1
|
Chun KH, Kang SM. Blood pressure and heart failure: focused on treatment. Clin Hypertens 2024; 30:15. [PMID: 38822445 PMCID: PMC11143661 DOI: 10.1186/s40885-024-00271-y] [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: 01/19/2024] [Accepted: 04/17/2024] [Indexed: 06/03/2024] Open
Abstract
Heart failure (HF) remains a significant global health burden, and hypertension is known to be the primary contributor to its development. Although aggressive hypertension treatment can prevent heart changes in at-risk patients, determining the optimal blood pressure (BP) targets in cases diagnosed with HF is challenging owing to insufficient evidence. Notably, hypertension is more strongly associated with HF with preserved ejection fraction than with HF with reduced ejection fraction. Patients with acute hypertensive HF exhibit sudden symptoms of acute HF, especially those manifested with severely high BP; however, no specific vasodilator therapy has proven beneficial for this type of acute HF. Since the majority of medications used to treat HF contribute to lowering BP, and BP remains one of the most important hemodynamic markers, targeted BP management is very concerned in treatment strategies. However, no concrete guidelines exist, prompting a trend towards optimizing therapies to within tolerable ranges, rather than setting explicit BP goals. This review discusses the connection between BP and HF, explores its pathophysiology through clinical studies, and addresses its clinical significance and treatment targets.
Collapse
Affiliation(s)
- Kyeong-Hyeon Chun
- Division of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Seok-Min Kang
- Division of Cardiology, Severance Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
2
|
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.
Collapse
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.
| |
Collapse
|
3
|
Lasica R, Djukanovic L, Vukmirovic J, Zdravkovic M, Ristic A, Asanin M, Simic D. Clinical Review of Hypertensive Acute Heart Failure. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:133. [PMID: 38256394 PMCID: PMC10818732 DOI: 10.3390/medicina60010133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 12/20/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024]
Abstract
Although acute heart failure (AHF) is a common disease associated with significant symptoms, morbidity and mortality, the diagnosis, risk stratification and treatment of patients with hypertensive acute heart failure (H-AHF) still remain a challenge in modern medicine. Despite great progress in diagnostic and therapeutic modalities, this disease is still accompanied by a high rate of both in-hospital (from 3.8% to 11%) and one-year (from 20% to 36%) mortality. Considering the high rate of rehospitalization (22% to 30% in the first three months), the treatment of this disease represents a major financial blow to the health system of each country. This disease is characterized by heterogeneity in precipitating factors, clinical presentation, therapeutic modalities and prognosis. Since heart decompensation usually occurs quickly (within a few hours) in patients with H-AHF, establishing a rapid diagnosis is of vital importance. In addition to establishing the diagnosis of heart failure itself, it is necessary to see the underlying cause that led to it, especially if it is de novo heart failure. Given that hypertension is a precipitating factor of AHF and in up to 11% of AHF patients, strict control of arterial blood pressure is necessary until target values are reached in order to prevent the occurrence of H-AHF, which is still accompanied by a high rate of both early and long-term mortality.
Collapse
Affiliation(s)
- Ratko Lasica
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (R.L.); (L.D.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.Z.); (A.R.)
| | - Lazar Djukanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (R.L.); (L.D.); (M.A.)
| | - Jovanka Vukmirovic
- Faculty of Organizational Sciences, University of Belgrade, 11000 Belgrade, Serbia;
| | - Marija Zdravkovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.Z.); (A.R.)
- Clinical Center Bezanijska Kosa, 11000 Belgrade, Serbia
| | - Arsen Ristic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.Z.); (A.R.)
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Milika Asanin
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (R.L.); (L.D.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.Z.); (A.R.)
| | - Dragan Simic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.Z.); (A.R.)
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Harrison NE, Ehrman R, Pang P, Armitage S, Abidov A, Perkins D, Peacock J, Montelauro N, Gupta S, Favot MJ, Levy P. The significance of historical troponin elevation in acute heart failure: Not as reassuring as previously assumed. Acad Emerg Med 2023; 30:1223-1236. [PMID: 37641846 PMCID: PMC10863562 DOI: 10.1111/acem.14798] [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: 07/11/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Historical cardiac troponin (cTn) elevation is commonly interpreted as lessening the significance of current cTn elevations at presentation for acute heart failure (AHF). Evidence for this practice is lacking. Our objective was to determine the incremental prognostic significance of historical cTn elevation compared to cTn elevation and ischemic heart disease (IHD) history at presentation for AHF. METHODS A total of 341 AHF patients were prospectively enrolled at five sites. The composite primary outcome was death/cardiopulmonary resuscitation, mechanical cardiac support, intubation, new/emergent dialysis, and/or acute myocardial infarction (AMI)/percutaneous coronary intervention (PCI)/coronary artery bypass grafting (CABG) at 90 days. Secondary outcomes were 30-day AMI/PCI/CABG and in-hospital AMI. Logistic regression compared outcomes versus initial emergency department (ED) cTn, the most recent electronic medical record cTn, estimated glomerular filtration rate, age, left ventricular ejection fraction, and IHD history (positive, negative by prior coronary workup, or unknown/no prior workup). RESULTS Elevated cTn occurred in 163 (49%) patients, 80 (23%) experienced the primary outcome, and 29 had AMI (9%). cTn elevation at ED presentation, adjusted for historical cTn and other covariates, was associated with the primary outcome (adjusted odds ratio [aOR] 2.39, 95% confidence interval [CI] 1.30-4.38), 30-day AMI/PCI/CABG, and in-hospital AMI. Historical cTn elevation was associated with greater odds of the primary outcome when IHD history was unknown at ED presentation (aOR 5.27, 95% CI 1.24-21.40) and did not alter odds of the outcome with known positive (aOR 0.74, 95% CI 0.33-1.70) or negative IHD history (aOR 0.79, 95% CI 0.26-2.40). Nevertheless, patients with elevated ED cTn were more likely to be discharged if historical cTn was also elevated (78% vs. 32%, p = 0.025). CONCLUSIONS Historical cTn elevation in AHF patients is a harbinger of worse outcomes for patients who have not had a prior IHD workup and should prompt evaluation for underlying ischemia rather than reassurance for discharge. With known IHD history, historical cTn elevation was neither reassuring nor detrimental, failing to add incremental prognostic value to current cTn elevation alone.
Collapse
Affiliation(s)
| | - Robert Ehrman
- Indiana University School of Medicine, Department of Emergency Medicine
| | - Peter Pang
- Indiana University School of Medicine, Department of Emergency Medicine
| | - Sarah Armitage
- Wayne State University School of Medicine, Department of Emergency Medicine
| | - Aiden Abidov
- Wayne State University School of Medicine, Department of Medicine, Division of Cardiology
| | - Daniel Perkins
- Indiana University School of Medicine, Department of Emergency Medicine
| | - Johnathon Peacock
- Indiana University School of Medicine, Department of Emergency Medicine
| | | | - Sushane Gupta
- Wayne State University School of Medicine, Department of Emergency Medicine
| | - Mark J Favot
- Wayne State University School of Medicine, Department of Emergency Medicine
| | - Phillip Levy
- Wayne State University School of Medicine, Department of Emergency Medicine
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Haywood HB, Fonarow GC, Khan MS, Van Spall HGC, Morris AA, Nassif ME, Kittleson MM, Butler J, Greene SJ. Hospital at Home as a Treatment Strategy for Worsening Heart Failure. Circ Heart Fail 2023; 16:e010456. [PMID: 37646170 DOI: 10.1161/circheartfailure.122.010456] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 07/17/2023] [Indexed: 09/01/2023]
Abstract
Hospital at home (HaH) is an innovative care model that may be particularly suited for heart failure (HF). Outpatient visits and inpatient care have been the 2 traditional settings for HF care, yet may not match the social and medical needs of patients at all times. Alternative models such as HaH may represent an effective and patient-centered option for select patients with worsening HF. To date, limited research in HF and other disease states has supported HaH as being safe and lower cost than traditional inpatient admission. Supporting HaH are new payment structures, such as Medicare's Acute Hospital Care at Home waiver program. In combination with outpatient visits, outpatient intravenous diuretic clinics, inpatient care, and cardiac intensive care, HaH could be a core component of a comprehensive care model with the potential to match resource utilization with the needs of patients across the spectrum of HF severity, and improve patient outcomes.
Collapse
Affiliation(s)
- Hubert B Haywood
- Department of Medicine, Duke University Medical Center, Durham, NC (H.B.H.)
| | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center (G.C.F.)
| | | | - Harriette G C Van Spall
- Department of Medicine (H.G.C.V.S.), McMaster University, Hamilton, ON, Canada
- Population Health Research Institute (H.G.C.V.S.), McMaster University, Hamilton, ON, Canada
| | | | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (M.E.N.)
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX (J.B.)
- Department of Medicine, University of Mississippi, Jackson (J.B.)
| | - Stephen J Greene
- Division of Cardiology, Duke University Medical Center, Durham, NC (M.S.K., S.J.G.)
- Duke Clinical Research Institute, Durham, NC (S.J.G.)
| |
Collapse
|
8
|
Poliwoda J, Eagles D, Yadav K, Nemnom MJ, Walmsley CG, Mielniczuk L, Stiell IG. Outcomes of acute heart failure patients managed in the emergency department. CAN J EMERG MED 2023; 25:752-760. [PMID: 37537320 DOI: 10.1007/s43678-023-00555-6] [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: 04/24/2023] [Accepted: 06/24/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Acute heart failure is a serious condition commonly seen in the emergency department (ED). The HEARTRISK6 Scale has been recently developed to identify the risk of poor outcomes but has not been tested. We sought to describe the management and outcomes of ED patients with acute heart failure and to evaluate the potential impact of the HEARTRISK6 Scale. METHODS We conducted a health records review of 300 consecutive acute heart failure patients presenting to two tertiary care EDs. Two evaluators abstracted clinical variables, ED management and treatment details, and patient outcomes using the electronic health records platform (EPIC) and attending physicians verified the data. The primary outcome measure was a short-term serious outcome, as shown in Results. In addition, the HEARTRISK6 score was calculated retrospectively. RESULTS We included 300 patients with mean age of 78.5 years, 51.0% male, 56.3% arrival by ambulance, and 67.0% admitted to hospital. 25.3% experienced a short-term serious outcome 1) after admission (N = 201): non-invasive ventilation 14.9%, intubation 1.5%, major cardiac procedure 5.0%, myocardial infarction 2.0%, death 8.5%; 2) after ED discharge (N = 99): return to ED 21.2%, death 4.0%. Those initially admitted experienced a much higher proportion of serious outcomes compared to those discharged (29.9% vs. 16.2%). A HEARTRISK6 Scale cut-point score of ≥ 1 would have had a sensitivity of 91.0%, specificity 24.5%, and negative likelihood ratio 0.37 for short-term serious outcomes and suggested hospital admission for 80.7% of cases. CONCLUSION There was a large range of severity of illness of acute heart failure patients and a wide variety of treatments were administered in the ED. Both admitted and discharged patients experienced a high proportion of poor outcomes. The HEARTRISK6 Scale showed a high sensitivity for short-term serious outcomes but with the potential to increase hospital admissions. Further validation of the HEARTRISK6 Scale is required before routine clinical use.
