Burden and Timing of Hospitalizations in Heart Failure: A Community Study

Is it time to consider a "time-out" before primary prevention implantable cardioverter-defibrillator placement in currently or recently hospitalized older patients with heart failure?

BACKGROUND

Trajectories of mortality after primary prevention implantable cardioverter-defibrillator (ICD) placement for older patients with heart failure during or soon after acute hospitalization have not been assessed.

OBJECTIVE

The purpose of this study was to compare trajectories of mortality after primary prevention ICD placement during or soon after acute cardiac or non-cardiac hospitalization.

METHODS

We identified older patients with heart failure undergoing primary prevention ICD placement using 20% Medicare data (2008-2018). Placement settings were as follows: (1) Current-H-during current hospitalization, (2) Recent-H-within 90 days of hospitalization, or (3) Chronic stable. Hospitalization was categorized as cardiac vs non-cardiac. Interval mortality rates and hazard ratios (HRs) using Cox regression were estimated at 0-30, 31-90, and 91-365 days after ICD placement.

RESULTS

Of the 61,710 patients (mean age 76 years; 35% female; 85% white), 19% (11,947), 25% (15,147), and 56% (34,616) had ICDs in Current-H, Recent-H, and Chronic stable settings. Mortality rates (per 100 person-years) were highest during 0-30 days, with 38 (34-42) and 22 (19-24) for Current-H and Recent-H, which declined to 21 (20-22) and 16 (15-17) during 91-365 days, respectively. Compared to Chronic stable, HRs were highest during 0-30 days post-ICD placement (5.5 [4.5-6.8] for Current-H and 3.4 [2.8-4.2] for Recent-H) and decreased during 91-365 days (2.0 [1.8-2.1] for Current-H and 1.6 [1.5-1.7] for Recent-H). HR pattens were similar for cardiac and non-cardiac hospitalizations.

CONCLUSION

Primary prevention ICD placement during or soon after hospitalization for any reason was associated with worse mortality with diminishing risks after 90 days. Hospitalization likely identifies a sicker population in whom early mortality with or without ICD may be higher. Our results support careful consideration regarding ICD placement during the 90 days after hospitalization.

Prediction of heart failure events based on physiologic sensor data in HINODE defibrillator patients

AIMS

Hospitalizations are common in patients with heart failure and are associated with high mortality, readmission and economic burden. Detecting early signs of worsening heart failure may enable earlier intervention and reduce hospitalizations. The HeartLogic algorithm is designed to predict worsening heart failure using diagnostic data from multiple device sensors. The main objective of this analysis was to evaluate the sensitivity of the HeartLogic alert calculation in predicting worsening heart failure events (HFEs). We also evaluated the false positive alert rate (FPR) and compared the incidence of HFEs occurring in a HeartLogic alert state to those occurring out of an alert state.

METHODS

The HINODE study enrolled 144 patients (81 ICD and 63 CRT-D) with device sensor data transmitted via a remote monitoring system. HeartLogic alerts were then retrospectively simulated using relevant sensor data. Clinicians and patients were blinded to calculated alerts. Reported adverse events with HF symptoms were adjudicated and classified by an independent HFE committee. Sensitivity was defined as the ratio of the number of detected usable HFEs (true positives) to the total number of usable HFEs. A false positive alert was defined as an alert with no usable HFE between the alert onset date and the alert recovery date plus 30 days. The patient follow-up period was categorized as in alert state or out of alert state. The event rate ratio was the HFE rate calculated in alert to out of alert.

RESULTS

The patient cohort was 79% male and had an average age of 68 ± 12 years. This analysis yielded 244 years of follow-up data with 73 HFEs from 37 patients. A total of 311 HeartLogic alerts at the nominal threshold (16) occurred across 106 patients providing an alert rate of 1.27 alerts per patient-year. The HFE rate was 8.4 times greater while in alert compared with out of alert (1.09 vs. 0.13 events per patient-year; P < 0.001). At the nominal alert threshold, 80.8% of HFEs were detected by a HeartLogic alert [95% confidence interval (CI): 69.9%-89.1%]. The median time from first true positive alert to an adjudicated clinical HFE was 53 days. The FPR was 1.16 (95% CI: 0.98-1.38) alerts per patient-year.

CONCLUSIONS

Results suggest that signs of worsening HF can be detected successfully with remote patient follow-up. The use of HeartLogic may predict periods of increased risk for HF or clinically significant events, allowing for early intervention and reduction of hospitalization in a vulnerable patient population.

Effects of Sacubitril/Valsartan on All-Cause Hospitalizations in Heart Failure: Post Hoc Analysis of the PARADIGM-HF and PARAGON-HF Randomized Clinical Trials

Importance

Sacubitril/valsartan is indicated to reduce the risk of cardiovascular death and heart failure (HF) hospitalizations in patients with chronic HF. However, many of these patients are older and have multiple comorbidities that increase the risk of hospitalization for causes other than HF.

Objective

To assess the effects of sacubitril/valsartan on hospitalizations of any cause across the spectrum of left ventricular ejection fraction (LVEF).

Design, Setting, and Participants

This post hoc, participant-level, pooled analysis of the PARADIGM-HF (in patients with an LVEF ≤40%) and PARAGON-HF (in patients with an LVEF ≥45%) randomized clinical trials was conducted from February 5, 2024, to April 5, 2024. Participants with chronic HF, New York Heart Association classes II through IV symptoms, and elevated natriuretic peptides were randomized to treatment with either sacubitril/valsartan or a renin-angiotensin system inhibitor (RASi)-enalapril in the PARADIGM-HF trial or valsartan in the PARAGON-HF trial.

Intervention

Sacubitril/valsartan vs RASi (enalapril or valsartan).

Main Outcomes and Measures

The effects of sacubitril/valsartan on time to first investigator-reported all-cause and cause-specific hospitalizations were examined using Cox proportional hazards models, stratified by geographic region and trial. Effect modification by LVEF as a continuous function was examined.

Results

Among 13 194 participants in the PARADIGM-HF and PARAGON-HF trials, mean (SD) patient age was 67 (11) years, 8883 patients (67.3%) were male, and mean (SD) LVEF was 40% (15%). Sacubitril/valsartan significantly reduced the risk of all-cause hospitalization (ACH) compared with RASi over a median (IQR) follow-up period of 2.5 (1.8-3.1) years (hazard ratio [HR], 0.92; 95% CI, 0.88-0.97; P = .002). The incidence rate of first ACH was 25 (95% CI, 24-26) per 100 patient-years in the sacubitril/valsartan arm and 27 (95% CI, 26-28) per 100 patient-years in the RASi arm. The absolute risk reduction (ARR) was 2.1 per 100 patient-years, corresponding to a number needed to treat (NNT) of 48 patient-years of treatment exposure to prevent 1 ACH. Reductions in overall hospitalizations seemed primarily driven by lower rates of cardiac and pulmonary hospitalizations with sacubitril/valsartan. Patients in the 2 treatment arms had similar rates of composite noncardiac hospitalizations. Treatment heterogeneity on ACH by LVEF was observed (P for interaction = .03), with benefits most apparent in patients with an LVEF less than 60% (HR, 0.91; 95% CI, 0.86-0.96), but not in patients with an LVEF of 60% or more (HR, 0.97; 95% CI, 0.86-1.09).

Conclusions and Relevance

In this post hoc pooled analysis of 13 194 patients with chronic HF in the PARADIGM-HF and PARAGON-HF randomized clinical trials, sacubitril/valsartan significantly reduced hospitalization for any reason, with benefits most apparent in patients with an LVEF below normal. This reduction appeared to be principally driven by lower rates of cardiac and pulmonary hospitalizations.

Trial Registrations

ClinicalTrials.gov Identifiers: NCT01035255 (PARADIGM-HF) and NCT01920711 (PARAGON-HF).

Identifying Predictors of Heart Failure Readmission in Patients From a Statutory Health Insurance Database: Retrospective Machine Learning Study

BACKGROUND

Patients with heart failure (HF) are the most commonly readmitted group of adult patients in Germany. Most patients with HF are readmitted for noncardiovascular reasons. Understanding the relevance of HF management outside the hospital setting is critical to understanding HF and factors that lead to readmission. Application of machine learning (ML) on data from statutory health insurance (SHI) allows the evaluation of large longitudinal data sets representative of the general population to support clinical decision-making.

OBJECTIVE

This study aims to evaluate the ability of ML methods to predict 1-year all-cause and HF-specific readmission after initial HF-related admission of patients with HF in outpatient SHI data and identify important predictors.

