Predictors of in-hospital mortality present at admission among patients hospitalised because of decompensated heart failure

Cardiovascular disease and covid-19: A systematic review

Background

Cardiovascular complications of COVID-19 are numerous and aspects of this phenomenon are not well known. The main objective of this manuscript is a systematic review of the acute and chronic cardiovascular complications secondary to COVID-19.

Methods

A systematic review of the literature through Medline via PubMed was conducted (2020-2024).

Results

There is a plethora of effects of COVID-19 on the heart in the acute setting. Here we discuss pathophysiology, myocardial infarctions, heart failure, Takotsubo Cardiomyopathy, myocardial injury, myocarditis and arrhythmias that are caused by COVID-19. Additionally, these cardiovascular injuries can linger and may be an underlying cause of some Long COVID symptoms.

Conclusions

Cardiovascular complications of COVID-19 are numerous and life-threatening. Long COVID can affect cardiovascular health. Microclotting induced by SARS-CoV-2 infection could be a therapeutic target for some aspects of Long Covid.

A Systematic Review of Frailty Scores Used in Heart Failure Patients

BACKGROUND

Frailty is a complex, multi-dimensional syndrome commonly observed in patients with heart failure (HF). The presence of frailty in patients living with HF is strongly associated with increased vulnerability to adverse events, including falls, hospitalisation, and increased mortality. Several scoring systems have been developed to assess the presence of frailty in patients with HF. These scoring systems vary in their complexity and applicability; however, they provide the physician with a more comprehensive understanding of the biological, functional, and psycho-social needs of these patients.

OBJECTIVES

To assess the clinical applicability of frailty tools in HF patients and their prognostic value, specifically relating to outcomes such as mortality, readmissions, and clinical deterioration.

METHODS

A literature search using six electronic databases (PubMed, Scopus, Embase, Medline, Cochrane and Web of Science) was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Key search Medical Subject Headings (MeSH) terms combined "Frailty" AND "Heart failure". Studies were included if they assessed frailty using systematically defined criteria in a HF population. The PRISMA guidelines were used to include all relevant articles based on titles and abstracts. Full text articles were screened based on abstract relevance. A systematic narrative review of the literature was conducted on the final list of full text articles.

RESULTS

An initial search yielded 8,066 articles. Following the removal of duplicates, title, and abstract searches, the remaining 154 articles underwent full text review, with 31 articles accepted for final qualitative synthesis. The two most utilised frailty scores were the Fried Frailty Phenotype (n=10) and the Barthel Index (n=8). The frailty scores provide prognostic data on multiple outcomes including mortality, increased hospitalisation, and functional decline.

CONCLUSION

At the present time there is no universally applied frailty measure in a HF population. Choice of frailty score should be guided by physician experience and clinical setting, as well as tailored to a patient's functional, biological, and psycho-social circumstances. A push to adopt a single universal scoring system may help to ensure that frailty is assessed in all patients who live with HF.

Clinical characteristics and risk factors for mortality upon admission in patients with heart failure hospitalized due to COVID-19 in Spain

BACKGROUND

There are few studies on patients with heart failure (HF) hospitalized for COVID-19. Our aim is to describe the clinical characteristics of patients with HF hospitalized for COVID-19 and identify risk factors for in-hospital mortality upon admission.

METHODS

We conducted a retrospective, multicenter study in patients with HF hospitalized for COVID-19 in 150 Spanish hospitals (SEMI-COVID-19 Registry). A multivariate logistic regression analysis was performed to identify admission factors associated with in-hospital mortality.

RESULTS

A total of 1718 patients were analyzed (56.5% men; median age 81.4 years). The overall case fatality rate was 47.6% (n = 819). The independent risk factors at admission for in-hospital mortality were: age (adjusted odds ratio [AOR]: 1.03; 95% confidence interval [95%CI]: 1.02-1.05; p < 0.001); severe dependence (AOR: 1.62; 95%CI: 1.19-2.20; p = 0.002); tachycardia (AOR: 1.01; 95%CI: 1.00-1.01; p = 0.004); and high C-reactive protein (AOR: 1.004; 95%CI:1.002-1.004; p < 0.001), LDH (AOR: 1.001; 95%CI: 1.001-1.002; p < 0.001), and serum creatinine levels (AOR: 1.35; 95%CI: 1.18-1.54; p < 0.001).