Collapse
Affiliation(s)
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Lisa Mielniczuk
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| |
Collapse
|
9
|
Gao R, Qu Q, Guo Q, Sun J, Liao S, Zhu Q, Zhu X, Cheang I, Yao W, Zhang H, Li X, Zhou Y. Construction of a web-based dynamic nomogram for predicting the prognosis in acute heart failure. ESC Heart Fail 2023. [PMID: 37076115 PMCID: PMC10375097 DOI: 10.1002/ehf2.14371] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 03/17/2023] [Accepted: 03/23/2023] [Indexed: 04/21/2023] Open
Abstract
AIMS The early identification and appropriate management may provide clinically meaningful and substained benefits in patients with acute heart failure (AHF). This study aimed to develop an integrative nomogram with myocardial perfusion imaging (MPI) for predicting the risk of all-cause mortality in AHF patients. METHODS AND RESULTS Prospective study of 147 patients with AHF who received gated MPI (59.0 [47.5, 68.0] years; 78.2% males) were enrolled and followed for the primary endpoint of all-cause mortality. We analysed the demographic information, laboratory tests, electrocardiogram, and transthoracic echocardiogram by the least absolute shrinkage and selection operator (LASSO) regression for selection of key features. A multivariate stepwise Cox analysis was performed to identify independent risk factors and construct a nomogram. The predictive values of the constructed model were compared by Kaplan-Meier curve, area under the curves (AUCs), calibration plots, continuous net reclassification improvement, integrated discrimination improvement, and decision curve analysis. The 1, 3, and 5 year cumulative rates of death were 10%, 22%, and 29%, respectively. Diastolic blood pressure [hazard ratio (HR) 0.96, 95% confidence interval (CI) 0.93-0.99; P = 0.017], valvular heart disease (HR 3.05, 95% CI 1.36-6.83; P = 0.007), cardiac resynchronization therapy (HR 0.37, 95% CI 0.17-0.82; P = 0.014), N-terminal pro-B-type natriuretic peptide (per 100 pg/mL; HR 1.02, 95% CI 1.01-1.03; P < 0.001), and rest scar burden (HR 1.03, 95% CI 1.01-1.06; P = 0.008) were independent risk factors for patients with AHF. The cross-validated AUCs (95% CI) of nomogram constructed by diastolic blood pressure, valvular heart disease, cardiac resynchronization therapy, N-terminal pro-B-type natriuretic peptide, and rest scar burden were 0.88 (0.73-1.00), 0.83 (0.70-0.97), and 0.79 (0.62-0.95) at 1, 3, and 5 years, respectively. Continuous net reclassification improvement and integrated discrimination improvement were also observed, and the decision curve analysis identified the greater net benefit of the nomogram across a wide range of threshold probabilities (0-100% at 1 and 3 years; 0-61% and 62-100% at 5 years) compared with dismissing the included factors or using either factor alone. CONCLUSIONS A predictive nomogram for the risk of all-cause mortality in patients with AHF was developed and validated in this study. The nomogram incorporated the rest scar burden by MPI is highly predictive, and may help to better stratify clinical risk and guide treatment decisions in patients with AHF.
Collapse
Affiliation(s)
- Rongrong Gao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Qiang Qu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Qixin Guo
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jinyu Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Shengen Liao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Qingqing Zhu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Xu Zhu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Iokfai Cheang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Wenming Yao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Haifeng Zhang
- Department of Cardiology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, 26 Daoqian Street, Suzhou, 215002, China
- Department of Cardiology, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Xinli Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Yanli Zhou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| |
Collapse
|
10
|
Phan J, Barroca C, Fernandez J. A Suggested Model for the Vulnerable Phase of Heart Failure: Assessment of Risk Factors, Multidisciplinary Monitoring, Cardiac Rehabilitation, and Addressing the Social Determinants of Health. Cureus 2023; 15:e35602. [PMID: 37007340 PMCID: PMC10063247 DOI: 10.7759/cureus.35602] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/25/2023] [Indexed: 03/06/2023] Open
Abstract
The vulnerable phase (VP) of heart failure (HF) is 30 to 90 days after hospital discharge and is associated with increased rehospitalization and mortality rates. The pathophysiological mechanism that drives the VP is due to the progressive increase in left ventricular filling pressure, which can cause hemodynamic congestion and long-term multiorgan injury. Our team analyzed English-written, peer-reviewed research through PubMed from 2018 to 2022, to gather current information on the VP and generate a multipronged approach toward the assessment and intervention of patients with posthospitalization HF. It is our opinion that a structured approach using remote vital monitoring and risk-stratifying tools will be best to identify patients at risk for decompensatory HF during the VP. Medical management can then be targeted toward these high-risk patients by using an organized multidisciplinary team and a disease management program, which includes remote patient-monitoring systems, addressing social determinants of health, and cardiac rehabilitation, to improve rehospitalization and mortality rates.
Collapse
|
11
|
Harrison NE, Koester J, Farmer A, Hannon A, Jakupco N, Nanagas J, Park S, Li X, Collins S, Monahan P, Pang PS. Emergency physician risk tolerance in acute heart failure is higher than previously thought and compatible with modern disposition decision instruments. Acad Emerg Med 2022. [PMID: 36520547 DOI: 10.1111/acem.14641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022]
Affiliation(s)
| | - Jami Koester
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Annabelle Farmer
- Marian University College of Osteopathic Medicine, Indianapolis, Indiana, USA
| | - Aidan Hannon
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nicholas Jakupco
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jill Nanagas
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Seho Park
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Xiaochun Li
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sean Collins
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Patrick Monahan
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Peter S Pang
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
12
|
Harrison NE, Favot MJ, Gowland L, Lenning J, Henry S, Gupta S, Abidov A, Levy P, Ehrman R. Point-of-care echocardiography of the right heart improves acute heart failure risk stratification for low-risk patients: The REED-AHF prospective study. Acad Emerg Med 2022; 29:1306-1319. [PMID: 36047646 PMCID: PMC9671834 DOI: 10.1111/acem.14589] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/23/2022] [Accepted: 08/26/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Validated acute heart failure (AHF) clinical decision instruments (CDI) insufficiently identify low-risk patients meriting consideration of outpatient treatment. While pilot data show that tricuspid annulus plane systolic excursion (TAPSE) is associated with adverse events, no AHF CDI currently incorporates point-of-care echocardiography (POCecho). We evaluated whether TAPSE adds incremental risk stratification value to an existing CDI. METHODS Prospectively enrolled patients at two urban-academic EDs had POCechos obtained before or <1 h after first intravenous diuresis, positive pressure ventilation, and/or nitroglycerin. STEMI and cardiogenic shock were excluded. AHF diagnosis was adjudicated by double-blind expert review. TAPSE, with an a priori cutoff of ≥17 mm, was our primary measure. Secondary measures included eight additional right heart and six left heart POCecho parameters. STRATIFY is a validated CDI predicting 30-day death/cardiopulmonary resuscitation, mechanical cardiac support, intubation, new/emergent dialysis, and acute myocardial infarction or coronary revascularization in ED AHF patients. Full (STRATIFY + POCecho variable) and reduced (STRATIFY alone) logistic regression models were fit to calculate adjusted odds ratios (aOR), category-free net reclassification index (NRIcont ), ΔSensitivity (NRIevents ), and ΔSpecificity (NRInonevents ). Random forest assessed variable importance. To benchmark risk prediction to standard of care, ΔSensitivity and ΔSpecificity were evaluated at risk thresholds more conservative/lower than the actual outcome rate in discharged patients. RESULTS A total of 84/120 enrolled patients met inclusion and diagnostic adjudication criteria. Nineteen percent experiencing the primary outcome had higher STRATIFY scores compared to those event free (233 vs. 212, p = 0.009). Five right heart (TAPSE, TAPSE/PASP, TAPSE/RVDD, RV-FAC, fwRVLS) and no left heart measures improved prediction (p < 0.05) adjusted for STRATIFY. Right heart measures also had higher variable importance. TAPSE ≥ 17 mm plus STRATIFY improved prediction versus STRATIFY alone (aOR 0.24, 95% confidence interval [CI] 0.06-0.91; NRIcont 0.71, 95% CI 0.22-1.19), and specificity improved by 6%-32% (p < 0.05) at risk thresholds more conservative than the standard-of-care benchmark without missing any additional events. CONCLUSIONS TAPSE increased detection of low-risk AHF patients, after use of a validated CDI, at risk thresholds more conservative than standard of care.
Collapse
Affiliation(s)
- Nicholas E. Harrison
- Indiana University School of MedicineIndianapolisIndianaUSA,Wayne State UniversityDetroitMichiganUSA
| | | | | | | | | | | | | | | | | |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
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]
|
15
|
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.
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
Aktaa S, Batra G, Cleland JGF, Coats A, Lund LH, McDonagh T, Rosano G, Seferovic P, Vasko P, Wallentin L, Maggioni AP, Casadei B, Gale CP. Data standards for heart failure: the European Unified Registries for Heart Care Evaluation and Randomized Trials (EuroHeart). Eur Heart J 2022; 43:2185-2195. [PMID: 35443059 PMCID: PMC9336560 DOI: 10.1093/eurheartj/ehac151] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 02/18/2022] [Accepted: 03/09/2022] [Indexed: 11/14/2022] Open
Abstract
Standardized data definitions are essential for assessing the quality of care and patient outcomes in observational studies and randomized controlled trials. The European Unified Registries for Heart Care Evaluation and Randomized Trials (EuroHeart) project of the European Society of Cardiology (ESC) aims to create contemporary pan-European data standards for cardiovascular diseases, including heart failure (HF). We followed the EuroHeart methodology for cardiovascular data standard development. A Working Group including experts in HF registries, representatives from the Heart Failure Association of the ESC, and the EuroHeart was formed. Using Embase and Medline (2016-21), we conducted a systematic review of the literature on data standards, registries, and trials to identify variables pertinent to HF. A modified Delphi method was used to reach a consensus on the final set of variables. For each variable, the Working Group developed data definitions and agreed on whether it was mandatory (Level 1) or additional (Level 2). In total, 84 Level 1 and 79 Level 2 variables were selected for nine domains of HF care. These variables were reviewed by an international Reference Group with the Level 1 variables providing the dataset for registration of patients with HF on the EuroHeart IT platform. By means of a structured process and interaction with international stakeholders, harmonized data standards for HF have been developed. In the context of the EuroHeart, this will facilitate quality improvement, international observational research, registry-based randomized trials, and post-marketing surveillance of devices and pharmacotherapies across Europe.
Collapse
Affiliation(s)
- Suleman Aktaa
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,Leeds Institute for Data Analytics, University of Leeds, Leeds, UK.,Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gorav Batra
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - John G F Cleland
- Robertson Centre for Biostatistics and Glasgow Clinical Trials Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow Royal Infirmary, Glasgow & National Heart & Lung Institute, Imperial College London, London, UK
| | - Andrew Coats
- University of Warwick, Coventry, UK.,Heart Failure Association of the European Society of Cardiology
| | - Lars H Lund
- Unit of Cardiology, Department of Medicine, Karolinska Institute, Stockholm, Sweden.,Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Theresa McDonagh
- Department of Cardiology, King's College Hospital London, Denmark Hill, Brixton, London, UK.,School of Cardiovascular Medicine and Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Giuseppe Rosano
- Cardiovascular Clinical Academic Group, St George's Hospitals NHS Trust University of London, London, UK.,IRCCS San Raffaele Pisana, Rome, Italy
| | - Petar Seferovic
- Serbian Academy of Sciences and Arts, Heart Failure Center, Faculty of Medicine, Belgrade University Medical Center, Belgrade, Serbia
| | - Peter Vasko
- Department of Cardiology, University Hospital, Linköping, Sweden.,SWEDEHEART - Swedish Web-system for Enhancement and Development of Evidence-Based Care in Heart disease Evaluated According to Recommended Therapies, Växjö, Sweden.,SwedeHF - Swedish Heart Failure Registry, Växjö, Sweden
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Aldo P Maggioni
- National Association of Hospital Cardiologists Research Center (ANMCO), Florence, Italy
| | - Barbara Casadei
- Division of Cardiovascular Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,Leeds Institute for Data Analytics, University of Leeds, Leeds, UK.,Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | |
Collapse
|
18
|
Rao VU, Bhasin A, Vargas J, Arun Kumar V. A multidisciplinary approach to heart failure care in the hospital: improving the patient journey. Hosp Pract (1995) 2022; 50:170-182. [PMID: 35658810 DOI: 10.1080/21548331.2022.2082776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Despite advancements in care for patients with heart failure (HF), morbidity and mortality remain high. Hospitalizations and readmissions for HF have been the focus of significant attention among health care providers and payers, with an eye towards reducing health care costs. However, considerable variability exists with regard to inpatient workflows and management for patients with HF, which represents a significant opportunity to improve care. Here we provide a summary of optimal inpatient management strategies for HF, focusing on the multidisciplinary team of emergency medicine providers, admitting hospitalists, cardiovascular consultants, pharmacists, nurses, and social workers. The patient journey serves as the template for this review article, from the initial presentation in the emergency department, to decongestion and stabilization, optimization of guideline-directed medical therapy, and discharge and appropriate disposition. Lastly, this review aims not to be proscriptive but rather to provide best practices that are clinically relevant and actionable, with the goal of improving care for patients during the sentinel hospitalization for HF.