METHODS

We identified individuals with HF using outpatient data from 2012 to 2018 from the AOK Baden-Württemberg SHI in Germany. We then trained and applied regression and ML algorithms to predict the first all-cause and HF-specific readmission in the year after the first admission for HF. We fitted a random forest, an elastic net, a stepwise regression, and a logistic regression to predict readmission by using diagnosis codes, drug exposures, demographics (age, sex, nationality, and type of coverage within SHI), degree of rurality for residence, and participation in disease management programs for common chronic conditions (diabetes mellitus type 1 and 2, breast cancer, chronic obstructive pulmonary disease, and coronary heart disease). We then evaluated the predictors of HF readmission according to their importance and direction to predict readmission.

RESULTS

Our final data set consisted of 97,529 individuals with HF, and 78,044 (80%) were readmitted within the observation period. Of the tested modeling approaches, the random forest approach best predicted 1-year all-cause and HF-specific readmission with a C-statistic of 0.68 and 0.69, respectively. Important predictors for 1-year all-cause readmission included prescription of pantoprazole, chronic obstructive pulmonary disease, atherosclerosis, sex, rurality, and participation in disease management programs for type 2 diabetes mellitus and coronary heart disease. Relevant features for HF-specific readmission included a large number of canonical HF comorbidities.

CONCLUSIONS

While many of the predictors we identified were known to be relevant comorbidities for HF, we also uncovered several novel associations. Disease management programs have widely been shown to be effective at managing chronic disease; however, our results indicate that in the short term they may be useful for targeting patients with HF with comorbidity at increased risk of readmission. Our results also show that living in a more rural location increases the risk of readmission. Overall, factors beyond comorbid disease were relevant for risk of HF readmission. This finding may impact how outpatient physicians identify and monitor patients at risk of HF readmission.

Advanced Heart Failure Characteristics and Outcomes in Women and Men

BACKGROUND

The epidemiology and pathophysiology of heart failure (HF) differ in women and men. Whether these differences extend to the subgroup of patients with advanced HF is not well defined.

METHODS AND RESULTS

This is a retrospective cohort study of all adult Olmsted County, Minnesota residents with advanced HF (European Society of Cardiology criteria) from 2007 to 2017. Differences in survival and hospitalization risks in women and men following advanced HF development were examined using Cox proportional hazard regression and Andersen-Gill models, respectively. Of 936 individuals with advanced HF, 417 (44.6%) were women and 519 (55.4%) were men (self-reported sex). Time from development of HF to advanced HF was similar in women and men (median 3.2 versus 3.6 years). Women were older at diagnosis (mean age 79 versus 75 years), less often had coronary disease and hyperlipidemia, but more often had hypertension and depression (P<0.05 for each). Advanced HF with preserved ejection fraction was more prevalent in women than men (60% versus 30%, p<0.001). There were no differences in adjusted risks of all-cause mortality (hazard ratio [HR], 0.89 [95% CI, 0.77-1.03]), cardiovascular mortality (HR, 0.85 [95% CI, 0.70-1.02]), all-cause hospitalizations (HR, 1.04 [95% CI, 0.90-1.20]), or HF hospitalizations (HR, 0.91 [95% CI, 0.75-1.11]) between women and men. However, adjusted cardiovascular mortality was lower in women versus men with advanced HF with reduced ejection fraction (HR, 0.72 [95% CI, 0.56-0.93]).

CONCLUSIONS

Women more often present with advanced HF with preserved ejection fraction and men with atherosclerotic disease and advanced HF with reduced ejection fraction. Despite these differences, survival and hospitalization risks are largely comparable in women and men with advanced HF.

Predicting the risk of mortality and rehospitalization in heart failure patients: A retrospective cohort study by machine learning approach

BACKGROUND

Heart failure (HF) is a global problem, affecting more than 26 million people worldwide. This study evaluated the performance of 10 machine learning (ML) algorithms and chose the best algorithm to predict mortality and readmission of HF patients by using The Fasa Registry on Systolic HF (FaRSH) database.

HYPOTHESIS

ML algorithms may better identify patients at increased risk of HF readmission or death with demographic and clinical data.

METHODS

Through comprehensive evaluation, the best-performing model was used for prediction. Finally, all the trained models were applied to the test data, which included 20% of the total data. For the final evaluation and comparison of the models, five metrics were used: accuracy, F1-score, sensitivity, specificity and Area Under Curve (AUC).

RESULTS

Ten ML algorithms were evaluated. The CatBoost (CAT) algorithm uses a series of decision tree models to create a nonlinear model, and this CAT algorithm performed the best of the 10 models studied. According to the three final outcomes from this study, which involved 2488 participants, 366 (14.7%) of the patients were readmitted to the hospital, 97 (3.9%) of the patients died within 1 month of the follow-up, and 342 (13.7%) of the patients died within 1 year of the follow-up. The most significant variables to predict the events were length of stay in the hospital, hemoglobin level, and family history of MI.

CONCLUSIONS

The ML-based risk stratification tool was able to assess the risk of 5-year all-cause mortality and readmission in patients with HF. ML could provide an explicit explanation of individualized risk prediction and give physicians an intuitive understanding of the influence of critical features in the model.

Heart failure symptom burden in outpatient cardiology: observational cohort study

OBJECTIVES

To assess the self-reported symptom burden in patients with a diagnosis of heart failure attending an outpatient cardiology clinic through the utilisation of validated patient-reported outcome measures.

METHODS

Eligible patients were invited to partake in this observational cohort study. Participant demographics and comorbidities were recorded, followed by participants recording their symptoms using the Integrated Palliative care Outcome Scale (IPOS) and Brief Pain Inventory (BPI) outcome measure tools.

RESULTS

A total of 22 patients were included in the study. The majority were male (n=15). The median age was 74.5 (range 55-94) years. Atrial fibrillation and hypertension were the most common comorbidities (n=10). Dyspnoea, weakness and poor mobility were the most prevalent symptoms, affecting 15 (68%) of the 22 patients. Dyspnoea was reported as being the most troublesome symptom. The BPI was completed by 68% (n=15) of the study participants. Median average pain score was 5/10; median worst pain score in the preceding 24 hours was 6/10 and median pain score at time of BPI completion was 3/10. The impact of pain on daily living during the preceding 24 hours ranged from impacting on all activities (n=7) to not impacting on activities (n=1).

CONCLUSIONS

Patients with heart failure experience a range of symptoms that vary in severity. Introduction of a symptom assessment tool in the cardiology outpatient setting could help identify patients with a high symptom burden and prompt timely referral to specialist palliative care services.

Habitual physical activity levels of adults with heart failure: systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to quantify habitual physical activity (PA) levels of patients with heart failure (HF) and assess the quality of reporting of device-assessed PA.

METHODS

Eight electronic databases were searched up to 17 November 2021. Data on the study and population characteristics, method of PA measurement and PA metrics were extracted. A random-effects meta-analysis (restricted maximum likelihood with Knapp-Hartung SE adjustment) was conducted.

RESULTS

Seventy-five studies were included in the review (n=7775 patients with HF). Meta-analysis was restricted to mean steps per day, encompassing 27 studies (n=1720 patients with HF). Pooled mean steps per day were 5040 (95% CI: 4272 to 5807). The 95% prediction interval for mean steps per day in a future study was 1262 to 8817. Meta-regression at the study level revealed that a 10-year increment in the mean age of patients was associated with 1121 fewer steps per day (95% CI: 258 to 1984).

CONCLUSIONS

Patients with HF are a low-active population. These findings have implications for the way in which PA is targeted in patients with HF, and interventions should focus on addressing the age-related decline observed as well as increasing PA to improve HF symptoms and quality of life.

PROSPERO REGISTRATION NUMBER

CRD42020167786.

Prognostic role of renal replacement therapy among hospitalized patients with heart failure in the Brazilian national public health system

Introduction

Data on patients hospitalized with acute heart failure in Brazil scarce.

Methods

We performed a cross-sectional, retrospective, records-based study using data retrieved from a large public database of heart failure admissions to any hospital from the Brazilian National Public Health System (SUS) (SUS Hospital Information System [SIHSUS] registry) to determine the in-hospital all-cause mortality rate, in-hospital renal replacement therapy rate and its association with outcome.

