissions following hospital discharge for heart failure (HF) remain a major concern. Among the various strategies designed to reduce readmissions, home evaluations have been observed to have a favorable impact. We assessed the feasibility of integrating community paramedics into the outpatient management of HF patients.Methods: Selected paramedics completed an educational HF curriculum. These Mobile Integrated Health Paramedics (MIHP) performed scheduled home visits 2- and 15-days post-discharge for patients with Stage C HF (Phase I) and patients with Stage D HF (Phase II). Facilitated by a Call Center, a process was created for performing urgent MIHP house calls within 60 minutes of a medical provider's request. A HF specialist, with an on-call emergency department command physician, could order an intravenous diuretic during home visits. During each phase of the study the incidence of 30-day HF readmissions, 30-day all-cause readmissions, emergency room evaluations, unplanned office encounters, as well as any adverse events were prospectively documented.Results: Collaborative relationships between our hospital network and local EMS organizations were created. There were 82 MIHP home visits. Eight patients received urgent home evaluations within 60-minutes post-request, one requiring transport to an ED. The incidence of all-cause 30-day readmissions in 20 Stage C and 20 Stage D patients was 15% and 40%, respectively. There were no adverse events attributable to the MIHP house calls.Conclusions: It is feasible to integrate MIHPs into the outpatient management of HF. Signals of effectiveness for reducing early readmissions were observed. Obstacles to creating an effective paramedic "House Calls" program were identified. A randomized trial is required to assess the value of this care process and its impact on early readmissions in patients with Stage C and Stage D HF.
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Stubblefield WB, Jenkins CA, Liu D, Storrow AB, Spertus JA, Pang PS, Levy PD, Butler J, Chang AM, Char D, Diercks DB, Fermann GJ, Han JH, Hiestand BC, Hogan CJ, Khan Y, Lee S, Lindenfeld JM, McNaughton CD, Miller K, Peacock WF, Schrock JW, Self WH, Singer AJ, Sterling SA, Collins SP. Improvement in Kansas City Cardiomyopathy Questionnaire Scores After a Self-Care Intervention in Patients With Acute Heart Failure Discharged From the Emergency Department. Circ Cardiovasc Qual Outcomes 2021; 14:e007956. [PMID: 34555929 PMCID: PMC8628372 DOI: 10.1161/circoutcomes.121.007956] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We conducted a secondary analysis of changes in the Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 over 30 days in a randomized trial of self-care coaching versus structured usual care in patients with acute heart failure who were discharged from the emergency department. METHODS Patients in 15 emergency departments completed the KCCQ-12 at emergency department discharge and at 30 days. We compared change in KCCQ-12 scores between the intervention and usual care arms, adjusted for enrollment KCCQ-12 and demographic characteristics. We used linear regression to describe changes in KCCQ-12 summary scores and logistic regression to characterize clinically meaningful KCCQ-12 subdomain changes at 30 days. RESULTS There were 350 patients with both enrollment and 30-day KCCQ summary scores available; 166 allocated to usual care and 184 to the intervention arm. Median age was 64 years (interquartile range, 55-70), 37% were female participants, 63% were Black, median KCCQ-12 summary score at enrollment was 47 (interquartile range, 33-64). Self-care coaching resulted in significantly greater improvement in health status compared with structured usual care (5.4-point greater improvement, 95% CI, 1.12-9.68; P=0.01). Improvements in health status in the intervention arm were driven by improvements within the symptom frequency (adjusted odds ratio, 1.62 [95% CI, 1.01-2.59]) and quality of life (adjusted odds ratio, 2.39 [95% CI, 1.46-3.90]) subdomains. CONCLUSIONS In this secondary analysis, patients with acute heart failure who received a tailored, self-care intervention after emergency department discharge had clinically significant improvements in health status at 30 days compared with structured usual care largely due to improvements within the symptom frequency and quality of life subdomains of the KCCQ-12. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02519283.