Collapse
Affiliation(s)
- Vijay U Rao
- Indiana Heart Physicians,Franciscan Health, Indianapolis, IN, USA
| | - Atul Bhasin
- Department of Internal Medicine, CentraState Medical Center, Freehold, and Hackensack Meridian Health Hospice, Wall, NJ, USA
| | - Jesus Vargas
- University of Pennsylvania Medical Center Harrisburg Hospital, Harrisburg, PA, USA
| | - Vijaya Arun Kumar
- Department of Emergency Medicine, Wayne State University, School of Medicine, Detroit, MI, USA
| |
Collapse
|
19
|
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.
Collapse
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
| | | |
Collapse
|
20
|
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]
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Harrison NE, Meram S, Li X, White MB, Henry S, Gupta S, Zhu D, Pang P, Levy P. Hemodynamic profiles by non-invasive monitoring of cardiac index and vascular tone in acute heart failure patients in the emergency department: External validation and clinical outcomes. PLoS One 2022; 17:e0265895. [PMID: 35358231 PMCID: PMC8970400 DOI: 10.1371/journal.pone.0265895] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 03/09/2022] [Indexed: 11/18/2022] Open
Abstract
Background Non-invasive finger-cuff monitors measuring cardiac index and vascular tone (SVRI) classify emergency department (ED) patients with acute heart failure (AHF) into three otherwise-indistinguishable subgroups. Our goals were to validate these “hemodynamic profiles” in an external cohort and assess their association with clinical outcomes. Methods AHF patients (n = 257) from five EDs were prospectively enrolled in the validation cohort (VC). Cardiac index and SVRI were measured with a ClearSight finger-cuff monitor (formerly NexFin, Edwards Lifesciences) as in a previous study (derivation cohort, DC, n = 127). A control cohort (CC, n = 127) of ED patients with sepsis was drawn from the same study as the DC. K-means cluster analysis previously derived two-dimensional (cardiac index and SVRI) hemodynamic profiles in the DC and CC (k = 3 profiles each). The VC was subgrouped de novo into three analogous profiles by unsupervised K-means consensus clustering. PERMANOVA tested whether VC profiles 1–3 differed from profiles 1–3 in the DC and CC, by multivariate group composition of cardiac index and vascular tone. Profiles in the VC were compared by a primary outcome of 90-day mortality and a 30-day ranked composite secondary outcome (death, mechanical cardiac support, intubation, new/emergent dialysis, coronary intervention/surgery) as time-to-event (survival analysis) and binary events (odds ratio, OR). Descriptive statistics were used to compare profiles by two validated risk scores for the primary outcome, and one validated score for the secondary outcome. Results The VC had median age 60 years (interquartile range {49–67}), and was 45% (n = 116) female. Multivariate profile composition by cardiac index and vascular tone differed significantly between VC profiles 1–3 and CC profiles 1–3 (p = 0.001, R2 = 0.159). A difference was not detected between profiles in the VC vs. the DC (p = 0.59, R2 = 0.016). VC profile 3 had worse 90-day survival than profiles 1 or 2 (HR = 4.8, 95%CI 1.4–17.1). The ranked secondary outcome was more likely in profile 1 (OR = 10.0, 1.2–81.2) and profile 3 (12.8, 1.7–97.9) compared to profile 2. Diabetes prevalence and blood urea nitrogen were lower in the high-risk profile 3 (p<0.05). No significant differences between profiles were observed for other clinical variables or the 3 clinical risk scores. Conclusions Hemodynamic profiles in ED patients with AHF, by non-invasive finger-cuff monitoring of cardiac index and vascular tone, were replicated de novo in an external cohort. Profiles showed significantly different risks of clinically-important adverse patient outcomes.
Collapse
Affiliation(s)
- Nicholas Eric Harrison
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
- * E-mail:
| | - Sarah Meram
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Xiangrui Li
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Morgan B. White
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Sarah Henry
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Sushane Gupta
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Dongxiao Zhu
- Department of Computer Science, Wayne State University College of Engineering, Detroit, Michigan, United States of America
| | - Peter Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Phillip Levy
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| |
Collapse
|
23
|
Yin T, Shi S, Zhu X, Cheang I, Lu X, Gao R, Zhang H, Yao W, Zhou Y, Li X. A Survival Prediction for Acute Heart Failure Patients via Web-Based Dynamic Nomogram with Internal Validation: A Prospective Cohort Study. J Inflamm Res 2022; 15:1953-1967. [PMID: 35342297 PMCID: PMC8947803 DOI: 10.2147/jir.s348139] [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: 11/06/2021] [Accepted: 03/09/2022] [Indexed: 12/12/2022] Open
Abstract
Purpose The current study aimed to develop a convenient and accurate prognostic dynamic nomogram model for the risk of all-cause death in acute heart failure (AHF) patients that incorporates clinical characteristics including N-terminal pro-brain natriuretic peptide (NT-pro BNP) and growth stimulation expresses gene 2 protein (ST2). Patients and Methods We prospectively studied 537 consecutive AHF patients and derived a clinical prediction model. The least absolute shrinkage and selection operator regression model combined with clinical characteristics were used for dimensional reduction and feature selection. Multivariate Cox proportional hazard analysis and “Dynnom” package were used to build the dynamic nomogram for prediction of 1-,2-,and 5-year overall survival for AHF. With bootstrap validation, the time-dependent concordance index (C-index) and calibration curves were used to assess predictive discrimination and accuracy. The contributions of NT-pro BNP and ST2 to the nomogram were evaluated using integrated discrimination improvement (IDI) and net reclassification improvement (NRI), while decision curve analysis (DCA) was used to assess clinical value. Results Patients were randomly divided into derivation (74.9%, n=402) and validation (25.1%, n=135) cohorts. Optimal independent prognostic factors for 1-,2-, and 5-year all-cause mortality were BS-ACMR (B: NT-pro BNP; S: ST2; A: age; C: complete right bundle branch block; M: mean arterial pressure; and R: red cell distribution width >14.5%); these were incorporated into the dynamic nomogram (https://bs-acmr-nom.shinyapps.io/dynnomapp/) with bootstrap validation. The C-indexes in the derivation (0.793) and validation (0.782) cohorts were consistent with comparable performance parameters. The calibration curve showed good agreement between the nomogram-predicted and actual survival. Adding NT-pro BNP and ST2 provided a significant net benefit and improved performance over other less adequate schemes in terms of DCA of survival probability compared to those neglecting either of these two factors. Conclusion The study constructed a dynamic BS-ACMR nomogram, which is a convenient, practical and effective clinical decision-making tool for providing accurate prognosis in AHF patients.
Collapse
Affiliation(s)
- Ting Yin
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, People’s Republic of China
| | - Shi Shi
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, People’s Republic of China
| | - Xu Zhu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, People’s Republic of China
| | - Iokfai Cheang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, People’s Republic of China
| | - Xinyi Lu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, People’s Republic of China
| | - Rongrong Gao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, People’s Republic of China
| | - Haifeng Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, People’s Republic of China
- Department of Cardiology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, 215002, People’s Republic of China
| | - Wenming Yao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, People’s Republic of China
| | - Yanli Zhou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, People’s Republic of China
| | - Xinli Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, People’s Republic of China
- Correspondence: Xinli Li; Yanli Zhou, Tel +86 136 1157 3111; +86 137 7787 9077, Email ;
| |
Collapse
|
24
|
Cho I, Oh J, Kim IC, Chung H, Lee JH, Kim HM, Byun YS, Yoo BS, Choi EY, Chung WJ, Pyun WB, Kang SM. Rivaroxaban Once-Daily vs. Dose-Adjusted Vitamin K Antagonist on Biomarkers in Acute Decompensated Heart Failure and Atrial Fibrillation (ROAD HF-AF): Rationale and Design of an Investigator-Initiated Multicenter Randomized Prospective Open-Labeled Pilot Clinical Study. Front Cardiovasc Med 2022; 8:765081. [PMID: 35096995 PMCID: PMC8790040 DOI: 10.3389/fcvm.2021.765081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 12/06/2021] [Indexed: 12/04/2022] Open
Abstract
Background: Clinical trials of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with chronic heart failure and atrial fibrillation (AF) have demonstrated reduced risks of stroke and bleeding compared with vitamin K antagonists (VKAs). Here, we aim to assess the clinical efficacy and safety of rivaroxaban, a NOAC, compared with warfarin, a VKA, and the effects of rivaroxaban on cardiovascular biomarkers in patients with acute decompensated heart failure (ADHF) with reduced ejection fraction (≤40%) and AF. Methods: Rivaroxaban Once-daily vs. dose-adjusted vitamin K antagonist on biomarkers in Acute Decompensated Heart Failure and Atrial Fibrillation (ROAD HF-AF) is a randomized, open-labeled, controlled, prospective, multicenter pilot study designed to assess cardiovascular biomarkers and the safety of rivaroxaban (20 or 15 mg in patients with creatinine clearance 30-49 mL/min per day) compared with VKA (target international normalized range: 2-3) in 150 patients hospitalized with ADHF and AF. The primary endpoint is the change in circulating high-sensitivity cardiac troponin (hsTn) during hospitalization. The secondary endpoints are bleeding, hospital stay duration, in-hospital mortality, and changes in cardiovascular, renal, and thrombosis biomarkers. Patients will be followed for 180 days. Conclusion: We hypothesize that rivaroxaban will reduce myocardial injury and hemodynamic stress, as reflected by the biomarker status, within 72 h in patients with ADHF and AF, compared with VKA. We hope to facilitate future biomarker-based, large-scale outcome trials using NOACs in patients with ADHF and AF, based on the results of this multicenter, randomized, controlled study.