Results

In total, 910,128 hospitalizations due to heart failure were identified in the SIHSUS registry between April 2017 and August 2021, of which 106,383 (11.7%) resulted in in-hospital death. Renal replacement therapy (required by 8,179 non-survivors [7.7%] and 11,496 survivors [1.4%, p < 0.001]) was associated with a 56% increase in the risk of death in the univariate regression model (HR 1.56, 95% CI 1.52 -1.59), a more than threefold increase of the duration of hospitalization, and a 45% or greater increase of cost per day. All forms of renal replacement therapy remained independently associated with in-hospital mortality in multivariable analysis (intermittent hemodialysis: HR 1.64, 95% CI 1.60 -1.69; continuous hemodialysis: HR 1.52, 95% CI 1.42 -1.63; peritoneal dialysis: HR 1.47, 95% CI 1.20 -1.88).

Discussion

The in-hospital mortality rate of 11.7% observed among patients with acute heart failure admitted to Brazilian public hospitals was alarmingly high, exceeding that of patients admitted to North American and European institutions. This is the first report to quantify the rate of renal replacement therapy in patients hospitalized with acute heart failure in Brazil.

Effect of intravenous iron replacement on recurrent heart failure hospitalizations and cardiovascular mortality in patients with heart failure and iron deficiency: A Bayesian meta-analysis

AIMS

Iron deficiency is common in patients with heart failure (HF) and reduced ejection fraction (HFrEF) and is associated with a poor prognosis. Whether intravenous iron replacement improves recurrent HF hospitalizations and cardiovascular mortality of these patients is uncertain although several trials were conducted. Moreover, none of the trials were powered to assess the effect of intravenous iron in clinically important subgroups. Therefore, we conducted a Bayesian analysis to derive precise estimates of the effect of intravenous iron replacement on recurrent HF hospitalizations and cardiovascular mortality in iron-deficient HFrEF patients using consistent subgroup definitions across trials.

METHODS AND RESULTS

Individual participant data were used from the FAIR-HF (n = 459), CONFIRM-HF (n = 304) and AFFIRM-AHF (n = 1108) trials. These data were re-analysed following as closely as possible the approach taken in the analyses of IRONMAN (n = 1137), for which study level data were used. Definitions of outcomes and subgroups from the FAIR-HF, CONFIRM-HF and AFFIRM-AHF were matched with those used in IRONMAN. The primary endpoint was recurrent HF hospitalizations and cardiovascular mortality. The analysis of recurrent events was based on rate ratios (RR) derived from the Lin-Wei-Yang-Ying model, and the data were pooled using Bayesian random-effects meta-analysis. Compared with placebo, intravenous iron significantly reduced the rates of recurrent HF hospitalizations and cardiovascular mortality (RR 0.73, 95% credible interval [CI] 0.48-0.99; between-trial heterogeneity tau = 0.16). The pooled treatment effects did not provide evidence for any differential effects for subgroups based on sex (ratio of rate ratios [RRR] 1.49 [95% CI 0.95-2.37], age <69.4 vs. ≥69.4 years) (RRR 0.68 [0.40-1.15]), ischaemic versus non-ischaemic aetiology of HF (RRR 0.73 [0.42-1.33]), transferrin saturation <20% vs. ≥20% (RRR 0.75 [0.40-1.34]), estimated glomerular filtration rate ≤60 versus >60 ml/min/1.73 m2 (RRR 0.97 [0.56-1.68]), haemoglobin <11.8 versus ≥11.8 (RRR 0.95 [0.53-1.60]), ferritin <35 versus ≥35 μg/L (RRR 1.26 [0.72-2.48]) and New York Heart Association class II versus III/IV (RRR 0.91 [0.54-1.56]).

CONCLUSIONS

Treatment of iron-deficient HFrEF patients with intravenous iron - namely with ferric carboxymaltose or ferric derisomaltose - results in significant reduction in recurrent HF hospitalizations and cardiovascular mortality. Results were nominally consistent across the subgroups studied, but for several of these subgroups uncertainty remains present.

Heart Failure Emergency Readmission Prediction Using Stacking Machine Learning Model

Heart failure is a devastating disease that has high mortality rates and a negative impact on quality of life. Heart failure patients often experience emergency readmission after an initial episode, often due to inadequate management. A timely diagnosis and treatment of underlying issues can significantly reduce the risk of emergency readmissions. The purpose of this project was to predict emergency readmissions of discharged heart failure patients using classical machine learning (ML) models based on Electronic Health Record (EHR) data. The dataset used for this study consisted of 166 clinical biomarkers from 2008 patient records. Three feature selection techniques were studied along with 13 classical ML models using five-fold cross-validation. A stacking ML model was trained using the predictions of the three best-performing models for final classification. The stacking ML model provided an accuracy, precision, recall, specificity, F1-score, and area under the curve (AUC) of 89.41%, 90.10%, 89.41%, 87.83%, 89.28%, and 0.881, respectively. This indicates the effectiveness of the proposed model in predicting emergency readmissions. The healthcare providers can intervene pro-actively to reduce emergency hospital readmission risk and improve patient outcomes and decrease healthcare costs using the proposed model.

Health Care Utilization and Death in Patients With Heart Failure During the COVID-19 Pandemic

Objective

To compare the 1-year health care utilization and mortality in persons living with heart failure (HF) before and during the coronavirus disease 2019 (COVID-19) pandemic.

Patients and Methods

Residents of a 9-county area in southeastern Minnesota aged 18 years or older with a HF diagnosis on January 1, 2019; January 1, 2020; and January 1, 2021, were identified and followed up for 1-year for vital status, emergency department (ED) visits, and hospitalizations.

Results

We identified 5631 patients with HF (mean age, 76 years; 53% men) on January 1, 2019, 5996 patients (mean age, 76 years; 52% men) on January 1, 2020, and 6162 patients (mean age, 75 years; 54% men) on January 1, 2021. After adjustment for comorbidities and risk factors, patients with HF in 2020 and patients with HF in 2021 experienced similar risks of mortality compared with those in 2019. After adjustment, patients with HF in 2020 and 2021 were less likely to experience all-cause hospitalizations (2020: rate ratio [RR], 0.88; 95% CI, 0.81-0.95; 2021: RR, 0.90; 95% CI, 0.83-0.97) compared with patients in 2019. Patients with HF in 2020 were also less likely to experience ED visits (RR, 0.85; 95% CI, 0.80-0.92).

Conclusion

In this large population-based study in southeastern Minnesota, we observed an approximately 10% decrease in hospitalizations among patients with HF in 2020 and 2021 and a 15% decrease in ED visits in 2020 compared with those in 2019. Despite the change in health care utilization, we found no difference in the 1-year mortality between patients with HF in 2020 and those in 2021 compared with those in 2019. It is unknown whether any longer-term consequences will be observed.

Cost-effectiveness of Sodium-Glucose Cotransporter-2 Inhibitors for the Treatment of Heart Failure With Preserved Ejection Fraction

Importance

Adding a sodium-glucose cotransporter-2 inhibitor (SGLT2-I) to standard-of-care treatment in patients with heart failure with preserved ejection fraction (HFpEF) reduces the risk of a composite outcome of worsening heart failure or cardiovascular mortality, but the cost-effectiveness in US patients with HFpEF is uncertain.

Objective

To evaluate the lifetime cost-effectiveness of standard therapy plus an SGLT2-I compared with standard therapy in individuals with HFpEF.

Design, Setting, and Participants

In this economic evaluation conducted from September 8, 2021, to December 12, 2022, a state-transition Markov model simulated monthly health outcomes and direct medical costs. Input parameters including hospitalization rates, mortality rates, costs, and utilities were extracted from HFpEF trials, published literature, and publicly available data sets. The base-case annual cost of SGLT2-I was $4506. A simulated cohort with similar characteristics as participants of the Empagliflozin in Heart Failure With a Preserved Ejection Fraction (EMPEROR-Preserved) and Dapagliflozin in Heart Failure With Mildly Reduced or Preserved Ejection Fraction (DELIVER) trials was used.

Exposures

Standard of care plus SGLT2-I vs standard of care.

Main Outcomes and Measures

The model simulated hospitalizations, urgent care visits, and cardiovascular and noncardiovascular death. Future medical costs and benefits were discounted by 3% per year. Main outcomes were quality-adjusted life-years (QALYs), direct medical costs (2022 US dollars), and incremental cost-effectiveness ratio (ICER) of SGLT2-I therapy from a US health care sector perspective. The ICER of SGLT2-I therapy was evaluated according to the American College of Cardiology/American Heart Association value framework (high value: <$50 000; intermediate value: $50 000 to <$150 000; and low value: ≥$150 000).