CONCLUSIONS

Patients with HF hospitalized for COVID-19 have a high in-hospital mortality rate. Some simple clinical and laboratory tests can help to identify patients with a worse prognosis.

[Clinical characteristics and risk factors for mortality upon admission in patients with heart failure hospitalized due to COVID-19 in Spain]

Background

There are few studies on patients with heart failure (HF) hospitalized for COVID-19. Our aim is to describe the clinical characteristics of patients with HF hospitalized for COVID-19 and identify risk factors for in-hospital mortality upon admission.

Methods

We conducted a retrospective, multicenter study in patients with HF hospitalized for COVID-19 in 150 Spanish hospitals (SEMI-COVID-19 Registry). A multivariate logistic regression analysis was performed to identify admission risk factors associated with in-hospital mortality.

Results

A total of 1,718 patients were analyzed (56.5% men; median age 81.4 years). The overall case fatality rate was 47.6% (n=819). The independent risk factors at admission for in-hospital mortality were: age (adjusted odds ratio [AOR]: 1.03; 95% confidence interval [95%CI]: 1.02-1.05; p< .001); severe dependence (AOR: 1.62; 95%CI: 1.19-2.20; p=.002); tachycardia (AOR: 1.01; 95%CI: 1.00-1.01; p=.004); and high C-reactive protein (AOR: 1.004; 95%CI:1.002-1.004; p< .001), LDH (AOR: 1.001; 95%CI: 1.001-1.002; p< .001), and serum creatinine levels (AOR: 1.35; 95%CI: 1.18-1.54; p< .001).

Conclusions

Patients with HF hospitalized for COVID-19 have a high in-hospital mortality rate. Some simple clinical and laboratory tests can help to identify patients with a worse prognosis.

Differences in clinical characteristics and outcome of de novo heart failure compared to acutely decompensated chronic heart failure - systematic review and meta-analysis

BACKGROUND

Recent evidence showed that the characteristics and outcome of those with de novo heart failure (HF) and acutely decompensated chronic heart failure (ADCHF) were different. We aimed to perform a comprehensive search on the clinical characteristics and outcome of patients with de novo HF and ADCHF.

METHODS

We performed a comprehensive search on de novo/new onset acute HF vs ADCHF from inception up until December 2019.

RESULTS

There were 38320 patients from 15 studies. De novo HF were younger and, had less prevalent hypertension, diabetes mellitus, ischaemic heart disease, chronic obstructive pulmonary disease, atrial fibrillation, and history of stroke/transient ischaemic attack compared to ADCHF. Five studies showed a lower NT-proBNP in de novo HF patients, while one study showed no difference. Valvular heart disease as aetiology of heart failure was less frequent in de novo HF, and upon sensitivity analysis, hypertensive heart disease was more frequent in de novo HF. As for precipitating factors, ACS (OR 2.42; I²:89%) was more frequently seen in de novo HF, whereas infection was less frequently (OR 0.69; I²:32%) in ADCHF. De novo HF was associated with a significantly lower 3-month mortality (OR 0.63; I²:91%) and 1-year (OR 0.59; I²:59%) mortality. Meta-regression showed that 1-year mortality did not significantly vary with age (p = .106), baseline ejection fraction (p = .703), or HF reduced ejection fraction (p = .262).

CONCLUSION

Risk factors, aetiology, and precipitating factors of HF in de novo and ADCHF differ. De novo HF also had lower 1-year mortality and 3-month mortality compared to ADCHF.

Clinical Characteristics of De Novo Heart Failure and Acute Decompensated Chronic Heart Failure: Are They Distinctive Phenotypes That Contribute to Different Outcomes?

Heart failure is currently one of the leading causes of morbidity and mortality. Patients with heart failure often present with acute symptoms and may have a poor prognosis. Recent evidence shows differences in clinical characteristics and outcomes between de novo heart failure (DNHF) and acute decompensated chronic heart failure (ADCHF). Based on a better understanding of the distinct pathophysiology of these two conditions, new strategies may be considered to treat heart failure patients and improve outcomes. In this review, the authors elaborate distinctions regarding the clinical characteristics and outcomes of DNHF and ADCHF and their respective pathophysiology. Future clinical trials of therapies should address the potentially different phenotypes between DNHF and ADCHF if meaningful discoveries are to be made.