Collapse
Affiliation(s)
- Iksung Cho
- Cardiology Division, Cardiovascular Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jaewon Oh
- Cardiology Division, Cardiovascular Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - In-Cheol Kim
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Hyemoon Chung
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University, Seoul, South Korea
| | - Jung-Hee Lee
- Division of Cardiology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, South Korea
| | - Hyue Mee Kim
- Division of Cardiology, Department of Internal Medicine, Chung-Ang University, Seoul, South Korea
| | - Young Sup Byun
- Division of Cardiology, Sanggye-Paik Hospital, Inje University, Seoul, South Korea
| | - Byung-Su Yoo
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Eui-Young Choi
- Division of Cardiology, Heart Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Wook-Jin Chung
- Department of Cardiovascular Medicine, Gachon University Gil Medical Center, Incheon, South Korea
| | - Wook Bum Pyun
- Division of Cardiology, Department of Internal Medicine, Ewha Womans University, Seoul, South Korea
| | - Seok-Min Kang
- Cardiology Division, Cardiovascular Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea,*Correspondence: Seok-Min Kang
| |
Collapse
|
25
|
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]
|
26
|
Verdu-Rotellar JM, Abellana R, Vaillant-Roussel H, Gril Jevsek L, Assenova R, Kasuba Lazic D, Torsza P, Glynn LG, Lingner H, Demurtas J, Thulesius H, Muñoz MA. Risk stratification in heart failure decompensation in the community: HEFESTOS score. ESC Heart Fail 2021; 9:606-613. [PMID: 34811953 PMCID: PMC8787964 DOI: 10.1002/ehf2.13707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/01/2021] [Accepted: 10/29/2021] [Indexed: 12/28/2022] Open
Abstract
Aims Because evidence regarding risk stratification predicting prognosis of patients with heart failure (HF) decompensation attended in primary care is lacking, we developed and externally validated a model to forecast death/hospitalization during the first 30 days after an episode of decompensation. The predictive model is based on variables easily obtained in primary care settings. Methods and results HEFESTOS is a multinational study consisting of a derivation cohort of HF patients recruited in 14 primary healthcare centres in Barcelona and a validation cohort from primary healthcare in 9 other European countries. The derivation and validation cohorts included 561 and 250 patients, respectively. Percentages of women in the derivation and validation cohorts were 56.3% and 47.6% (P = 0.026), respectively. Mean age was 82.2 years (SD 8.03) in the derivation cohort, and 79.3 years (SD 10.3) in the validation one (P = 0.001). HF with preserved ejection fraction represented 72.1% in the derivation cohort and 58.8% in the validation one (P = 0.004). Mortality/hospitalization during the first 30 days after a decompensation episode was 30.5% and 26% (P = 0.225) for the derivation and validation cohorts, respectively. Multivariable logistic regression models were performed to develop a score of risk. The identified predictors were worsening of dyspnoea [odds ratio (OR): 2.5; P = 0.001], orthopnoea (OR: 2.16; P = 0.01), paroxysmal nocturnal dyspnoea (OR: 2.25; P = 0.01), crackles (OR: 2.35; P = 0.01), New York Heart Association functional class III/IV (OR: 2.11; P = 0.001), oxygen saturation ≤ 90% (OR: 4.98; P < 0.001), heart rate > 100 b.p.m. (OR: 2.72; P = 0.002), and previous hospitalization due to HF (OR: 2.45; P < 0.001). The model showed an area under the curve (AUC) of 0.807, 95% confidence interval (CI): [0.770; 0.845] in the derivation cohort and AUC 0.73, 95% CI: [0.660; 0.808] in the validation one. No significant differences between both cohorts were observed (P = 0.08). Regarding probability of hospitalization/death, three risk groups were defined: low <5%, medium 5–20%, and high >20%. Outcome incidence was 2.7% for the low‐risk group, 12.8% for medium risk, and 46.2% for high risk in the derivation cohort, and 9.1%, 12.9%, and 39.6% in the validation one. Conclusions The HEFESTOS score, based on variables easily accessible in a community setting and validated in an external European cohort, properly predicted the risk of death/hospitalization during the first 30 days after an HF decompensation episode.
Collapse
Affiliation(s)
- José-María Verdu-Rotellar
- Gerencia Territorial de Barcelona, Institut Català de la Salut, Barcelona, Spain.,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), Barcelona, Spain.,School of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Rosa Abellana
- Departament de Fonaments Clinics, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
| | - Helene Vaillant-Roussel
- Faculty of Medicine, UPU ACCePPT, Department of General Practice, CHU, Direction de La Recherche Clinique et de l'Innovation, Clermont Auvergne University, Clermont-Ferrand, France
| | | | - Radost Assenova
- Department of Urology and General Medicine, Faculty of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Djurdjica Kasuba Lazic
- Department of Family Medicine "Andrija Stampar" School of Public Health, School of Medicine University of Zagreb, Zagreb, Croatia
| | | | - Liam George Glynn
- Health Research Institute and Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Heidrun Lingner
- Hannover Medical School-Center for Public Health and Healthcare, Hannover, Germany
| | - Jacopo Demurtas
- Primary Care Department, Azienda Usl Toscana Sud Est, Grosseto, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Hans Thulesius
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Medicine and Optometry, Linnaeus University, Växjö, Sweden
| | - Miguel Angel Muñoz
- Gerencia Territorial de Barcelona, Institut Català de la Salut, Barcelona, Spain.,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), Barcelona, Spain.,School of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | | |
Collapse
|
27
|
Lombardi CM, Cimino G, Pellicori P, Bonelli A, Inciardi RM, Pagnesi M, Tomasoni D, Ravera A, Adamo M, Carubelli V, Metra M. Congestion in Patients with Advanced Heart Failure: Assessment and Treatment. Heart Fail Clin 2021; 17:575-586. [PMID: 34511206 DOI: 10.1016/j.hfc.2021.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Heart failure (HF) is characterized by frequent hospital admissions due to acute decompensation and shortened life span with a progressive clinical course leading to an advanced stage where traditional therapies become ineffective. Due to aging of the population and improved therapies, only a small of proportion of patients with advanced HF are candidates for surgical treatments, such as mechanical circulatory support or heart transplantation. In most cases, prompt identification and management of congestion is paramount to improving symptoms and quality of life and avoiding progression to severe multiorgan dysfunction and death.
Collapse
Affiliation(s)
- Carlo Mario Lombardi
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Giuliana Cimino
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Pierpaolo Pellicori
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - Andrea Bonelli
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo Maria Inciardi
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Matteo Pagnesi
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Alice Ravera
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Valentina Carubelli
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
| |
Collapse
|
28
|
Scherrenberg M, Storms V, van der Velde AE, Boyne J, Bruins W, Vranken J, Leenen JPL, Brunner-La Rocca HP, De Kluiver EP, Dendale P. A Home Hospitalisation Strategy for Patients with an Acute Episode of Heart Failure Using a Digital Health-Supported Platform: A Multicentre Feasibility Study - A Rationale and Study Design. Cardiology 2021; 146:793-800. [PMID: 34438396 DOI: 10.1159/000519085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 08/04/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Heart failure (HF) is a common cause of hospitalisation and mortality in elderly. The frequent rehospitalisations put a serious burden on patients, health-care budgets, and health-care capacity. Frequent hospital admissions are also associated with a substantial additional hazard for serious complications and reduced quality of life. The NWE-Chance project will explore the feasibility and scalability of providing home hospitalisation supported by a newly developed digital health-supported platform and daily visits of specialised nurses. METHODS/DESIGN Hundred patients with chronic HF will be recruited over a 1-year period. The digital health-supported home hospitalisation strategy will be tested in 3 hospitals with different experience in delivering home hospitalisation: Isala Zwolle, Maastricht UMC+, both in The Netherlands, and Jessa Hospital, Hasselt in Belgium. The home hospitalisation intervention will have a maximal duration of 14 days. Feasibility will be measured with acceptability, satisfaction, and usability questionnaires for patients, nurses, and physicians. Furthermore, safety and costs will be assessed for 30 days after the start of the home hospitalisation intervention. DISCUSSION The NWE-Chance project will be one of the first studies to examine the feasibility of a digital health-supported home hospitalisation platform for HF patients. It has the potential to augment current standard HF care and quality of life of HF patients and to innovate the standard HF care to potentially lower the hospitalisation-related complications, the burden of HF on health-care systems, and to potentially implement more patient-centred care strategies.
Collapse
Affiliation(s)
- Martijn Scherrenberg
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium, .,UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium, .,Mobile Health Unit, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium,
| | - Valerie Storms
- UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium.,Mobile Health Unit, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Josiane Boyne
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Julie Vranken
- UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium.,Mobile Health Unit, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Jobbe P L Leenen
- Isala Heart Centre, Zwolle, The Netherlands.,Connected Care Center, Isala, Zwolle, The Netherlands
| | | | | | - Paul Dendale
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium.,UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium.,Mobile Health Unit, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| |
Collapse
|
29
|
Tersalvi G, Gasperetti A, Schiavone M, Dauw J, Gobbi C, Denora M, Krul JD, Cioffi GM, Mitacchione G, Forleo GB. Acute heart failure in elderly patients: a review of invasive and non-invasive management. J Geriatr Cardiol 2021; 18:560-576. [PMID: 34404992 PMCID: PMC8352772 DOI: 10.11909/j.issn.1671-5411.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Acute heart failure (AHF) is a major cause of unplanned hospitalisations in the elderly and is associated with high mortality. Its prevalence has grown in the last years due to population aging and longer life expectancy of chronic heart failure patients. Although international societies have provided guidelines for the management of AHF in the general population, scientific evidence for geriatric patients is often lacking, as these are underrepresented in clinical trials. Elderly have a different risk profile with more comorbidities, disability, and frailty, leading to increased morbidity, longer recovery time, higher readmission rates, and higher mortality. Furthermore, therapeutic options are often limited, due to unfeasibility of invasive strategies, mechanical circulatory support and cardiac transplantation. Thus, the in-hospital management of AHF should be tailored to each patient's clinical situation, cardiopulmonary condition and geriatric assessment. Palliative care should be considered in some cases, in order to avoid unnecessary diagnostics and/or treatments. After discharge, a strict follow-up through outpatient clinic or telemedicine is can improve quality of life and reduce rehospitalisation rates. The aim of this review is to offer an insight on current literature and provide a clinically oriented, patient-tailored approach regarding assessment, treatment and follow-up of elderly patients admitted for AHF.
Collapse
Affiliation(s)
- Gregorio Tersalvi
- Department of Internal Medicine, Hirslanden Klinik St. Anna, Lucerne, Switzerland
| | - Alessio Gasperetti
- Cardiology Unit, ASST-Fatebenefratelli Sacco, Luigi Sacco University Hospital, Milan, Italy
| | - Marco Schiavone
- Cardiology Unit, ASST-Fatebenefratelli Sacco, Luigi Sacco University Hospital, Milan, Italy
| | - Jeroen Dauw
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Cecilia Gobbi
- Institut Cardiovasculaire de Caen, Hôpital Privé Saint Martin, Caen, France
| | - Marialessia Denora
- Cardiology Unit, ASST-Fatebenefratelli Sacco, Luigi Sacco University Hospital, Milan, Italy
| | - Joel Daniel Krul
- Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Giacomo Maria Cioffi
- Division of Cardiology, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Gianfranco Mitacchione
- Cardiology Unit, ASST-Fatebenefratelli Sacco, Luigi Sacco University Hospital, Milan, Italy
| | - Giovanni B. Forleo
- Cardiology Unit, ASST-Fatebenefratelli Sacco, Luigi Sacco University Hospital, Milan, Italy
| |
Collapse
|
30
|
Hwang IC, Cho GY, Choi HM, Yoon YE, Park JJ, Park JB, Park JH, Lee SP, Kim HK, Kim YJ, Sohn DW. Derivation and validation of a mortality risk prediction model using global longitudinal strain in patients with acute heart failure. Eur Heart J Cardiovasc Imaging 2021; 21:1412-1420. [PMID: 31819981 DOI: 10.1093/ehjci/jez300] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 09/30/2019] [Accepted: 11/18/2019] [Indexed: 02/06/2023] Open
Abstract
AIMS To develop a mortality risk prediction model in patients with acute heart failure (AHF), using left ventricular (LV) function parameters with clinical factors. METHODS AND RESULTS In total, 4312 patients admitted for AHF were retrospectively identified from three tertiary centres, and echocardiographic parameters including LV ejection fraction (LV-EF) and LV global longitudinal strain (LV-GLS) were measured in a core laboratory. The full set of risk factors was available in 3248 patients. Using Cox proportional hazards model, we developed a mortality risk prediction model in 1859 patients from two centres (derivation cohort) and validated the model in 1389 patients from one centre (validation cohort). During 32 (interquartile range 13-54) months of follow-up, 1285 patients (39.6%) died. Significant predictors for mortality were age, diabetes, diastolic blood pressure, body mass index, natriuretic peptide, glomerular filtration rate, failure to prescribe beta-blockers, failure to prescribe renin-angiotensin system blockers, and LV-GLS; however, LV-EF was not a significant predictor. Final model including these predictors to estimate individual probabilities of mortality had C-statistics of 0.75 [95% confidence interval (CI) 0.73-0.78; P < 0.001] in the derivation cohort and 0.78 (95% CI 0.75-0.80; P < 0.001) in the validation cohort. The prediction model had good performance in both heart failure (HF) with reduced EF, HF with mid-range EF, and HF with preserved EF. CONCLUSION We developed a mortality risk prediction model for patients with AHF incorporating LV-GLS as the LV function parameter, and other clinical factors. Our model provides an accurate prediction of mortality and may provide reliable risk stratification in AHF patients.