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Affiliation(s)
- William B Stubblefield
- Department of Emergency Medicine (W.B.S., A.B.S., J.H.H., C.D.M., K.M., W.H.S., S.P.C.), Vanderbilt University Medical Center, Nashville, TN
| | - Cathy A Jenkins
- Department of Biostatistics (C.A.J., D.L.), Vanderbilt University Medical Center, Nashville, TN
| | - Dandan Liu
- Department of Biostatistics (C.A.J., D.L.), Vanderbilt University Medical Center, Nashville, TN
| | - Alan B Storrow
- Department of Emergency Medicine (W.B.S., A.B.S., J.H.H., C.D.M., K.M., W.H.S., S.P.C.), Vanderbilt University Medical Center, Nashville, TN
| | - John A Spertus
- Department of Biomedical and Health Informatics, University of Missouri, Kansas City and Saint Luke's Mid America Heart Institute, MO (J.A.S.)
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.S.P.)
| | - Phillip D Levy
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI (P.D.L.)
| | - Javed Butler
- Department of Medicine (J.B.), University of Mississippi Medical Center, Jackson
| | - Anna Marie Chang
- Department of Emergency Medicine, Thomas Jefferson University Hospital (A.M.C.)
| | - Douglas Char
- Division of Emergency Medicine, Department of Internal Medicine, Washington University, Seattle (D.C.)
| | - Deborah B Diercks
- Department of Emergency Medicine, UT Southwestern Medical Center, Dallas, TX (D.B.D.)
| | - Gregory J Fermann
- Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.)
| | - Jin H Han
- Department of Emergency Medicine (W.B.S., A.B.S., J.H.H., C.D.M., K.M., W.H.S., S.P.C.), Vanderbilt University Medical Center, Nashville, TN
| | - Brian C Hiestand
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (B.C.H.)
| | - Christopher J Hogan
- Division of Trauma/Critical Care, Departments of Emergency Medicine and Surgery, Virginia Commonwealth University Medical Center, Richmond (C.J.H.)
| | - Yosef Khan
- Health Informatics and Analytics, Centers for Health Metrics and Evaluation, American Heart Association (Y.K.)
| | - Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine (S.L.)
| | - JoAnn M Lindenfeld
- Division of Cardiovascular Disease (J.M.L.), Vanderbilt University Medical Center, Nashville, TN
| | - Candace D McNaughton
- Department of Emergency Medicine (W.B.S., A.B.S., J.H.H., C.D.M., K.M., W.H.S., S.P.C.), Vanderbilt University Medical Center, Nashville, TN
| | - Karen Miller
- Department of Emergency Medicine (W.B.S., A.B.S., J.H.H., C.D.M., K.M., W.H.S., S.P.C.), Vanderbilt University Medical Center, Nashville, TN
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.)
| | - Jon W Schrock
- Department of Emergency Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH (J.W.S.)
| | - Wesley H Self
- Department of Emergency Medicine (W.B.S., A.B.S., J.H.H., C.D.M., K.M., W.H.S., S.P.C.), Vanderbilt University Medical Center, Nashville, TN
| | - Adam J Singer
- Department of Emergency Medicine, Stony Brook University, NY (A.J.S.)
| | - Sarah A Sterling
- Department of Emergency Medicine (S.A.S.), University of Mississippi Medical Center, Jackson
| | - Sean P Collins
- Department of Emergency Medicine (W.B.S., A.B.S., J.H.H., C.D.M., K.M., W.H.S., S.P.C.), Vanderbilt University Medical Center, Nashville, TN
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Grand J, Miger K, Sajadieh A, Køber L, Torp-Pedersen C, Ertl G, López-Sendón J, Pietro Maggioni A, Teerlink JR, Sato N, Gimpelewicz C, Metra M, Holbro T, Nielsen OW. Systolic Blood Pressure and Outcome in Patients Admitted With Acute Heart Failure: An Analysis of Individual Patient Data From 4 Randomized Clinical Trials. J Am Heart Assoc 2021; 10:e022288. [PMID: 34514815 PMCID: PMC8649519 DOI: 10.1161/jaha.121.022288] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In acute heart failure (AHF), systolic blood pressure (SBP) is an important clinical variable. This study assessed the association between SBP and short‐term and long‐term outcomes in a large cohort of patients with AHF. METHODS AND RESULTS This is an analysis of 4 randomized controlled trials investigating serelaxin versus placebo in patients admitted with AHF and SBPs from 125 to 180 mm Hg. Outcomes were 180‐day all‐cause mortality and a composite end point of all‐cause mortality, worsening heart failure, or hospital readmission for heart failure the first 14 days. Left ventricular ejection fraction (LVEF) was examined as LVEF<40% and LVEF≥40%. Multivariable Cox regression models were adjusted for known confounders of outcomes in AHF. A total of 10 533 patients with a mean age of 73 (±12) years and a mean SBP of 145 (±7) mm Hg were included. LVEF was assessed in 9863 patients (93%); 4737 patients (45%) had LVEF<40%. Increasing SBP was inversely associated with 180‐day mortality (adjusted hazard ratio [HRadjusted], 