Results

The simulated cohort had a mean (SD) age of 71.7 (9.5) years and 6828 of 12 251 participants (55.7%) were male. Standard of care plus SGLT2-I increased quality-adjusted survival by 0.19 QALYs at an increased cost of $26 300 compared with standard of care. The resulting ICER was $141 200 per QALY gained, with 59.1% of 1000 probabilistic iterations indicating intermediate value and 40.9% indicating low value. The ICER was most sensitive to SGLT2-I costs and effect of SGLT2-I therapy on cardiovascular death (eg, increasing to $373 400 per QALY gained if SGLT2-I therapy was assumed to have no effect on mortality).

Conclusions and Relevance

Results of this economic evaluation suggest that at 2022 drug prices, adding an SGLT2-I to standard of care was of intermediate or low economic value compared with standard of care in US adults with HFpEF. Efforts to expand access to SGLT2-I for individuals with HFpEF should be coupled with efforts to lower the cost of SGLT2-I therapy.

Patients with Congestive Cardiac Failure Referred to Specialist Palliative Care

BACKGROUND

Congestive cardiac failure is a chronic, progressive condition with a significant symptom burden. There is limited data available regarding the palliative care requirements of the heart failure population.

AIMS

To characterise patients with a primary diagnosis of congestive cardiac failure referred to a specialist palliative care (SPC) service in Ireland.

METHODS

A retrospective chart review of patients with congestive cardiac failure admitted to the specialist palliative care unit or reviewed by the community palliative care team over 2 years was carried out, utilising a data collection template.

RESULTS

57 patient charts were included. 54% (n = 31) were female. Mean age was 81 [60 - 97] years. GP's referred 42% (n = 24), Cardiologists 39% (n = 22) and other hospital consultants 19% (n = 11). The commonest symptom reported was dyspnoea (n = 47). Time from referral to death ranged from less than one month (n =22) to greater than one year (n = 3). 14 patients were discharged from the service due to lack of SPC needs. Place of death was distributed between home, hospice, nursing home and acute hospital.

CONCLUSIONS

Patients with congestive cardiac failure experience high symptom burden. More than 50% of patients that died while receiving SPC input had been referred less than 1 month prior, while almost a quarter of all referrals resulted in patient discharge. This highlights the importance of further education regarding indication for specialist palliative care referral and the benefits of early referral in this patient cohort when appropriate.

Socioeconomic and Health-Related Factors Affecting Congestive Heart Failure Readmissions

Congestive heart failure (CHF) readmissions are frequent and costly but preventable. The purpose of this study was to analyze socioeconomic and health-related factors of CHF readmissions by examining the relationship between 30-day readmissions of individuals with CHF and their payer status, race, ethnicity, primary language spoken, living arrangement, and comorbidities. This retrospective case-control study used secondary data from 450 CHF patients admitted to a not-for-profit Northern Virginia hospital from July 2014 to December 2017. Data were analyzed using χ 2 and logistic regression. Living arrangements and comorbid chronic renal failure (CRF) were statistically significant predictors of CHF readmissions; all other factors were nonsignificant. Patients who lived with family and those in assisted living facilities were less likely to be readmitted than those who lived alone (odds ratio [OR] = 0.2 and 0.5, respectively). Patients without CRF were less likely to be readmitted than those who had CRF (OR = 0.6). This study contributes data to inform community-based health programs tailored toward frequently readmitted individuals due to CHF exacerbation.

Thirty-day readmission in patients with heart failure with preserved ejection fraction: Insights from the nationwide readmission database

BACKGROUND

There are rising numbers of patients who have heart failure with preserved ejection fraction (HFpEF). Poorly understood pathophysiology of heart failure with preserved and reduced ejection fraction and due to a sparsity of studies, the management of HFpEF is challenging.

AIM

To determine the hospital readmission rate within 30 d of acute or acute on chronic heart failure with preserved ejection fraction and its effect on mortality and burden on health care in the United States.

METHODS

We performed a retrospective study using the Agency for Health-care Research and Quality Health-care Cost and Utilization Project, Nationwide Readmissions Database for the year 2017. We collected data on hospital readmissions of 60514 adults hospitalized for acute or acute on chronic HFpEF. The primary outcome was the rate of all-cause readmission within 30 d of discharge. Secondary outcomes were cause of readmission, mortality rate in readmitted and index patients, length of stay, total hospitalization costs and charges. Independent risk factors for readmission were identified using Cox regression analysis.

RESULTS

The thirty day readmission rate was 21%. Approximately 9.17% of readmissions were in the setting of acute on chronic diastolic heart failure. Hypertensive chronic kidney disease with heart failure (1245; 9.7%) was the most common readmission diagnosis. Readmitted patients had higher in-hospital mortality (7.9% vs 2.9%, P = 0.000). Our study showed that Medicaid insurance, higher Charlson co-morbidity score, patient admitted to a teaching hospital and longer hospital stay were significant variables associated with higher readmission rates. Lower readmission rate was found in residents of small metropolitan or micropolitan areas, older age, female gender, and private insurance or no insurance were associated with lower risk of readmission.

CONCLUSION

We found that patients hospitalized for acute or acute on chronic HFpEF, the thirty day readmission rate was 21%. Readmission cases had a higher mortality rate and increased healthcare resource utilization. The most common cause of readmission was cardio-renal syndrome.

Urinary sodium concentration predicts time to major adverse coronary events and all-cause mortality in men with heart failure over a 28–33-year period: a prospective cohort study

Background

Lower urinary sodium concentrations (UNa) may be a biomarker for poor prognosis in chronic heart failure (HF). However, no data exist to determine its prognostic association over the long-term. We investigated whether UNa predicted major adverse coronary events (MACE) and all-cause mortality over 28–33 years.

Methods

One hundred and eighty men with chronic HF from the Kuopio Ischaemic Heart Disease Risk Factor Study (KIHD) were included. Baseline data was collected between 1984 and 1989. MACE and all-cause outcomes were obtained using hospital linkage data (1984–2017) with a follow-up of 28–33 years. Cox proportional hazards models were generated using 24-h UNa tertiles at baseline (1 ≤ 173 mmol/day; 2 = 173-229 mmol/day; 3 = 230-491 mmol/day) as a predictor of time-to-MACE outcomes, adjusted for relevant covariates.

Results

Overall, 63% and 83% of participants (n = 114 and n = 150) had a MACE event (median 10 years) and all-cause mortality event (median 19 years), respectively. On multivariable Cox Model, relative to the lowest UNa tertile, no significant difference was noted in MACE outcome for individuals in tertiles 2 and 3 with events rates of 28% (HR:0.72; 95% CI: 0.46–1.12) and 21% (HR 0.79; 95% CI: 0.5–1.25) respectively.. Relative to the lowest UNa tertile, those in tertile 2 and 3 were 39% (HR: 0.61; 95% CIs: 0.41, 0.91) and 10% (HR: 0.90; 95% CIs: 0.62, 1.33) less likely to experience to experience all-cause mortality. The multivariable Cox model had acceptable prediction precision (Harrell's C concordance measure 0.72).

Conclusion

UNa was a significant predictor of all-cause mortality but not MACE outcomes over 28–33 years with 173–229 mmol/day appearing to be the optimal level. UNa may represent an emerging long-term prognostic biomarker that warrants further investigation.

Association of Perceived Stress With Incident Heart Failure

BACKGROUND

The relationship between psychological stress and heart failure (HF) has not been well studied. We sought to assess the relationship between perceived stress and incident HF.

METHODS

We used data from the national REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a large prospective biracial cohort study that enrolled community-dwellers aged 45 years and older between 2003 and 2007, with follow-up. We included participants free of suspected prevalent HF who completed the Cohen 4-item Perceived Stress Scale (PSS-4). Our outcome variables were incident HF event, HF with reduced ejection fraction events, and HF with preserved ejection fraction events. We estimated Cox proportional hazard models to determine if PSS-4 quartiles were independently associated with incident HF events, adjusting for sociodemographics, social support, unhealthy behaviors, comorbid conditions, and physiologic parameters. We also tested interactions by baseline statin use, given its anti-inflammatory properties.

RESULTS

Among 25,785 participants with a mean age of 64 ± 9.3 years, 55% were female and 40% were Black. Over a median follow-up of 10.1 years, 1109 ± 4.3% experienced an incident HF event. In fully adjusted models, the PSS-4 was not associated with HF or HF with reduced ejection fraction. However, PSS-4 quartiles 2-4 (compared with the lowest quartile) were associated with incident HF with preserved ejection fraction (Q2 hazard ratio 1.37, 95% confidence interval 1.00-1.88; Q3 hazard ratio 1.42, 95% confidence interval 1.03-1.95; Q4 hazard ratio 1.41, 95% confidence interval 1.04-1.92). Notably, this association was attenuated among participants who took a statin at baseline (P for interaction = .07).