Collapse
Affiliation(s)
- In-Chang Hwang
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, 82 Gumi-ro-173-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongro-gu, Seoul, 03080, South Korea
| | - Goo-Yeong Cho
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, 82 Gumi-ro-173-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongro-gu, Seoul, 03080, South Korea
| | - Hong-Mi Choi
- Division of Cardiology, Hallym Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang-si, Gyeonggi-do, 14068, South Korea
| | - Yeonyee E Yoon
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, 82 Gumi-ro-173-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongro-gu, Seoul, 03080, South Korea
| | - Jin Joo Park
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, 82 Gumi-ro-173-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongro-gu, Seoul, 03080, South Korea
| | - Jun-Bean Park
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongro-gu, Seoul, 03080, South Korea
- Cardiovascular Center and Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, South Korea
| | - Jae-Hyeong Park
- Department of Cardiology, Internal Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu Daejeon, 35015, South Korea
| | - Seung-Pyo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongro-gu, Seoul, 03080, South Korea
- Cardiovascular Center and Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, South Korea
| | - Hyung-Kwan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongro-gu, Seoul, 03080, South Korea
- Cardiovascular Center and Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, South Korea
| | - Yong-Jin Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongro-gu, Seoul, 03080, South Korea
- Cardiovascular Center and Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, South Korea
| | - Dae-Won Sohn
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongro-gu, Seoul, 03080, South Korea
- Cardiovascular Center and Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, South Korea
| |
Collapse
|
31
|
Kadoglou NPE, Parissis J, Karavidas A, Kanonidis I, Trivella M. Assessment of acute heart failure prognosis: the promising role of prognostic models and biomarkers. Heart Fail Rev 2021; 27:655-663. [PMID: 34036472 DOI: 10.1007/s10741-021-10122-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2021] [Indexed: 12/30/2022]
Abstract
Numerous models and biomarkers have been proposed to estimate prognosis and improve decision-making in patients with acute heart failure (AHF). The present literature review provides a critical appraisal of externally validated prognostic models in AHF, combining clinical data and biomarkers. We perform a literature review of clinical studies, using the following terms: "acute heart failure," "acute decompensated heart failure," "prognostic models," "risk scores," "mortality," "death," "hospitalization," "admission," and "biomarkers." We searched MEDLINE and EMBASE databases from 1990 to 2020 for studies documenting prognostic models in AHF. External validation of each prognostic model to another AHF cohort, containing at least one biomarker, was prerequisites for study selection. Among 358 initially screened studies, 9 of them fulfilled all searching criteria. The majority of prognostic models were simplified, including a narrow number of variables (up to 10), with good performance regarding calibration and discrimination (c-statistics > 0.65). Unfortunately, the derived and validated cohorts showed a wide variety in patients' characteristics (e.g., cause of AHF and therapy). Moreover, the prognostic models used various time-points and a plethora of combinations of variables determining different cut-off values. Although the application of valid prognostic models in AHF population is quite promising, a precise methodological approach should be set for the derivation and validation of prognostic models in AHF with unified characteristics to establish an effective performance in clinical practice.
Collapse
Affiliation(s)
- Nikolaos P E Kadoglou
- Medical School, University of Cyprus, 215/6 Old road Lefkosias-Lemesou, 2029, Aglantzia, Nicosia, Cyprus.
- Centre for Statistics in Medicine, NDORMS, University of Oxford, Oxford, UK.
| | - John Parissis
- 2nd Department of Cardiology, Attikon" University Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | | | - Ioannis Kanonidis
- Second Cardiology Department, "Hippokration" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Marialena Trivella
- Centre for Statistics in Medicine, NDORMS, University of Oxford, Oxford, UK
| |
Collapse
|
32
|
Sax DR, Rana JS, Mark DG, Huang J, Collins SP, Liu D, Storrow AB, Reed ME. Outcomes among acute heart failure emergency department patients by preserved vs. reduced ejection fraction. ESC Heart Fail 2021; 8:2889-2898. [PMID: 33978311 PMCID: PMC8318513 DOI: 10.1002/ehf2.13364] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/05/2021] [Accepted: 03/29/2021] [Indexed: 12/14/2022] Open
Abstract
Aims This study aimed to assess short‐term outcomes among emergency department (ED) patients with acute heart failure (AHF) by preserved (≥50%) vs. reduced (<50%) ejection fraction (EF). Methods and results We conducted a retrospective, multicentre study of adult ED patients with AHF from 2017 to 2018 in an integrated healthcare system with 21 hospitals. Among patients with known EF, our primary outcome was 30 day all‐cause mortality, comparing patients with heart failure with preserved EF (HFpEF) and heart failure with reduced EF (HFrEF), adjusted for known risk factors. We ran separate multivariate regression models to compare 30 day mortality between HFpEF and HFrEF patients stratified by ED disposition (admit, observe, and discharge). Our secondary outcomes were adjusted 30 day all‐cause return hospital admission and rates of non‐fatal serious adverse events, including new intra‐aorta balloon pump, endotracheal intubation, renal failure requiring dialysis, myocardial infarction, or coronary revascularization. We conducted a sensitivity analysis among patients with EF ≤ 40% and compared our primary and secondary outcomes among patients with EF ≤ 40% with those with EF ≥ 50%. Among the 26 050 total ED encounters for AHF, 15 275 (58.6%) had known EF and 62.4% had HFpEF. The mean age was 76, 49.6% were women, and 60.5% were white. We found that 62.4% of patients were admitted, 18.3% were observed, and 19.3% were discharged from the ED. The 30 day all‐cause mortality rate was lowest among discharged patients (3.9%), intermediate among observed patients (5.9%), and highest among admitted patients (13.9%). Overall, the adjusted 30 day mortality rate was significantly higher among HFpEF patients compared with HFrEF patients (10.2% vs. 8.4%, P = 0.0004). HFpEF patients had higher mortality regardless of ED disposition, although the difference was only significant among admitted patients. The adjusted 30 day return hospital admission rates were not significantly different between HFpEF and HFrEF patients (17.9% vs. 17.8%, P = 0.89). The adjusted 30 day non‐fatal serious adverse event rates were significantly higher among HFrEF patients compared with HFpEF patients (13.7% vs. 11.1%, P < 0.0001), driven by myocardial infarction and coronary revascularization. We found that 3692 patients had EF ≤ 40%. Patients with EF ≥ 50% had significantly higher adjusted 30 day mortality rates compared with those with EF ≤ 40% (10.2% vs. 8.4%, P < 0.05). Conclusion In a contemporary population, almost three quarters of ED patients with AHF and known EF have HFpEF. These patients have higher 30 day adjusted mortality compared with those with HFrEF. Further studies might evaluate the underlying factors associated with this difference and target interventions to improve outcomes.
Collapse
Affiliation(s)
- Dana R Sax
- Department of Emergency Medicine, The Permanente Medical Group, 3600 Broadway, Oakland, CA, 94611, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Jamal S Rana
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.,Department of Cardiology, The Permanente Medical Group, Oakland, CA, USA
| | - Dustin G Mark
- Department of Emergency Medicine, The Permanente Medical Group, 3600 Broadway, Oakland, CA, 94611, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Jie Huang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | | |
Collapse
|
33
|
Miró Ò, Rossello X, Platz E, Masip J, Gualandro DM, Peacock WF, Price S, Cullen L, DiSomma S, de Oliveira MT, McMurray JJ, Martín-Sánchez FJ, Maisel AS, Vrints C, Cowie MR, Bueno H, Mebazaa A, Mueller C. Risk stratification scores for patients with acute heart failure in the Emergency Department: A systematic review. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 9:375-398. [PMID: 33191763 DOI: 10.1177/2048872620930889] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIMS This study aimed to systematically identify and summarise all risk scores evaluated in the emergency department setting to stratify acute heart failure patients. METHODS AND RESULTS A systematic review of PubMed and Web of Science was conducted including all multicentre studies reporting the use of risk predictive models in emergency department acute heart failure patients. Exclusion criteria were: (a) non-original articles; (b) prognostic models without predictive purposes; and (c) risk models without consecutive patient inclusion or exclusively tested in patients admitted to a hospital ward. We identified 28 studies reporting findings on 19 scores: 13 were originally derived in the emergency department (eight exclusively using acute heart failure patients), and six in emergency department and hospitalised patients. The outcome most frequently predicted was 30-day mortality. The performance of the scores tended to be higher for outcomes occurring closer to the index acute heart failure event. The eight scores developed using acute heart failure patients only in the emergency department contained between 4-13 predictors (age, oxygen saturation and creatinine/urea included in six scores). Five scores (Emergency Heart Failure Mortality Risk Grade, Emergency Heart Failure Mortality Risk Grade 30 Day mortality ST depression, Epidemiology of Acute Heart Failure in Emergency department 3 Day, Acute Heart Failure Risk Score, and Multiple Estimation of risk based on Emergency department Spanish Score In patients with Acute Heart Failure) have been externally validated in the same country, and two (Emergency Heart Failure Mortality Risk Grade and Multiple Estimation of risk based on Emergency department Spanish Score In patients with Acute Heart Failure) further internationally validated. The c-statistic for Emergency Heart Failure Mortality Risk Grade to predict seven-day mortality was between 0.74-0.81 and for Multiple Estimation of risk based on Emergency department Spanish Score In patients with Acute Heart Failure to predict 30-day mortality was 0.80-0.84. CONCLUSIONS There are several scales for risk stratification of emergency department acute heart failure patients. Two of them are accurate, have been adequately validated and may be useful in clinical decision-making in the emergency department i.e. about whether to admit or discharge.