0.93; 95% CI, 0.89–0.98; P=0.008 per 10 mm Hg increase) and with the composite end point (HRadjusted, 0.90; 95% CI, 0.85–0.94; P<0.001 per 10 mm Hg increase). A significant interaction with LVEF was observed, revealing that SBP was not associated with mortality in patients with LVEF≥40% (HRadjusted, 0.98; 95% CI, 0.91–1.04; per 10 mm Hg increase), but was strongly associated with increased mortality in LVEF<40% (HRadjusted, 0.84; 95% CI, 0.77–0.92; per 10 mm Hg increase). CONCLUSIONS Elevated SBP is associated with favorable short‐term and long‐term outcomes in patients with AHF. In our predefined subgroup analysis, we found that baseline SBP was not associated with mortality in LVEF≥40%, but was strongly associated with mortality in patients with LVEF<40%.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology Bispebjerg Hospital University of Copenhagen Copenhagen Denmark
| | - Kristina Miger
- Department of Cardiology Bispebjerg Hospital University of Copenhagen Copenhagen Denmark
| | - Ahmad Sajadieh
- Department of Cardiology Bispebjerg Hospital University of Copenhagen Copenhagen Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | | | - Georg Ertl
- Comprehensive Heart Failure Center University Hospital Würzburg Germany.,Department of Cardiology Associazione Nazionale Medicin Cardiologi Ospedalieri Research Center Florence Italy
| | - José López-Sendón
- Department of Cardiology Hospital La PazIdiPazUniversidad Autonoma de Madrid Madrid Spain.,Department of Cardiology Maria Cecilia HospitalGruppo Villa Maria S.p.A Care & Research Lugo Italy
| | - Aldo Pietro Maggioni
- Department of Cardiology Hospital La PazIdiPazUniversidad Autonoma de Madrid Madrid Spain.,Department of Cardiology Maria Cecilia HospitalGruppo Villa Maria S.p.A Care & Research Lugo Italy
| | - John R Teerlink
- Department of Cardiology University of CaliforniaSan FranciscoSan Francisco VA Medical Center Cardiology San Francisco CA
| | - Naoki Sato
- Department of Cardiovascular Medicine Kawaguchi Cardiovascular and Respiratory Hospital Saitama Japan
| | | | - Marco Metra
- Cardiology Department of Medical and Surgical Specialties Cardiothoracic Department Radiological Sciences and Public Health Civil HospitalsUniversity of Brescia Brescia Italy
| | | | - Olav W Nielsen
- Department of Cardiology Bispebjerg Hospital University of Copenhagen Copenhagen Denmark
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Hirayama A, Goto T, Faridi MK, Camargo CA, Hasegawa K. Association of obstructive sleep apnea with all-cause readmissions after hospitalization for asthma exacerbation in adults aged 18-54 years: a population-based study, 2010-2013. J Asthma 2021; 58:1176-1185. [PMID: 32521180 PMCID: PMC7762726 DOI: 10.1080/02770903.2020.1781887] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 06/08/2020] [Accepted: 06/08/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To investigate associations between obstructive sleep apnea (OSA) and readmission risk after hospitalization for asthma exacerbation. METHODS We conducted a retrospective, population-based cohort study using State Inpatient Databases from seven U.S. states (Arkansas, California, Florida, Iowa, Nebraska, New York, and Utah) from 2010 to 2013. We identified all adults (aged 18-54 years) hospitalized for asthma exacerbation. The outcome measure was all-cause readmissions within one year after hospitalization for asthma exacerbation. To determine associations between OSA and readmission risk, we constructed negative binomial regression models estimating the incidence rate ratio (IRR) for readmissions and Cox proportional hazards models estimating hazard rate (HR) for the time-to-first readmission. RESULTS Among 65,731 patients hospitalized for asthma exacerbation, 6,549 (10.0%) had OSA. Overall, OSA was associated with significantly higher incident rate of all cause readmission (1.36 vs. 0.85 readmissions per person-year; unadjusted IRR 1.60; 95%CI 1.54-1.66). Additionally, OSA was associated with higher incident rates of readmissions for five major diseases-asthma (IRR 1.21; 95%CI 1.15-1.27), COPD (IRR 2.03; 95%CI 1.88-2.19), respiratory failure (IRR 3.04; 95%CI 2.76-3.34), pneumonia (IRR 1.67; 95%CI 1.49-1.88), and congestive heart failure (IRR 3.78; 95%CI 3.36-4.24), compared to non-OSA. The Cox model demonstrated that patients with OSA had significantly higher rates for all-cause readmission compared to those without OSA (HR 1.56; 95% CI 1.50-1.62). These associations remained significant after adjustment for confounders. CONCLUSIONS The observed association of OSA with a higher risk of readmissions after hospitalization for asthma exacerbation underscores the importance of identifying coexistent OSA in this population and optimizing both OSA and asthma management.