CONCLUSIONS

Elevated perceived stress was associated with incident HF with preserved ejection fraction but not HF with reduced ejection fraction.

Exercise Training Effects on Circulating Endothelial and Progenitor Cells in Heart Failure

Heart failure (HF) is a major public health issue worldwide with increased prevalence and a high number of hospitalizations. Patients with chronic HF and either reduced ejection fraction (HFrEF) or mildly reduced ejection fraction (HFmrEF) present vascular endothelial dysfunction and significantly decreased circulating levels of endothelial progenitor cells (EPCs). EPCs are bone marrow-derived cells involved in endothelium regeneration, homeostasis, and neovascularization. One of the unsolved issues in the field of EPCs is the lack of an established method of identification. The most widely approved method is the use of monoclonal antibodies and fluorescence-activated cell sorting (FACS) analysis via flow cytometry. The most frequently used markers are CD34, VEGFR-2, CD45, CD31, CD144, and CD146. Exercise training has demonstrated beneficial effects on EPCs by increasing their number in peripheral circulation and improving their functional capacities in patients with HFrEF or HFmrEF. There are two potential mechanisms of EPCs mobilization: shear stress and the hypoxic/ischemic stimulus. The combination of both leads to the release of EPCs in circulation promoting their repairment properties on the vascular endothelium barrier. EPCs are important therapeutic targets and one of the most promising fields in heart failure and, therefore, individualized exercise training programs should be developed in rehabilitation centers.

Sauver J, Bielinski SJ, Chamberlain AM, Weston SA, Jiang R, Roger VL. Alzheimer's disease and related dementias and heart failure: A community study

BACKGROUND

Cognitive function is essential to effective self-management of heart failure (HF). Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) can coexist with HF, but its exact prevalence and impact on health care utilization and death are not well defined.

METHODS

Residents from 7 southeast Minnesota counties with a first-ever diagnosis code for HF between January 1, 2013 and December 31, 2018 were identified. Clinically diagnosed AD/ADRD was ascertained using the Centers for Medicare and Medicaid (CMS) Chronic Conditions Data Warehouse algorithm. Patients were followed through March 31, 2020. Cox and Andersen-Gill models were used to examine associations between AD/ADRD (before and after HF) and death and hospitalizations, respectively.

RESULTS

Among 6336 patients with HF (mean age [SD] 75 years [14], 48% female), 644 (10%) carried a diagnosis of AD/ADRD at index HF diagnosis. The 3-year cumulative incidence of AD/ADRD after HF diagnosis was 17%. During follow-up (mean [SD] 3.2 [1.9] years), 2618 deaths and 15,475 hospitalizations occurred. After adjustment, patients with AD/ADRD before HF had nearly a 2.7 times increased risk of death, but no increased risk of hospitalization compared to those without AD/ADRD. When AD/ADRD was diagnosed after the index HF date, patients experienced a 3.7 times increased risk of death and a 73% increased risk of hospitalization compared to those who remain free of AD/ADRD.

CONCLUSIONS

In a large, community cohort of patients with incident HF, the burden of AD/ADRD is quite high as more than one-fourth of patients with HF received a diagnosis of AD/ADRD either before or after HF diagnosis. AD/ADRD markedly increases the risk of adverse outcomes in HF underscoring the need for future studies focused on holistic approaches to improve outcomes.

Burden of hospitalizations in newly diagnosed heart failure patients in Poland: real world population based study in years 2013-2019

Aims

We aim to report trends in unplanned hospitalizations among newly diagnosed heart failure patients with regard to hospitalizations types and their impact on outcomes.

Methods and results

A nation‐wide study of all citizens in Poland with newly diagnosed heart failure based on ICD‐10 coding who were beneficiaries of either public primary, secondary, or hospital care between 2013 and 2018 in Poland. Between 1 January 2013 and 31 December 2019, there were 1 124 118 newly diagnosed heart failure patients in Poland in both out‐ and inpatient settings. The median observation time was 946 days. As many as 49% experienced at least one acute heart failure hospitalization. Once hospitalized, 44.6% patients experienced at least one all‐cause rehospitalization and 26% another heart failure rehospitalization. The latter had the highest Charlson co‐morbidity index (1.36). The 30 day heart failure readmission rate was 2.96%. Kaplan–Meier analysis revealed very early readmissions (up to 1–7 days) were associated with better survival compared with rehospitalization between 8 and 30 days. All‐cause mortality was related to the number of hospitalization with adjusted estimated hazard ratios: 1.550 (95% CI: 1.52–158) for the second HF hospitalization, 2.158 (95% CI: 2.098–2.219) for third, and 2.788 (95% CI: 2.67–2.91) for the fourth HF hospitalization and subsequent ones, as compared with the first hospitalization.

Conclusions

Among newly diagnosed heart failure patients in Poland between 2013 and 2019, nearly half required at least one unplanned heart failure hospitalization. The risk of death was growing with every other hospital reoccurrence due to heart failure.

Comparison of 1-year healthcare resource utilization and related costs for patients with heart failure in the Chagas and non-Chagas matched cohorts

Background

Chagas disease is one of the leading causes of heart failure (HF) in Latin Americans, and there are limited data available that examine related costs of care for patients with HF. This study aimed to compare healthcare resource utilization and related costs for patients with HF, with and without Chagas disease.

Methods

A prospective matched-cohort study comparing the healthcare costs for patients with HF with Chagas disease and care costs for patients with HF without Chagas disease was conducted between January 2019 and December 2019. Only direct costs have been estimated, including hospitalization costs, medications and other cardiovascular interventions, and clinical and laboratory follow-up for up to 1 year.

Results

A total of 80 patients with chronic HF were included in the study. Of the 80 patients, 40 patients in the Chagas cohort and 40 patients in the non-Chagas cohort were matched for age, insurer and sex. From a social security system perspective, the total costs for the two cohorts during the study period were U$970,136. Specifically, the healthcare costs for the Chagas cohort were greater than the total healthcare costs for the non-Chagas group (U$511,931 versus U$458,205; p = 0.6183) Most costs were associated with hospitalizations (65.5% versus 59.6%), with averages of U$12,798.5 and U$11,455.1 per person in the Chagas and non-Chagas groups, respectively. In both the Chagas (51.6%) and non-Chagas cohorts (54.5%), causes of readmission unrelated to HF outweighed causes of readmission related to HF. High incidences of hospital admissions were observed during the rainy (cold) season for both cohorts.

Conclusions

Over a 12-month follow-up period, patients with chronic HF and Chagas consume as many healthcare resources as those with chronic HF and without Chagas. These data highlight the considerable and growing economic burden of HF on the Colombian health system.

A Comparative Spatial and Climate Analysis of Human Granulocytic Anaplasmosis and Human Babesiosis in New York State (2013-2018)

Human granulocytic anaplasmosis (HGA) and human babesiosis are tick-borne diseases spread by the blacklegged tick (Ixodes scapularis Say, Acari: Ixodidae) and are the result of infection with Anaplasma phagocytophilum and Babesia microti, respectively. In New York State (NYS), incidence rates of these diseases increased concordantly until around 2013, when rates of HGA began to increase more rapidly than human babesiosis, and the spatial extent of the diseases diverged. Surveillance data of tick-borne pathogens (2007 to 2018) and reported human cases of HGA (n = 4,297) and human babesiosis (n = 2,986) (2013-2018) from the New York State Department of Health (NYSDOH) showed a positive association between the presence/temporal emergence of each pathogen and rates of disease in surrounding areas. Incidence rates of HGA were higher than human babesiosis among White and non-Hispanic/non-Latino individuals, as well as all age and sex groups. Human babesiosis exhibited higher rates among non-White individuals. Climate, weather, and landscape data were used to build a spatially weighted zero-inflated negative binomial (ZINB) model to examine and compare associations between the environment and rates of HGA and human babesiosis. HGA and human babesiosis ZINB models indicated similar associations with forest cover, forest land cover change, and winter minimum temperature; and differing associations with elevation, urban land cover change, and winter precipitation. These results indicate that tick-borne disease ecology varies between pathogens spread by I. scapularis.