Collapse
Affiliation(s)
- Òscar Miró
- Emergency Department, University of Barcelona, Spain
| | - Xavier Rossello
- Cardiology Department, Hospital Universitari Son Espases, Spain.,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain.,Grupo de Fisiopatologia y Terapeutica Cardiovascular, Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
| | - Elke Platz
- Department of Emergency Medicine, Brigham and Women's Hospital and Harvard Medical School, USA
| | - Josep Masip
- Intensive Care Department, University of Barcelona, Spain.,Cardiology Department, Hospital Sanitas CIMA, Spain
| | - Danielle M Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Heart Institute (INCOR), University of Sao Paulo Medical School, Brazil
| | - W Frank Peacock
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, USA
| | - Susanna Price
- Royal Brompton and Harefield NHS Foundation Trust, Imperial College, UK
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Australia
| | - Salvatore DiSomma
- Royal Brompton and Harefield NHS Foundation Trust, Imperial College, UK
| | | | - John Jv McMurray
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Australia
| | - Francisco J Martín-Sánchez
- Department of Emergency Medicine, Hospital Clínico San Carlos, Spain.,Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Universidad Complutense de Madrid, Spain
| | - Alan S Maisel
- Coronary Care Unit and Heart Failure Program, Veteran Affairs (VA) San Diego, USA
| | | | - Martin R Cowie
- Royal Brompton and Harefield NHS Foundation Trust, Imperial College, UK
| | - Héctor Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain.,Department of Cardiology and Cardiovascular Research Area, Universidad Complutense de Madrid, Spain
| | - Alexandre Mebazaa
- University Paris Diderot, France.,APHP Hôpitaux Universitaires Saint Louis Lariboisière, France
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | | |
Collapse
|
34
|
Platz E, Jhund PS. Risk stratification in patients presenting with acute heart failure. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:113-115. [PMID: 33783504 DOI: 10.1093/ehjacc/zuab005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 01/26/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Elke Platz
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, 360 Longwood Ave., 7th Floor, Boston, MA 02115, USA
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| |
Collapse
|
35
|
Harrison N, Pang P, Collins S, Levy P. Blood Pressure Reduction in Hypertensive Acute Heart Failure. Curr Hypertens Rep 2021; 23:11. [PMID: 33611627 DOI: 10.1007/s11906-021-01127-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW To review the key clinical and research questions regarding blood pressure (BP) reduction with vasodilators in the early management of hypertensive acute heart failure (H-AHF). RECENT FINDINGS Despite numerous AHF vasodilator clinical trials in the past two decades, virtually none has studied a population where vasoconstriction is the predominant physiology, and with the agents and doses most commonly used in contemporary practice. AHF patients are remarkably heterogenous by vascular tone, and this heterogeneity is not always discernible through BP or clinical exam. Emerging data suggest that diastolic BP may be a stronger correlate of vascular tone in AHF than systolic BP, despite the latter historically serving as a key inclusion criterion for vasodilator clinical trials. Existing data are limited. A clinical trial that evaluates vasodilators in a manner of use consistent with contemporary practice, specifically within the subpopulation of patients with true H-AHF, is greatly needed. Until then, observational data supports long-standing vasodilators such as nitroglycerin, administered by IV bolus, and with goal reduction of SBP ≤25% as a safe first-line approach for patients with severe H-AHF presentations.
Collapse
Affiliation(s)
| | - Peter Pang
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sean Collins
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Phillip Levy
- Wayne State University School of Medicine, Detroit, MI, USA
| |
Collapse
|
36
|
Collins SP, Liu D, Jenkins CA, Storrow AB, Levy PD, Pang PS, Chang AM, Char D, Diercks DJ, Fermann GJ, Han JH, Hiestand B, Hogan C, Kampe CJ, Khan Y, Lee S, Lindenfeld J, Martindale J, McNaughton CD, Miller KF, Miller-Reilly C, Moser K, Peacock WF, Robichaux C, Rothman R, Schrock J, Self WH, Singer AJ, Sterling SA, Ward MJ, Walsh C, Butler J. Effect of a Self-care Intervention on 90-Day Outcomes in Patients With Acute Heart Failure Discharged From the Emergency Department: A Randomized Clinical Trial. JAMA Cardiol 2021; 6:200-208. [PMID: 33206126 DOI: 10.1001/jamacardio.2020.5763] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Up to 20% of patients who present to the emergency department (ED) with acute heart failure (AHF) are discharged without hospitalization. Compared with rates in hospitalized patients, readmission and mortality are worse for ED patients. Objective To assess the impact of a self-care intervention on 90-day outcomes in patients with AHF who are discharged from the ED. Design, Setting, and Participants Get With the Guidelines in Emergency Department Patients With Heart Failure was an unblinded, parallel-group, multicenter randomized trial. Patients were randomized 1:1 to usual care vs a tailored self-care intervention. Patients with AHF discharged after ED-based management at 15 geographically diverse EDs were included. The trial was conducted from October 28, 2015, to September 5, 2019. Interventions Home visit within 7 days of discharge and twice-monthly telephone-based self-care coaching for 3 months. Main Outcomes and Measures The primary outcome was a global rank of cardiovascular death, HF-related events (unscheduled clinic visit due to HF, ED revisit, or hospitalization), and changes in the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) summary score (SS) at 90 days. Key secondary outcomes included the global rank outcome at 30 days and changes in the KCCQ-12 SS score at 30 and 90 days. Intention-to-treat analysis was performed for the primary, secondary, and safety outcomes. Per-protocol analysis was conducted including patients who completed a home visit and had scheduled outpatient follow-up in the intervention arm. Results Owing to slow enrollment, 479 of a planned 700 patients were randomized: 235 to the intervention arm and 244 to the usual care arm. The median age was 63.0 years (interquartile range, 54.7-70.2), 302 patients (63%) were African American, 305 patients (64%) were men, and 178 patients (37%) had a previous ejection fraction greater than 50%. There was no significant difference in the primary outcome between patients in the intervention vs usual care arm (hazard ratio [HR], 0.89; 95% CI, 0.73-1.10; P = .28). At day 30, patients in the intervention arm had significantly better global rank (HR, 0.80; 95% CI, 0.64-0.99; P = .04) and a 5.5-point higher KCCQ-12 SS (95% CI, 1.3-9.7; P = .01), while at day 90, the KCCQ-12 SS was 2.7 points higher (95% CI, -1.9 to 7.2; P = .25). Conclusions and Relevance The self-care intervention did not improve the primary global rank outcome at 90 days in this trial. However, benefit was observed in the global rank and KCCQ-12 SS at 30 days, suggesting that an early benefit of a tailored self-care program initiated at an ED visit for AHF was not sustained through 90 days. Trial Registration ClinicalTrials.gov Identifier: NCT02519283.
Collapse
Affiliation(s)
- Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dandan Liu
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cathy A Jenkins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Phillip D Levy
- Department of Emergency Medicine, Detroit Medical Center, Detroit, Michigan
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University Medical Center, Indianapolis
| | - Anna Marie Chang
- Department of Emergency Medicine, Thomas Jefferson University Medical Center, Philadelphia, Pennsylvania
| | - Douglas Char
- Department of Emergency Medicine, Washington University Medical Center in St Louis, St Louis, Missouri
| | - Deborah J Diercks
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Gregory J Fermann
- Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brian Hiestand
- Department of Emergency Medicine, Wake Forest University Medical Center, Winston-Salem, North Carolina
| | - Christopher Hogan
- Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Christina J Kampe
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yosef Khan
- Department of Emergency Medicine, American Heart Association
| | - Sangil Lee
- Department of Emergency Medicine, University of Iowa Medical Center, Iowa City
| | - JoAnn Lindenfeld
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jennifer Martindale
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Candace D McNaughton
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Kelly Moser
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Russell Rothman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jon Schrock
- Department of Emergency Medicine, Metro Health Medical Center, Cleveland, Ohio
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adam J Singer
- Department of Emergency Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Sarah A Sterling
- Department of Medicine, University of Mississippi Medical Center, Jackson
| | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson
| |
Collapse
|
37
|
Sax DR, Mark DG, Huang J, Sofrygin O, Rana JS, Collins SP, Storrow AB, Liu D, Reed ME. Use of Machine Learning to Develop a Risk-Stratification Tool for Emergency Department Patients With Acute Heart Failure. Ann Emerg Med 2020; 77:237-248. [PMID: 33349492 DOI: 10.1016/j.annemergmed.2020.09.436] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 08/18/2020] [Accepted: 09/14/2020] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE We use variables from a recently derived acute heart failure risk-stratification rule (STRATIFY) as a basis to develop and optimize risk prediction using additional patient clinical data from electronic health records and machine-learning models. METHODS Using a retrospective cohort design, we identified all emergency department (ED) visits for acute heart failure between January 1, 2017, and December 31, 2018, among adult health plan members of a large system with 21 EDs. The primary outcome was any 30-day serious adverse event, including death, cardiopulmonary resuscitation, balloon-pump insertion, intubation, new dialysis, myocardial infarction, or coronary revascularization. Starting with the 13 variables from the STRATIFY rule (base model), we tested whether predictive accuracy in a different population could be enhanced with additional electronic health record-based variables or machine-learning approaches (compared with logistic regression). We calculated our derived model area under the curve (AUC), calculated test characteristics, and assessed admission rates across risk categories. RESULTS Among 26,189 total ED encounters, mean patient age was 74 years, 51.7% were women, and 60.7% were white. The overall 30-day serious adverse event rate was 18.8%. The base model had an AUC of 0.76 (95% confidence interval 0.74 to 0.77). Incorporating additional variables led to improved accuracy with logistic regression (AUC 0.80; 95% confidence interval 0.79 to 0.82) and machine learning (AUC 0.85; 95% confidence interval 0.83 to 0.86). We found that 11.1%, 25.7%, and 48.9% of the study population had predicted serious adverse event risk of less than or equal to 3%, less than or equal to 5%, and less than or equal to 10%, respectively, and 28% of those with less than or equal to 3% risk were admitted. CONCLUSION Use of a machine-learning model with additional variables improved 30-day risk prediction compared with conventional approaches.
Collapse
Affiliation(s)
- Dana R Sax
- Department of Emergency Medicine, The Permanente Medical Group, Oakland, CA.
| | - Dustin G Mark
- Department of Emergency Medicine, The Permanente Medical Group, Oakland, CA
| | - Jie Huang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Oleg Sofrygin
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Jamal S Rana
- Department of Cardiology, The Permanente Medical Group, Oakland, CA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| |
Collapse
|
38
|
Balderston JR, Sternberg ME, Joyce JM, Evans DP, Gertz ZM. Focused Cardiac Ultrasound in Dyspnea of Unclear Etiology in the Emergency Department: Utility of the FLUID Score. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:2211-2217. [PMID: 32395861 DOI: 10.1002/jum.15332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 04/14/2020] [Accepted: 04/20/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES We evaluated the utility of focused cardiac ultrasound to predict the length of stay in patients presenting to the emergency department with dyspnea of unclear etiology. METHODS Patients with focused cardiac ultrasound examinations performed in the emergency department for dyspnea over a 34-month period were retrospectively identified. Patients were excluded if they had a prior diagnosis of heart failure, dialysis requirement, or an etiology of dyspnea unrelated to the volume status. Left ventricular function was categorized as normal or reduced, and the inferior vena cava was categorized as normal or increased volume. A fast limited ultrasound to investigate dyspnea (FLUID) score was calculated by adding 1 point for reduced left ventricular function and 1 point for increased volume, producing a score of 0, 1, or 2. RESULTS There were 123 patients included. There was a significant correlation between the FLUID score and length of stay, with longer stays for higher scores (FLUID score 0, 7.4 hours median; FLUID score 1, 2.34 days; FLUID score 2, 5.56 days; analysis of variance P < .001). Of the other variables collected, only age, hypertension, diabetes, heart rate, and brain natriuretic peptide were significantly correlated with the length of stay. A multivariate analysis including those variables and the FLUID score showed that the FLUID score was the strongest independent predictor of the length of stay. CONCLUSIONS Focused cardiac ultrasound and calculation of a FLUID score for patients with undifferentiated dyspnea can be a powerful tool to predict the hospital length of stay.