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Affiliation(s)
- Atsushi Hirayama
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Tadahiro Goto
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
- Harvard T.H. Chan School of Public Health, Boston, MA
- Harvard Medical School, Boston, MA
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Activity of the adrenomedullin system to personalise post-discharge diuretic treatment in acute heart failure. Clin Res Cardiol 2021; 111:627-637. [PMID: 34302189 PMCID: PMC9151518 DOI: 10.1007/s00392-021-01909-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/07/2021] [Indexed: 11/25/2022]
Abstract
Background Quantifying the activity of the adrenomedullin system might help to monitor and guide treatment in acute heart failure (AHF) patients. The aims were to (1) identify AHF patients with marked benefit or harm from specific treatments at hospital discharge and (2) predict mortality by quantifying the adrenomedullin system activity. Methods This was a prospective multicentre study. AHF diagnosis and phenotype were centrally adjudicated by two independent cardiologists among patients presenting to the emergency department with acute dyspnoea. Adrenomedullin system activity was quantified using the biologically active component, bioactive adrenomedullin (bio-ADM), and a prohormone fragment, midregional proadrenomedullin (MR-proADM). Bio-ADM and MR-proADM concentrations were measured in a blinded fashion at presentation and at discharge. Interaction with specific treatments at discharge and the utility of these biomarkers on predicting outcomes during 365-day follow-up were assessed. Results Among 1886 patients with adjudicated AHF, 514 patients (27.3%) died during 365-day follow-up. After adjusting for age, creatinine, and treatment at discharge, patients with bio-ADM plasma concentrations above the median (> 44.6 pg/mL) derived disproportional benefit if treated with diuretics (interaction p values < 0.001). These findings were confirmed when quantifying adrenomedullin system activity using MR-proADM (n = 764) (interaction p values < 0.001). Patients with bio-ADM plasma concentrations above the median were at increased risk of death (hazard ratio 1.87, 95% CI 1.57–2.24; p < 0.001). For predicting 365-day all-cause mortality, both biomarkers performed well, with MR-proADM presenting an even higher predictive accuracy compared to bio-ADM (p < 0.001). Conclusions Quantifying the adrenomedullin’s system activity may help to personalise post-discharge diuretic treatment and enable accurate risk-prediction in AHF. Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01909-9.