The Dietary Approaches to Stop Hypertension (DASH) Diet Pattern and Incident Heart Failure

BACKGROUND

The Dietary Approaches to Stop Hypertension (DASH) diet pattern has shown some promise for preventing heart failure (HF), but studies have been conflicting.

OBJECTIVE

To determine whether the DASH diet pattern was associated with incident HF in a large biracial and geographically diverse population.

METHODS AND RESULTS

Among participants in the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort study of adults aged ≥45 years who were free of suspected HF at baseline in 2003-2007, the DASH diet score was derived from the baseline food frequency questionnaire. The main outcome was incident HF defined as the first adjudicated HF hospitalization or HF death through December 31, 2016. We estimated hazard ratios for the associations of DASH diet score quartiles with incident HF, and incident HF with reduced ejection fraction and HF with preserved ejection fraction using the Lunn-McNeil extension to the Cox model. We tested for several prespecified interactions, including with age. Compared with the lowest quartile, individuals in the second to fourth DASH diet score quartiles had a lower risk for incident HF after adjustment for sociodemographic and health characteristics: quartile 2 hazard ratio, 0.69 (95% confidence interval [CI], 0.56-0.85); quartile 3 hazard ratio, 0.71 (95% CI, 0.58-0.87); and quartile 4 hazard ratio, 0.73 (95% CI, 0.58-0.92). When stratifying results by age, quartiles 2-4 had a lower hazard for incident HF among those age <65 years, quartiles 3-4 had a lower hazard among those age 65-74, and the quartiles had similar hazard among those age ≥75 years (Pinteraction = .003). We did not find a difference in the association of DASH diet with incident HF with reduced ejection fraction vs HF with preserved ejection fraction (P = .11).

CONCLUSIONS

DASH diet adherence was inversely associated with incident HF, specifically among individuals <75 years old.

Rurality, Death, and Healthcare Utilization in Heart Failure in the Community

Background Prior reports indicate that living in a rural area may be associated with worse health outcomes. However, data on rurality and heart failure (HF) outcomes are scarce. Methods and Results Residents from 6 southeastern Minnesota counties with a first-ever code for HF (International Classification of Diseases, Ninth Revision [ICD-9], code 428, and International Classification of Diseases, Tenth Revision [ICD-10] code I50) between January 1, 2013 and December 31, 2016, were identified. Resident address was classified according to the rural-urban commuting area codes. Rurality was defined as living in a nonmetropolitan area. Cox regression was used to analyze the association between living in a rural versus urban area and death; Andersen-Gill models were used for hospitalization and emergency department visits. Among 6003 patients with HF (mean age 74 years, 48% women), 43% lived in a rural area. Rural patients were older and had a lower educational attainment and less comorbidity compared with patients living in urban areas (P<0.001). After a mean (SD) follow-up of 2.8 (1.7) years, 2440 deaths, 20 506 emergency department visits, and 11 311 hospitalizations occurred. After adjustment, rurality was independently associated with an increased risk of death (hazard ratio [HR], 1.18; 95% CI, 1.09-1.29) and a reduced risk of emergency department visits (HR, 0.89; 95% CI, 0.82-0.97) and hospitalizations (HR, 0.78; 95% CI, 0.73-0.84). Conclusions Among patients with HF, living in a rural area is associated with an increased risk of death and fewer emergency department visits and hospitalizations. Further study to identify and address the mechanisms through which rural residence influences mortality and healthcare utilization in HF is needed in order to reduce disparities in rural health.

Depression and Rehospitalization in Patients With Heart Failure After Discharge From Hospital to Home: An Integrative Review

Patients with heart failure are known to be particularly vulnerable to depression resulting in adverse health outcomes. However, there has been no literature review on current evidence regarding the relationship between depression and rehospitalization. This review aims to explore the relationship between depression and rehospitalization in patients with heart failure. A systematic review employing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines included articles published between 2001 and 2019 taken from Scopus, PubMed, CINAHL, and PsycINFO databases. We identified 12 relevant studies with participants ranging from 115 to 160,169 patients. Heart failure patients with depression were more likely to be rehospitalized than those without. To explain this, few reasons have been proposed. First, depression could disrupt the regulation of autonomic nervous system, neurohormonal activation, and body’s natural rhythm. Second, depressed patients tend to have poor adherence to medication. Healthcare providers should not only focus on drug and dietary management but also on implementing effective interventions to manage depression, in order to reduce the risk of rehospitalization. Moreover, palliative care should start at the stage of heart failure diagnosis to improve quality of life, better outcomes, and lower cost of care for the patients.

Precipitating factors and clinical impact of early rehospitalization for heart failure in patients with heart failure in Awaji Island, Japan

BACKGROUND

Recent reports have revealed that patients who experienced early rehospitalization for heart failure (HF) had worse prognoses in terms of all-cause and cardiovascular deaths as compared to those who did not. However, precipitating factors for early rehospitalization for HF remain unknown. In this study, we assessed the precipitating factors for early rehospitalization and their impact in patients with HF.

METHODS AND RESULTS

We consecutively included 242 patients (mean age: 80.4 years, females: 46.3%) with a history of rehospitalization for HF. They were divided into 2 groups: the early rehospitalization group (71 patients who were readmitted within 3 months of discharge) and the late rehospitalization group (171 patients who were readmitted after more than 3 months following discharge). During the mean follow-up period of 1,144 days (range: 857-1,417 days), 121 patients (50.0%) died. Kaplan-Meier analysis revealed that patients in the early rehospitalization group had worse prognosis (all-cause death and cardiovascular death) than those in the late rehospitalization group (log-rank p<0.001). As the major precipitating factor for rehospitalization, poor compliance with the doctor's instructions on fluid and physical activity restrictions (determined by the patients or their families admittance of non-compliance with the instructions given at the time of discharge) was higher in the early rehospitalization group than in the late rehospitalization group [poor compliance with fluid restriction: 19.7% vs. 7.6% (p = 0.006), poor compliance with physical activity restriction: 21.1% vs. 9.4% (p = 0.013)].

CONCLUSIONS

We concluded that early hospital readmission in patients with HF was associated with higher mortality rates. Compared to late rehospitalization, precipitating factors for early rehospitalization were more strongly dependent on the self-care behaviors of the patients. A more effective approach, such as multidisciplinary intervention, is essential to prevent early hospital readmission and subsequent poor prognosis.

Real-World Treatment Patterns, Healthcare Resource Utilization, and Costs for Patients with Newly Diagnosed Systolic versus Diastolic Heart Failure

BACKGROUND

Although the significant burden of heart failure (HF) is well recognized, the relative contributions of systolic HF versus diastolic HF are less defined.

OBJECTIVE

To explore the differential burden between patients with systolic and diastolic HF in terms of treatment patterns, healthcare resource utilization (HCRU), costs, and mortality risk.

METHODS

This retrospective cohort study used administrative claims data from a large US commercial health insurer integrated with mortality data. Patients newly diagnosed with HF between January 1, 2010, and June 30, 2016, were identified and grouped according to systolic HF or diastolic HF diagnosis and were followed up to 4 years after diagnosis. Treatment patterns, HCRU, costs, and mortality were compared between the 2 groups of patients.

RESULTS

Overall, 46,885 patients with systolic HF and 21,854 with diastolic HF were identified and included in the study. Patients with systolic HF had less HCRU than those with diastolic HF during the first year after HF diagnosis, including hospital admissions (70.2% vs 82.4%, respectively; P <.001) and emergency department visits (30.5% vs 39.1%, respectively; P <.001). The average per-patient costs for patients with systolic HF during the 1-year follow-up were higher than for those with diastolic HF ($64,154 vs $59,652, respectively; P <.001), but lower during years 2 through 4 (approximately $23,000-$25,000 annually vs approximately $28,000-$29,000 annually; P <.001). Patients with diastolic HF had a higher adjusted hospitalization risk (odds ratio, 1.62; 95% confidence interval [CI], 1.55-1.69), but comparable adjusted costs (exponentiated estimate, 1.01; 95% CI, 0.99-1.02) and slightly lower mortality risk (hazard ratio, 0.96; 95% CI, 0.93-0.99) versus patients with systolic HF. The number of HF-related medication classes received for other diagnoses during the year preceding an HF diagnosis was associated with lower risks for hospitalization, mortality, and lower costs, with a trend in benefits toward patients with systolic HF. Of note, 21.9% of patients with systolic HF and 25% of patients with diastolic HF filled no HF-related prescriptions in the year after diagnosis.

CONCLUSION

This real-world analysis confirms a high disease burden associated with HF and provides insight across the systolic HF and diastolic HF phenotypes. HF-related medication use after diagnosis was suboptimal and underscores a gap in patient care.