Collapse
Affiliation(s)
- Jessica R Balderston
- Departments of Emergency Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Michael E Sternberg
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - J Michael Joyce
- Departments of Emergency Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - David P Evans
- Departments of Emergency Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Zachary M Gertz
- Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia, USA
| |
Collapse
|
39
|
Shiraishi Y, Kohsaka S, Abe T, Nagai T, Goda A, Nishihata Y, Nagatomo Y, Saji M, Toyosaki Y, Takei M, Kitai T, Kohno T, Fukuda K, Matsue Y, Anzai T, Yoshikawa T. Derivation and Validation of Clinical Prediction Models for Rapid Risk Stratification for Time-Sensitive Management for Acute Heart Failure. J Clin Med 2020; 9:jcm9113394. [PMID: 33113911 PMCID: PMC7690673 DOI: 10.3390/jcm9113394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/14/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023] Open
Abstract
Early and rapid risk stratification of patients with acute heart failure (AHF) is crucial for appropriate patient triage and outcome improvements. We aimed to develop an easy-to-use, in-hospital mortality risk prediction tool based on data collected from AHF patients at their initial presentation. Consecutive patients’ data pertaining to 2006–2017 were extracted from the West Tokyo Heart Failure (WET-HF) and National Cerebral and Cardiovascular Center Acute Decompensated Heart Failure (NaDEF) registries (n = 4351). Risk model development involved stepwise logistic regression analysis and prospective validation using data pertaining to 2014–2015 in the Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure Syndrome (REALITY-AHF) (n = 1682). The final model included data describing six in-hospital mortality risk predictors, namely, age, systolic blood pressure, blood urea nitrogen, serum sodium, albumin, and natriuretic peptide (SOB-ASAP score), available at the time of initial triage. The model showed excellent discrimination (c-statistic = 0.82) and good agreement between predicted and observed mortality rates. The model enabled the stratification of the mortality rates across sixths (from 14.5% to <1%). When assigned a point for each associated factor, the integer score’s discrimination was similar (c-statistic = 0.82) with good calibration across the patients with various risk profiles. The models’ performance was retained in the independent validation dataset. Promptly determining in-hospital mortality risks is achievable in the first few hours of presentation; they correlate strongly with mortality among AHF patients, potentially facilitating clinical decision-making.
Collapse
Affiliation(s)
- Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (Y.S.); (K.F.)
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (Y.S.); (K.F.)
- Correspondence: ; Tel.: +81-3-3353-1211; Fax: +81-3-5843-6167
| | - Takayuki Abe
- Biostatistics, Clinical and Translational Research Center, Keio University School of Medicine, Tokyo 160-8582, Japan;
- School of Data Science, Yokohama City University, Yokohama 236-0027, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka 565-8565, Japan; (T.N.); (T.A.)
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University, Sapporo 060-8638, Japan
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Tokyo 181-8611, Japan; (A.G.); (T.K.)
| | - Yosuke Nishihata
- Department of Cardiology, St. Luke’s International Hospital, Tokyo 104-8560, Japan;
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College Hospital, Tokorozawa 359-8513, Japan;
| | - Mike Saji
- Department of Cardiology, Sakakibara Heart Institute, Tokyo 183-0003, Japan; (M.S.); (T.Y.)
| | - Yuichi Toyosaki
- Department of Cardiology, Saitama Medical University International Medical Center, Saitama 350-1298, Japan;
| | - Makoto Takei
- Department of Cardiology, Tokyo Saiseikai Central Hospital, Tokyo 108-0073, Japan;
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe 650-0047, Japan;
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Tokyo 181-8611, Japan; (A.G.); (T.K.)
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (Y.S.); (K.F.)
| | - Yuya Matsue
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan;
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka 565-8565, Japan; (T.N.); (T.A.)
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University, Sapporo 060-8638, Japan
| | - Tsutomu Yoshikawa
- Department of Cardiology, Sakakibara Heart Institute, Tokyo 183-0003, Japan; (M.S.); (T.Y.)
| |
Collapse
|
40
|
Rossello X, Bueno H, Gil V, Jacob J, Javier Martín-Sánchez F, Llorens P, Herrero Puente P, Alquézar-Arbé A, Raposeiras-Roubín S, López-Díez MP, Pocock S, Miró Ò. MEESSI-AHF risk score performance to predict multiple post-index event and post-discharge short-term outcomes. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 10:142-152. [PMID: 33609116 DOI: 10.1177/2048872620934318] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 05/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The multiple estimation of risk based on the emergency department Spanish score in patients with acute heart failure (MEESSI-AHF) is a risk score designed to predict 30-day mortality in acute heart failure patients admitted to the emergency department. Using a derivation cohort, we evaluated the performance of the MEESSI-AHF risk score to predict 11 different short-term outcomes. METHODS Patients with acute heart failure from 41 Spanish emergency departments (n=7755) were recruited consecutively in two time periods (2014 and 2016). Logistic regression models based on the MEESSI-AHF risk score were used to obtain c-statistics for 11 outcomes: three with follow-up from emergency department admission (inhospital, 7-day and 30-day mortality) and eight with follow-up from discharge (7-day mortality, emergency department revisit and their combination; and 30-day mortality, hospital admission, emergency department revisit and their two combinations with mortality). RESULTS The MEESSI-AHF risk score strongly predicted mortality outcomes with follow-up starting at emergency department admission (c-statistic 0.83 for 30-day mortality; 0.82 for inhospital death, P=0.121; and 0.85 for 7-day mortality, P=0.001). Overall, mortality outcomes with follow-up starting at hospital discharge predicted slightly less well (c-statistic 0.80 for 7-day mortality, P=0.011; and 0.75 for 30-day mortality, P<0.001). In contrast, the MEESSI-AHF score predicted poorly outcomes involving emergency department revisit or hospital admission alone or combined with mortality (c-statistics 0.54 to 0.62). CONCLUSIONS The MEESSI-AHF risk score strongly predicts mortality outcomes in acute heart failure patients admitted to the emergency department, but the model performs poorly for outcomes involving hospital admission or emergency department revisit. There is a need to optimise this risk score to predict non-fatal events more effectively.
Collapse
Affiliation(s)
- Xavier Rossello
- Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Spain.,Translational Laboratory for Cardiovascular Imaging and Therapy, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain
| | - Héctor Bueno
- Translational Laboratory for Cardiovascular Imaging and Therapy, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain.,Instituto de Investigación i+12 and Cardiology Department, Hospital Universitario 12 de Octubre, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - Víctor Gil
- Emergency Department, Hospital Clínic i Provincial de Barcelona, University of Barcelona, Spain
| | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, Spain
| | - Francisco Javier Martín-Sánchez
- Translational Laboratory for Cardiovascular Imaging and Therapy, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain.,Emergency Department, Hospital Clínico San Carlos, Spain.,Instituto de Investigación Sanitaria San Carlos (IdISSC), Universidad Complutense de Madrid, Spain
| | - Pere Llorens
- Emergency Department, Hospital General de Alicante, Spain
| | | | | | - Sergio Raposeiras-Roubín
- Translational Laboratory for Cardiovascular Imaging and Therapy, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain.,Department of Cardiology, University Hospital Álvaro Cunqueiro, Spain
| | | | - Stuart Pocock
- Translational Laboratory for Cardiovascular Imaging and Therapy, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain.,Department of Medical Statistics, London School of Hygiene and Tropical Medicine, UK
| | - Òscar Miró
- Emergency Department, Hospital Clínic i Provincial de Barcelona, University of Barcelona, Spain
| |
Collapse
|
41
|
Harjola V, Parissis J, Bauersachs J, Brunner‐La Rocca H, Bueno H, Čelutkienė J, Chioncel O, Coats AJ, Collins SP, Boer RA, Filippatos G, Gayat E, Hill L, Laine M, Lassus J, Lommi J, Masip J, Mebazaa A, Metra M, Miró Ò, Mortara A, Mueller C, Mullens W, Peacock WF, Pentikäinen M, Piepoli MF, Polyzogopoulou E, Rudiger A, Ruschitzka F, Seferovic P, Sionis A, Teerlink JR, Thum T, Varpula M, Weinstein JM, Yilmaz MB. Acute coronary syndromes and acute heart failure: a diagnostic dilemma and high‐risk combination. A statement from the Acute Heart Failure Committee of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2020; 22:1298-1314. [DOI: 10.1002/ejhf.1831] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 04/04/2020] [Accepted: 04/06/2020] [Indexed: 12/17/2022] Open
Affiliation(s)
- Veli‐Pekka Harjola
- Emergency Medicine University of Helsinki, Department of Emergency Medicine and Services, Helsinki University Hospital Helsinki Finland
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology Medical School Hannover Hannover Germany
| | | | - Hector Bueno
- Centro Nacional de Investigaciones Cardiovasculares Madrid Spain
- Cardiology Department Hospital Universitario 12 de Octubre Madrid Spain
- Universidad Complutense de Madrid Madrid Spain
| | - Jelena Čelutkienė
- Institute of Clinical Medicine, Clinic of Cardiac and Vascular Diseases, Faculty of Medicine Vilnius University Vilnius Lithuania
| | - Ovidiu Chioncel
- University of Medicine Carol Davila/Institute of Emergency for Cardiovascular Disease Bucharest Romania
| | | | - Sean P. Collins
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN USA
| | - Rudolf A. Boer
- Department of Cardiology University of Groningen, University Medical Center Groningen Groningen The Netherlands
| | | | - Etienne Gayat
- Département d'Anesthésie – Réanimation – SMUR Hôpitaux Universitaires Saint Louis – Lariboisière, INSERM – UMR 942, Assistance Publique – Hôpitaux de Paris, Université Paris Diderot Paris France
| | - Loreena Hill
- School of Nursing and Midwifery Queen's University Belfast UK
| | - Mika Laine
- Cardiology, Heart and Lung Center University of Helsinki, Helsinki University Hospital Helsinki Finland
| | - Johan Lassus
- Cardiology, Heart and Lung Center University of Helsinki, Helsinki University Hospital Helsinki Finland
| | - Jyri Lommi
- Cardiology, Heart and Lung Center University of Helsinki, Helsinki University Hospital Helsinki Finland
| | - Josep Masip
- Consorci Sanitari Integral University of Barcelona Barcelona Spain
- Hospital Sanitas CIMA Barcelona Spain
| | - Alexandre Mebazaa
- Département d'Anesthésie – Réanimation – SMUR Hôpitaux Universitaires Saint Louis – Lariboisière, INSERM – UMR 942, Assistance Publique – Hôpitaux de Paris, Université Paris Diderot Paris France
- U942 Inserm, AP‐HP Paris France
- Investigation Network Initiative Cardiovascular and Renal Clinical Trialists (INI‐CRCT) Nancy France
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health University of Brescia Brescia Italy
| | - Òscar Miró
- Emergency Department Hospital Clínic, University of Barcelona Catalonia Spain
| | - Andrea Mortara
- Department of Cardiology Policlinico di Monza Monza Italy
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University of Basel, University Hospital Basel Basel Switzerland
| | - Wilfried Mullens
- Department of Cardiology Ziekenhuis Oost Limburg, Genk – Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University Diepenbeek Belgium
| | - W. Frank Peacock
- Henry JN Taub Department of Emergency Medicine Baylor College of Medicine Houston TX USA
| | - Markku Pentikäinen
- Cardiology, Heart and Lung Center University of Helsinki, Helsinki University Hospital Helsinki Finland
| | | | | | - Alain Rudiger
- Cardio‐Surgical Intensive Care Unit University and University Hospital Zurich Zurich Switzerland
| | - Frank Ruschitzka
- University Heart Center University Hospital Zurich Zurich Switzerland
| | - Petar Seferovic
- Department of Internal Medicine Belgrade University School of Medicine and Heart Failure Center, Belgrade University Medical Center Belgrade Serbia
| | - Alessandro Sionis
- Cardiology Department Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona Barcelona Spain
| | - John R. Teerlink
- Section of Cardiology San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco CA USA
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS) Hannover Medical School Hannover Germany
| | - Marjut Varpula
- Cardiology, Heart and Lung Center University of Helsinki, Helsinki University Hospital Helsinki Finland
| | - Jean Marc Weinstein
- Cardiology Division Soroka University Medical Centre Beer‐Sheva Israel
- Faculty of Health Sciences Ben Gurion University of the Negev Beer‐Sheva Israel
| | - Mehmet B. Yilmaz
- Department of Cardiology Cumhuriyet University Faculty of Medicine Sivas Turkey
| |
Collapse
|
42
|
Stampehl M, Friedman HS, Navaratnam P, Russo P, Park S, Obi EN. Risk assessment of post-discharge mortality among recently hospitalized Medicare heart failure patients with reduced or preserved ejection fraction. Curr Med Res Opin 2020; 36:179-188. [PMID: 31469001 DOI: 10.1080/03007995.2019.1662654] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective: Targeted care management for hospitalized patients with acute decompensated heart failure (ADHF) with reduced or preserved ejection fraction (HFrEF/HFpEF) who are at higher risk for post-discharge mortality may mitigate this outcome. However, identification of the most appropriate population for intervention has been challenging. This study developed predictive models to assess risk of 30 day and 1 year post-discharge all-cause mortality among Medicare patients with HFrEF or HFpEF recently hospitalized with ADHF.Methods: A retrospective study was conducted using the 100% Centers for Medicare Services fee-for-service sample with complementary Part D files. Eligible patients had an ADHF-related hospitalization and ICD-9-CM diagnosis code for systolic or diastolic heart failure between 1 January 2010 and 31 December 2014. Data partitioned into training (60%), validation (20%) and test sets (20%) were used to evaluate the three model approaches: classification and regression tree, full logistic regression, and stepwise logistic regression. Performance across models was assessed by comparing the receiver operating characteristic (ROC), cumulative lift, misclassification rate, the number of input variables and the order of selection/variable importance.Results: In the HFrEF (N = 83,000) and HFpEF (N = 123,644) cohorts, 30 day all-cause mortality rates were 6.6% and 5.5%, respectively, and 1 year all-cause mortality rates were 33.6% and 29.5%. The stepwise logistic regression models performed best across both cohorts, having good discrimination (test set ROC of 0.75 for both 30 day mortality models and 0.74 for both 1 year mortality models) and the lowest number of input variables (18-34 variables).Conclusions: Post-discharge mortality risk models for recently hospitalized Medicare patients with HFrEF or HFpEF were developed and found to have good predictive ability with ROCs of greater than or equal to 0.74 and a reasonable number of input variables. Applying this risk model may help providers and health systems identify hospitalized Medicare patients with HFrEF or HFpEF who may benefit from more targeted care management.