Low Activities of Daily Living Associated With Increased Cardiovascular Disease Mortality in Japan - Analysis of Health Records From a Nationwide Claim-Based Database, JROAD-DPC

Background: The aim of this study was to clarify the clinical impact of activities of daily living (ADL) using the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination (JROAD-DPC) database.

Methods and Results: From April 2012 to March 2014, the JROAD-DPC database included 206,643 patients with acute coronary syndrome (ACS; n=49,784), heart failure (HF; n=136,878), or aortic aneurysm/dissection (Aorta; n=19,981). We divided them into 3 categories with regard to age (low, 20–59 years; middle, 60–79 years; high, ≥80 years) and admission ADL (low, Barthel index [BI] 0–70; middle, BI 75–95; high, BI 100). ACS, HF, and Aorta patients with low ADL had higher in-hospital mortality rates (18.3%, 16.7%, and 33.4%) than those with middle or high ADL (P<0.001, χ² test). On multivariable analysis, BI on admission was associated with in-hospital mortality of ACS (OR, 0.986 per 1 BI; P<0.001), HF (OR, 0.986 per 1 BI; P<0.001), and Aorta (OR, 0.986 per 1 BI; P<0.001), adjusted for gender, age, body mass index, hypertension, diabetes mellitus, dyslipidemia, and the Charlson comorbidity index. Moreover, patients with low age and low ADL had a higher in-hospital mortality rate than those with high age and high ADL in regard to HF (8.6% vs. 6.0%).

Conclusions: According to JROAD-DPC data, assessment of admission ADL is important in patients with cardiovascular disease.

Basal functional status predicts one-year mortality after a heart failure hospitalization in elderly patients - The RICA prospective study

BACKGROUND

Dependence for basic activities of the daily living (ADL) relates to adverse outcomes in elderly acute heart failure (AHF) patients.

METHODS

We evaluated patients ≥75years admitted because of AHF, divided according to preadmission Barthel Index (BI) category: severe (BI 0-60), moderate (BI 61-90) and slight dependence or independence for basic ADL (BI 91-100). We compared their baseline characteristics and used logistic regression models to determine whether a BI≤60 confers higher one-year mortality risk.

RESULTS

We included 2195 patients, mean age 83years; 57% women, Charlson Index 3, 65% with preserved left ventricular ejection fraction. Their median preadmission BI was 90 (65-100); 21.7% had BI≤60. Patients with BI≤60 were older, more often females, with higher comorbid and cognitive burden and more likely to be institutionalized. 560 patients (26%) died within the follow-up period. A preadmission BI≤60 was significantly associated with higher risk of 12-month mortality (HR 1.42, 95% CI 1.14-1.77) together with male sex (1.27, 1.04-1.54), valve disease (1.49, 1.20-1.83), worse preadmission NYHA class (1.44, 1.20-1.73), stage IV chronic kidney disease (1.70, 1.35-2.15), pulmonary edema (1.33, 1.01-1.76), no family support (1.47, 1.06-2.06), and higher Charlson Comorbidity Index (1.09, CI 1.05-1.13) and Pfeiffer cognitive screening questionnaire scores (1.10, 1.05-1.14).

CONCLUSION

Among elderly AHF patients, the presence of severe (BI≤60) preadmission dependence for basic ADL confers a significant and independent risk of one-year post-discharge mortality.

Cardiovascular Conditions in the Observation Unit: Beyond Chest Pain

The first emergency department observation units (EDOUs) focused on chest pain and potential acute coronary syndromes. However, most EDOUs now cover multiple other conditions that lend themselves to protocolized, aggressive diagnostic and therapeutic regimens. In this article, the authors discuss the management of 4 cardiovascular conditions that have been successfully deployed in EDOUs around the country.

Impact of Oral Treatment on Physical Function in Older Patients Hospitalized for Heart Failure: A Randomized Clinical Trial

Background

Frailty is a characteristic of older patients with heart failure, who undergo functional decline during hospitalization. At present, continuous intravenous infusion of diuretics is widely used for the treatment of hospitalized patients with heart failure. In this prospective, randomized, open-label controlled trial, we tested whether an early switch from continuous intravenous infusion therapy to oral treatment with diuretics prevents functional decline in patients hospitalized for heart failure.

Methods

A total of 59 patients hospitalized for heart failure were randomized to either continuous intravenous infusion (n = 30) or oral medication (n = 29) within 48 h of admission. The primary outcome was the Barthel index, a universally utilized scale to assess the functional status of patients in their activities of daily living, assessed at 10 days. Secondary outcomes included the number of daily steps counted using pedometers and average hospital costs.