Gender Differences in Hispanic Patients of Mexican Origin Hospitalized with Heart Failure

BACKGROUND

More than 3 million women in the United States die of heart failure (HF) annually. Women are significantly underrepresented in studies that inform practice guidelines, especially women hospitalized for HF despite the associated negative outcomes. HF is common in Hispanic people, the largest ethnic minority group in the United States, who are mostly of Mexican origin. There are no studies of gender differences in Mexican-Hispanic persons hospitalized for HF. We sought to describe gender differences in demographic and clinical characteristics, clinical presentation, treatment, in-hospital outcomes, and discharge status in Mexican-Hispanic patients hospitalized for HF.

METHODS

We conducted a secondary analysis of data collected for a study examining readmission in patients hospitalized with HF in a 107-bed community; hospital near the U.S.-Mexico border.

RESULTS

Of 155 self-identified Hispanic patients, 43.2% (n = 67) were women. Compared with men, women were equally affected by obesity, on average 6 years older (p < .01), and more likely to be widowed (31% vs 6%; p < .001). Women had significantly higher ejection fractions, more total comorbid conditions, more hyperlipidemia, more arthritis, more anxiety, and were less likely to be treated with digoxin and more likely to be treated with calcium channel blockers. At discharge, women were significantly less likely to receive an angiotensin-converting enzyme inhibitor or an aldosterone receptor blocker and had a higher systolic blood pressure.

CONCLUSIONS

Key gender differences in chronic illness burden, treatment, and discharge status were found, highlighting the heterogeneity of women with HF and the need for further gender-specific research to develop care strategies specific to women of all races and ethnicities.

Spending and quality after three years of Medicare's bundled payments for medical conditions: quasi-experimental difference-in-differences study

OBJECTIVE

To evaluate whether longer term participation in the bundled payments for care initiative (BPCI) for medical conditions in the United States, which held hospitals financially accountable for all spending during an episode of care from hospital admission to 90 days after discharge, was associated with changes in spending, mortality, or health service use.

DESIGN

Quasi-experimental difference-in-differences analysis.

SETTING

US hospitals participating in bundled payments for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease (COPD), or pneumonia, and propensity score matched to non-participating hospitals.

PARTICIPANTS

238 hospitals participating in the Bundled Payments for Care Improvement initiative (BPCI) and 1415 non-BPCI hospitals. 226 BPCI hospitals were matched to 700 non-BPCI hospitals.

MAIN OUTCOME MEASURES

Primary outcomes were total spending on episodes and death 90 days after discharge. Secondary outcomes included spending and use by type of post-acute care. BPCI and non-BPCI hospitals were compared by patient, hospital, and hospital market characteristics. Market characteristics included population size, competitiveness, and post-acute bed supply.

RESULTS

In the 226 BPCI hospitals, episodes of care totaled 261 163 in the baseline period and 93 562 in the treatment period compared with 211 208 and 78 643 in the 700 matched non-BPCI hospitals, respectively, with small differences in hospital and market characteristics after matching. Differing trends were seen for some patient characteristics (eg, mean age change -0.3 years at BPCI hospitals v non- BPCI hospitals, P<0.001). In the adjusted analysis, participation in BPCI was associated with a decrease in total episode spending (-1.2%, 95% confidence interval -2.3% to -0.2%). Spending on care at skilled nursing facilities decreased (-6.3%, -10.0% to -2.5%) owing to a reduced number of facility days (-6.2%, -9.8% to -2.6%), and home health spending increased (4.4%, 1.4% to 7.5%). Mortality at 90 days did not change (-0.1 percentage points, 95% confidence interval -0.5 to 0.2 percentage points).

CONCLUSIONS

In this longer term evaluation of a large national programme on medical bundled payments in the US, participation in bundles for four common medical conditions was associated with savings at three years. The savings were generated by practice changes that decreased use of high intensity care after hospital discharge without affecting quality, which also suggests that bundles for medical conditions could require multiple years before changes in savings and practice emerge.

Risk Factors for Heart Failure in the Community: Differences by Age and Ejection Fraction

BACKGROUND

Differences in comorbid conditions in patients with heart failure compared with population controls, and whether differences exist by type of heart failure or age, have not been well documented.

METHODS

The prevalence of 17 chronic conditions were obtained in 2643 patients with incident heart failure from 2000 to 2013 and controls matched 1:1 on sex and age from Olmsted County, Minnesota. Logistic regression determined associations of each condition with heart failure.

RESULTS

Among 2643 matched pairs (mean age 76.2 years, 45.6% men), the comorbidities with the largest attributable risk of heart failure were arrhythmia (48.7%), hypertension (28.4%), and coronary artery disease (33.9%); together these explained 73.0% of heart failure. Similar associations were observed for patients with reduced and preserved ejection fraction, with the exception of hypertension. The risk of heart failure attributable to hypertension was 2-fold higher in patients with heart failure with preserved ejection fraction (38.7%) than in patients with heart failure with reduced ejection fraction (17.8%). Hypertension, coronary artery disease, arrhythmia, and diabetes were more strongly associated with heart failure in younger (≤75 years) compared to older (>75 years) persons.

CONCLUSIONS

Patients with heart failure have a higher prevalence of many chronic conditions than controls. Similar associations were observed in patients with reduced and preserved ejection fraction, with the exception of hypertension, which was more strongly associated with heart failure with preserved ejection fraction. Finally, some cardiometabolic risk factors were more strongly associated with heart failure in younger persons, highlighting the importance of optimizing prevention and treatment of risk factors and, in particular, cardiometabolic risk factors.

Potentially harmful drug prescription in elderly patients with heart failure with reduced ejection fraction

Aims

This study aimed to evaluate the prescription frequency of potentially harmful prescription drugs as defined in current heart failure guidelines among elderly patients with a diagnosis of heart failure with reduced ejection fraction and their association with clinical outcomes.

Methods and results

We used the Centers for Medicare & Medicaid Services data from a nationally representative 5% sample for the years 2014–2016 to identify patients admitted to acute care hospitals with a primary diagnosis of heart failure with reduced ejection fraction. The primary exposure was filling a prescription for a potentially harmful drug. Potentially harmful drug fills were treated as a time‐dependent covariate to examine their association on readmission and mortality. A total of 8993 patients met study criteria. Potentially harmful drugs were prescribed in 1077 (11.9%) patients within 90 days of discharge from the heart failure hospitalization. Non‐steroidal anti‐inflammatory agents were the most frequently prescribed potentially harmful drug (6.7%) followed by calcium channel blockers (4.7%), thiazolidinedione (0.59%), and select antiarrhythmic (0.33%). Factors independently associated with potentially harmful drug prescription were female gender, Hispanic ethnicity, severe obesity, among others. In the multivariable Cox model, the prescription of a potentially harmful drug was associated with an increased risk of readmission (hazard ratio 1.14; 95% confidence interval 1.05–1.23, P < 0.001). Among drug subgroups, only calcium channel blockers were associated with an increased risk of readmission (hazard ratio 1.225; 95% confidence interval 1.085–1.382, P = 0.0011).

Conclusions

In elderly patients discharged with a primary diagnosis of heart failure with reduced ejection fraction on guideline‐directed medical therapy, prescription of a potentially harmful drug was frequent. Calcium channel blockers were associated with an increased risk of readmission.

Heart failure with preserved ejection fraction: insights from recent clinical researches

Heart failure (HF) with preserved ejection fraction (HFpEF) accounts for nearly half of the cases of HF and its incidence might be increasing with the aging society. Patients with HFpEF present with significant symptoms, including exercise intolerance, impaired quality of life, and have a poor prognosis as well as frequent hospitalization and increased mortality compared with HF with reduced ejection fraction. The concept of HFpEF is still evolving and may be a virtual complex rather than a real systemic disorder. Thus, beyond solely targeting cardiac abnormalities management strategies need to be extended, such as left ventricular diastolic dysfunction. In this review, we examine new diagnostic algorithms, pathophysiology, current management status, and ongoing trials based on heterogeneous pathophysiology and etiology in HFpEF.