Collapse
Affiliation(s)
| | | | | | | | - Siyeon Park
- Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Engels N Obi
- Novartis Pharmaceutical Corporation, Hanover, NJ, USA
| |
Collapse
|
43
|
Apakama DU, Slovis BH. Using Data Science to Predict Readmissions in Heart Failure. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2019. [DOI: 10.1007/s40138-019-00197-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
44
|
Analysis of How Emergency Physicians’ Decisions to Hospitalize or Discharge Patients With Acute Heart Failure Match the Clinical Risk Categories of the MEESSI-AHF Scale. Ann Emerg Med 2019; 74:204-215. [DOI: 10.1016/j.annemergmed.2019.03.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 02/14/2019] [Accepted: 03/11/2019] [Indexed: 01/18/2023]
|
45
|
Roset A, Jacob J, Herrero-Puente P, Alquézar A, Martín-Sanchez FJ, Llorens P, Llauger L, Gil V, Miró Ò. Characteristics and prognosis of patients with acute heart failure without troponin determination: The EAHFE-TROPICA3 study. Arch Cardiovasc Dis 2019; 112:390-399. [PMID: 31014989 DOI: 10.1016/j.acvd.2019.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 01/08/2019] [Accepted: 02/19/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND The absence of cardiac troponin (cTn) determination in an episode of acute heart failure (AHF) is frequent. The characteristics of these patients are not well known; nor is it known whether they have a better prognosis than patients in whom cTn is determined. AIM The objective of the EAHFE-TROPICA3 study was to analyse the characteristics of patients consulting for AHF in whom cTn was not determined (nocTn), and to evaluate the relationship of cTn determination (wcTn) with patient outcomes. METHODS This was an analysis of the multipurpose prospective EAHFE registry of patients with AHF consulting at the emergency departments of 34 Spanish hospitals. RESULTS Data from 8850 patients with AHF were analysed; cTn was not determined in 4216 of these patients (47.6%), who had a lower prevalence of ischaemic heart disease, more frequent use of loop diuretics at baseline, a greater rate of oedema in the acute episode, more frequent history of heart failure, and less use of angiotensin-converting enzyme inhibitors or aldosterone receptor antagonists and beta-blockers at baseline. Compared with the wcTn group, the nocTn group had the same in-hospital mortality (adjusted odds ratio [OR] 1.21, 95% confidence interval [CI] 0.98-1.50), mortality at 30 days (adjusted OR 1.07, 95% CI 0.90-1.28) and reconsultation at 30 days (adjusted OR 0.90, 95% CI 0.80-1.02). CONCLUSIONS Patients presenting with AHF with and without cTn determination have different characteristics. These differences are not related to a better prognosis.
Collapse
Affiliation(s)
- Alex Roset
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, 08907 Barcelona, Catalonia, Spain
| | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, 08907 Barcelona, Catalonia, Spain.
| | - Pablo Herrero-Puente
- Emergency Department, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
| | - Aitor Alquézar
- Emergency Department, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Catalonia, Spain
| | - Francisco Javier Martín-Sanchez
- Emergency Department, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Pere Llorens
- Department of Emergency Medicine, Short-Stay Unit and Hospital At-Home, Hospital General Universitario de Alicante, 03010 Alicante, Spain
| | - Lluís Llauger
- Department of Emergency Medicine, Hospital Universitari de Vic, 08500 Barcelona, Catalonia, Spain
| | - Victor Gil
- Emergency Department, Hospital Clínic, Research Group "Emergencies: Processes and Pathologies", IDIBAPS, 08036 Barcelona, Catalonia, Spain
| | - Òscar Miró
- Emergency Department, Hospital Clínic, Research Group "Emergencies: Processes and Pathologies", IDIBAPS, 08036 Barcelona, Catalonia, Spain
| | | |
Collapse
|
46
|
Sepehrvand N, Youngson E, Bakal JA, McAlister FA, Rowe BH, Ezekowitz JA. External Validation and Refinement of Emergency Heart Failure Mortality Risk Grade Risk Model in Patients With Heart Failure in the Emergency Department. CJC Open 2019; 1:123-130. [PMID: 32159095 PMCID: PMC7063601 DOI: 10.1016/j.cjco.2019.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 03/01/2019] [Indexed: 11/29/2022] Open
Abstract
Background Emergency Heart Failure Mortality Risk Grade (EHMRG) assesses the risk of death within 7 days of emergency department (ED) presentation for patients with acute heart failure (AHF). We aimed to externally validate and refine the EHMRG model in patients who presented to the ED with AHF. Methods We performed a cohort study using administrative data for all ambulance-transported patients from Alberta (2012-2016) presenting to the ED with a primary diagnosis of AHF. Results Among 6708 patients with AHF, the 7-day mortality was 0.0%, 0.8%, 1.6%, 4.0%, 4.2%, and 12.0% across EHMRG risk categories (1-4, 5A and 5B). The EHMRG score had a c-index of 0.73 (95% confidence interval [CI], 0.71-0.76) for 7-day mortality and 0.71 (95% CI, 0.70-0.73) for 30-day mortality, but lower c-statistics for other outcomes (0.61-0.67). The inclusion of natriuretic peptides to the EHMRG model improved prediction (Net Reclassification Improvement, 0.268; 95% CI, 0.173-0.363; P < 0.01) for 7-day mortality, as did the addition of the Canadian Triage and Acuity Scale (Net Reclassification Improvement, 0.111; 95% CI, 0.005-0.218; P = 0.04). Conclusion The EHMRG model exhibited moderate discriminative ability in a large population-based cohort of patients with AHF in the ED. Revision of the EHMRG score through factor inclusion and exclusion could improve the model’s performance.
Collapse
Affiliation(s)
- Nariman Sepehrvand
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Erik Youngson
- Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Jeffrey A Bakal
- Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Finlay A McAlister
- Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada.,Division of General Internal Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| |
Collapse
|
47
|
|
48
|
Marrero-Rivera GE, Vargas P, López-Candales A. Heart failure readmissions: a losing battle or an opportunity for improvement? Postgrad Med 2019; 131:182-184. [PMID: 30843457 DOI: 10.1080/00325481.2019.1589154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Despite great strides in diagnosis and management of heart failure (HF), this chronic illness continues to be a worldwide epidemic with approximately 23 million people afflicted across the globe. In the US, over 6.5 million carry a HF diagnosis with almost 90% of all HF deaths occurring in patients over the age of 70. Since one in five Americans are expected to be older than 65 years by 2050, almost 1,000,000 new HF cases are expected to be diagnosed every year. The staggering nature of these numbers only pales in comparison to current dismal HF survival statistics. The unavoidable natural history of HF continues to be characterized by the occurrence of repetitive hospital admissions. Not only are hospital readmissions demarcated as one of the most important risk factors associated with mortality; but also, a well-recognized trigger for additional hospital readmissions. Even when HF treatment guidelines have been recently updated; the mere fact that four HF societies have issued individual recommendations without reaching a common unifying consensus statement adds to the complexity of HF patient management. The purpose of this Editorial not only to fuel more interest on this topic but also to spark the notion that we have a potential catastrophe in our hands and is the responsibility of all health-care professionals to attend to this vital issue.
Collapse
Affiliation(s)
| | - Pedro Vargas
- b Cardiovascular Medicine Division of the University of Puerto Rico School of Medicine , San Juan , Puerto Rico
| | - Angel López-Candales
- b Cardiovascular Medicine Division of the University of Puerto Rico School of Medicine , San Juan , Puerto Rico
| |
Collapse
|
49
|
Miró Ò, Rosselló X, Gil V, Martín-Sánchez FJ, Llorens P, Herrero P, Jacob J, López-Grima ML, Gil C, Lucas Imbernón FJ, Garrido JM, Pérez-Durá MJ, López-Díez MP, Richard F, Bueno H, Pocock SJ. Utilidad de la escala MEESSI para la estratificación del riesgo de pacientes con insuficiencia cardiaca aguda en servicios de urgencias. Rev Esp Cardiol 2019. [DOI: 10.1016/j.recesp.2018.04.035] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
50
|
Russell FM, Pang PS. Acute Heart Failure Risk Stratification in the Emergency Department: Are We There Yet? REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2019; 72:190-191. [PMID: 30318186 DOI: 10.1016/j.rec.2018.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/10/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Frances M Russell
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, United States.
| |
Collapse
|