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Suciadi LP, Wibawa K, Jessica G, Henrina J, Cahyadi I, Santi BT, Hariadi TK, Tedjasukmana F, Kristanti NM, Pakpahan EF, Manullang RA, Sutandar A. Tachycardia and Pre-existing Chronic Kidney Disease Are Predictors of the Worse Clinical Outcomes in Patients Recently Hospitalized With Acute Heart Failure. Cureus 2021; 13:e15802. [PMID: 34306870 PMCID: PMC8294205 DOI: 10.7759/cureus.15802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 11/12/2022] Open
Abstract
Background: This study aimed to assess the factors contributing to the outcomes of recently hospitalized patients with heart failure (HF). Methods: A prospective data of 76 adults who were admitted due to acute HF between October 1, 2019 and June 30, 2020 at our center were analyzed. Endpoints included survival and rehospitalization within six months after discharge. Results: The mean age was 64.9 ± 13.8 years, with a male preponderance (68.4%). Approximately 60.5% of patients had the left ventricular ejection fraction (LVEF) <40%, whereas 26.3% of patients had LVEF ≥50%. Coronary artery disease (75%), arterial hypertension (72.4%), chronic kidney disease (46.1%), and diabetes mellitus (46.1%) were the most frequent comorbidities. Poor compliance (40.8%) and non-cardiac infection (21.1%) were the common precipitating factors for hospitalization. The majority of subjects had severe symptoms, indicated by the frequent need of intensive care unit (43%), high N-terminal prohormone brain natriuretic peptide levels [NT-proBNP; median, 4765 (1539.7-11782.2) pg/mL], and presence of either atrial fibrillation, severe mitral regurgitation, or significant pulmonary hypertension in approximately one-third of cases. Even though in-hospital mortality was relatively low (2.6%), the all-cause mortality and rehospitalization rates in the next six months after discharge were still high, reaching 22.54% and 19.72%, respectively. Further survival analysis showed that tachycardia on admission and pre-existing chronic kidney disease (CKD) resulted in low six-month survival rates among these patients. Conclusion: After hospital discharge, patients with HF were still exposed to higher risks of death and readmission albeit with the medication addressed. Tachycardia on admission and pre-existing CKD might predict worse outcomes.
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Affiliation(s)
- Leonardo P Suciadi
- Cardiology, Siloam Heart Institute/Siloam Hospitals Kebon Jeruk, Jakarta, IDN
| | | | | | | | | | - Bryany T Santi
- Epidemiology, School of Medicine and Health Sciences Atma Jaya Catholic University of Indonesia, Jakarta, IDN
| | - Titus K Hariadi
- Cardiology, Siloam Heart Institute/Siloam Hospitals Kebon Jeruk, Jakarta, IDN
| | - Firman Tedjasukmana
- Cardiology, Siloam Heart Institute/Siloam Hospitals Kebon Jeruk, Jakarta, IDN
| | | | - Elisa F Pakpahan
- Cardiology, Siloam Heart Institute/Siloam Hospitals Kebon Jeruk, Jakarta, IDN
| | - Reynold A Manullang
- Cardiology, Siloam Heart Institute/Siloam Hospitals Kebon Jeruk, Jakarta, IDN
| | - Antono Sutandar
- Cardiology, Siloam Heart Institute/Siloam Hospitals Kebon Jeruk, Jakarta, IDN
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Association between acute heart failure and major cardiovascular events in atrial fibrillation patients presenting at the emergency department: an EMERG-AF ancillary study. Eur J Emerg Med 2021; 28:210-217. [PMID: 33323724 DOI: 10.1097/mej.0000000000000779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is little evidence concerning the impact of acute heart failure (AHF) on the prognosis of atrial fibrillation patients attending the emergency department (ED). OBJECTIVE To know the influence of AHF on adverse long-term outcomes in patients presenting with atrial fibrillation in ED. DESIGN, SETTING AND PARTICIPANTS Secondary analysis of a prospective, multicenter, observational cohort of consecutive atrial fibrillation patients, performed in 62 Spanish EDs. EXPOSURE Patients presenting with atrial fibrillation in ED were divided by the presence or absence of AHF at arrival. OUTCOME MEASURES AND ANALYSIS Primary outcome: combination of 1-year all-cause mortality, major bleeding, stroke and other major cardiovascular events (MACE). Secondary outcomes: each of these events analyzed separately. Cox and logistic regression were used to investigate adjusted significant associations between AHF and outcomes. MAIN RESULTS Totally, 1107 consecutive ED patients with atrial fibrillation attending ED were analyzed, 262 (23.7%) with AHF. The primary outcome occurred in 433 patients (39.1%), 1-year all-cause mortality in 151 patients (13.6%), major bleeding in 47 patients (4.2 %), stroke in 31 patients (2.8 %) and other MACE in 333 patients (30.1%). AHF was independently related to the primary outcome [odds ratio (OR), 1.422; 95% confidence interval (CI), 1.020-1.981; P = 0.037)] and 1-year MACE (OR, 1.797; 95% CI, 1.285-2.512; P = 0.001), but not to 1-year all-cause mortality, stroke or bleeding. CONCLUSIONS The coexistence of AHF in patients presenting with atrial fibrillation in ED is associated to a worse 1-year outcome mainly due to MACE, but does not impact in overall mortality.
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