Suppression of Tumourigenicity 2 in Heart Failure With Preserved Ejection Fraction

Heart failure (HF), with steadily increasing incidence rates and mortality in an ageing population, represents a major challenge. Evidence suggests that more than half of all patients with a diagnosis of HF suffer from HF with preserved ejection fraction (HFpEF). Emerging novel biomarkers to improve and potentially guide the treatment of HFpEF are the subject of discussion. One of these biomarkers is suppression of tumourigenicity 2 (ST2), a member of the interleukin (IL)-1 receptor family, binding to IL-33. Its two main isoforms – soluble ST2 (sST2) and transmembrane ST2 (ST2L) – show opposite effects in cardiovascular diseases. While the ST2L/IL-33 interaction is considered as being cardioprotective, sST2 antagonises this beneficial effect by competing for binding to IL-33. Recent studies show that elevated levels of sST2 are associated with increased mortality in HF with reduced ejection fraction. Nevertheless, the significance of sST2 in HFpEF remains uncertain. This article aims to give an overview of the current evidence on sST2 in HFpEF with an emphasis on prognostic value, clinical association and interaction with HF treatment. The authors conclude that sST2 is a promising biomarker in HFpEF. However, further research is needed to fully understand underlying mechanisms and ultimately assess its full value.

Increased hospitalization rates following heart failure diagnosis in rheumatoid arthritis as compared to the general population

OBJECTIVE

To compare the frequency of and trends in hospitalizations after heart failure (HF) diagnosis in patients with and without rheumatoid arthritis (RA) during 1987-2015.

METHODS

The study included a retrospectively identified population-based cohort of patients with incident HF and prior RA (age≥18 years, 1987 ACR criteria) and a cohort of incident HF patients without RA matched 3:1 on age, sex, and year of HF diagnosis. Hospitalizations at the time of HF diagnosis were excluded. All subjects were followed until death, migration, or 12/31/2015.

RESULTS

The study included 212 patients with RA (mean age at HF diagnosis 78.3 years; 68% female) and 636 non-RA patients (mean age at HF diagnosis 78.6 years; 68% female). The hospitalization rate after HF diagnosis was higher in RA vs non-RA (rate ratio [RR] 1.17; 95%CI 1.08-1.26). Hospitalization rates in both groups have been declining since 2005 and the difference between patients with and without RA may be decreasing after 2010. The magnitude of the increase was similar in both sexes and across all ages. Patients with RA were more likely to be hospitalized for non-cardiovascular causes (RR 1.26; 95%CI 1.14-1.39), but not for HF or other cardiovascular causes compared to non-RA patients.

CONCLUSIONS

The hospitalization rate following HF diagnosis was higher in RA versus non-RA patients regardless of sex and age. Increased hospitalization risk in patients with RA was driven by increased rates of non-cardiovascular hospitalization.

Clinical and Socioeconomic Predictors of Heart Failure Readmissions: A Review of Contemporary Literature

Heart failure represents a clinical syndrome that results from a constellation of disease processes affecting myocardial function. Although recent studies have suggested a declining or stable incidence of heart failure, patients with heart failure continue to have high hospitalization and readmission rates, resulting in a substantial economic and public health burden. We searched PubMed and Google Scholar to identify published literature from 1998 through 2018 using the following keywords: heart failure, readmissions, predictors, prediction models, and interventions. Cited references were also used to identify relevant literature. Developments in the diagnosis and management of patients with heart failure have improved hospitalization and readmission rates in the past few decades. However, heart failure remains the most common cause of hospitalization in persons older than 65 years. As a result, given the enormous clinical and financial burden associated with heart failure readmissions on health care, there has been growing interest in the investigation of mechanisms aimed at improving outcomes and curtailing associated costs of care. Herein, we review the current literature on clinical and socioeconomic predictors of heart failure readmissions, briefly discussing limitations of existing strategies and providing an overview of current technology aimed at reducing hospitalizations.

Fatigue in heart failure outpatients: levels, associated factors, and the impact on quality of life

Introduction

Heart failure (HF) patients experience various psychosocial issues and physical symptoms such as fatigue, which adversely affect their quality of life (QoL). The aim of the study was to assess levels of fatigue in HF outpatients and the associated factors, as well as to explore the correlation between fatigue and QoL.

Material and methods

One hundred and thirty patients were enrolled in the study. Data collection was performed by the completion of “Minnesota Living With Heart Failure” questionnaire (MLHFQ) and the Greek version of the Modified Fatigue Impact Scale (MFIS-Greek). Data also included self-reported patients’ characteristics.

Results

Of the 130 HF outpatients, 50% scored above 69 (median) in total fatigue and above 41 and 29 (median) in physical and mental fatigue, respectively. Furthermore, 50% scored above 66 (median) in total QoL and above 32.5 and 13 (median) in the physical and mental state, respectively. These values indicate moderate to high impact of HF on fatigue and on patients’ QoL. Total fatigue was statistically significantly associated with NYHA stage (p = 0.001), confidence to acknowledge health deteriorations (p = 0.004), decrease in appetite (p = 0.001), dyspnoea at night (p = 0.001), oedema in lower limbs (p = 0.023), relation with health professionals (p = 0.031), and whether patients had limited daily activities (p = 0.002), social contacts (p = 0.014), and if they had financial worries (p = 0.003). Finally, as the score of fatigue increased, so the QoL score also increased.

Conclusions

A broader understanding of this distressing symptom in HF may contribute to the development of suitable interventions with the ultimate goal of improving QoL.

Chronic exposure to traffic-related air pollution and cancer incidence among 10,000 patients undergoing percutaneous coronary interventions: A historical prospective study

Background Exposure to traffic-related air pollution (TRAP) is considered to have a carcinogenic effect. The authors previously reported a nonsignificant association between TRAP and cancer risk in a relatively small cohort of myocardial infarction survivors. This study assessed whether TRAP exposure is associated with subsequent cancer in a large cohort of coronary patients. Methods & results Consecutive patients undergoing percutaneous coronary interventions in a major medical centre in central Israel from 2004 to 2014 were followed for cancer through 2015. Residential levels of nitrogen oxides (NO_x) - a proxy for TRAP - were estimated based on a high-resolution national land use regression model. Cox proportional hazards models were constructed to study relationships with cancer. Among 12,784 candidate patients, 9816 had available exposure data and no history of cancer (mean age, 68 years; 77% men). During a median (25th-75th percentiles) follow-up of 7.0 (3.9-9.3) years, 773 incident cases of cancer (8%) were diagnosed. In a multivariable-adjusted model, a 10-ppb increase in mean NO_x exposure was associated with hazard ratios (HRs) of 1.07 (95% confidence interval [CI] 1.00-1.15) for all-site cancer and 1.16 (95% CI 1.05-1.28) for cancers previously linked to TRAP (lung, breast, prostate, kidney and bladder). A stronger association was observed for breast cancer (HR = 1.43; 95% CI 1.12-1.83). Associations were slightly strengthened after limiting the cohort to patients with more precise exposure assessment. Conclusion Coronary patients exposed to TRAP are at increased risk of several types of cancer, particularly lung, prostate and breast. As these cancers are amenable to prevention strategies, identifying highly exposed patients may provide an opportunity to improve clinical care.

Heart Failure After Myocardial Infarction Is Associated With Increased Risk of Cancer

BACKGROUND

Heart failure (HF) is associated with excess morbidity and mortality for which noncardiac causes are increasingly recognized. The authors previously described an increased risk of cancer among HF patients compared with community controls.

OBJECTIVES

This study examined whether HF was associated with an increased risk of subsequent cancer among a homogenous population of first myocardial infarction (MI) survivors.

METHODS

A prospective cohort study was conducted among Olmsted County, Minnesota, residents with incident MI from 2002 to 2010. Patients with prior cancer or HF diagnoses were excluded.

RESULTS

A total of 1,081 participants (mean age 64 ± 15 years; 60% male) were followed for 5,327 person-years (mean 4.9 ± 3.0 years). A total of 228 patients developed HF, and 98 patients developed cancer (excluding nonmelanoma skin cancer). Incidence density rates for cancer diagnosis (per 1,000 person-years) were 33.7 for patients with HF and 15.6 for patients without HF (p = 0.002). The hazard ratio (HR) for cancer associated with HF was 2.16 (95% confidence interval [CI]: 1.39 to 3.35); adjusted for age, sex, and Charlson comorbidity index; HR: 1.71 (95% CI: 1.07 to 2.73). The HRs for mortality associated with cancer were 4.90 (95% CI: 3.10 to 7.74) for HF-free and 3.91 (95% CI: 1.88 to 8.12) for HF patients (p for interaction = 0.76).

CONCLUSIONS

Patients who develop HF after MI have an increased risk of cancer. This finding extends our previous report of an elevated cancer risk after HF compared with controls, and calls for a better understanding of shared risk factors and underlying mechanisms.