Results

Barthel index scores were significantly higher in the oral medication group than in the intravenous group (78.1 ± 20.8 vs. 59.6 ± 34.2, P = 0.029). The number of daily steps was significantly higher in the oral treatment group relative to the intravenous group (P < 0.001), and the average hospital costs were similar between the randomized groups. Multivariate analysis revealed that oral medication was a significant independent predictor of Barthel index score at day 10, and the number of daily steps was significantly associated with the patient’s functional outcome.

Conclusions

This trial showed that, in patients hospitalized for heart failure, oral medication increased functional independence during hospitalization compared with sustained continuous intravenous infusion, most likely because the release from the infusion line enabled the patients to be more mobile. Notably, these beneficial effects were achieved without increasing hospital costs.

[Key messages for the initial management of the elderly patient with acute heart failure]

Acute heart failure is a high prevalence geriatric syndrome that has become one of the most frequent causes of visits to emergency departments, as well as hospital admission, and is associated with high morbidity, mortality and functional impairment. There has been an increasing amount of information published in recent years on the initial management of acute heart failure and the results of the short-term outcomes, as well as the natural history of the disease. The objective of this study is to provide several recommendations that should be taken into account in the initial management of the elderly patient with acute heart failure in the emergency departments, and to review the most interesting currently on-going clinical trials.

Epidemiology of heart failure in Spain over the last 20 years

Heart failure is a major health care problem in Spain, although its precise impact is unknown due to the lack of data from appropriately designed studies. In contrast with the 2% prevalence of heart failure elsewhere in Europe and in the United States, studies in Spain report figures of 5%, probably because of methodological limitations. Heart failure consumes enormous quantities of health care resources; it is the first cause of hospitalization in persons aged 65 years or older and represents 3% of all hospital admissions and 2.5% of health care costs. There are two patterns of heart failure: one with preserved systolic function, more often associated with high blood pressure, and another with depressed systolic function, more often associated with ischemic heart disease. In 2010, heart failure accounted for 3% of all deaths in men and for 10% of all deaths in women. In recent years, the mortality rate from heart failure has gradually fallen. The rise in hospital admissions for heart failure and the decrease in mortality from this cause could partly be explained by temporary changes in diagnostic coding, but there is evidence that the reduced mortality could also be due to adherence to clinical practice guidelines.

[Predictive variables for mortality in elderly patients hospitalized due to heart failure with preserved ejection fraction]

BACKGROUND AND OBJECTIVES

The prevalence of heart failure (HF) increases with age. Even though the mortality of patients ≥ 80 years of age with HF and preserved left ventricle ejection fraction (LVEF) is very high, the predictor variables are not well-known. The main goal of this study was to evaluate the mortality predictor factors in this subgroup of the elderly population.

PATIENTS AND METHODS

An observational and prospective study of patients hospitalized due to HF with preserved LVEF has been conducted. The demographic, clinical, functional and analytic factors were evaluated when the patients were admitted with special attention to the co-morbidities. The primary endpoint was the total mortality in the subgroup of patients ≥ 80 years of age after a year of follow-up. The predictor variables were studied by means of a multivariate Cox regression model.

RESULTS

From a total of 218 patients with an average age of 75.6 (±8.7) years of age, 75 patients (34.4%) were ≥ 80 years. The mortality rate of patients ≥ 80 years of age totaled 42.7%, in relation to 26.6% for the lower age group (log-rank<.001). After a multivariate analysis using the Cox regression model in patients ≥ 80, the serum urea levels above the average (hazard ratio [HR] 3.93; 95% confidence interval [95% CI] 1.58-9.75; P = .003), the age (HR 1.17; 95% CI 1.07-1.28; P<.001), the hyponatremia (HR 3.19; 95% CI 1.51-6.74; P = .002) and a lower score on the Barthel index (BI) (HR 1.016; 95% CI 1.002-1.031; P = .034) were independent mortality predictors after an one-year follow-up.

CONCLUSIONS

Serum urea levels, age, hyponatremia and a low BI score could be proposed as independent mortality predictors in patients ≥ 80 of age hospitalized for HF with preserved LVEF.

Clinical characteristics and one-year survival in heart failure patients more than 85 years of age compared with younger

BACKGROUND

Heart failure (HF) is frequent in elderly patients, but few studies have focused on patients older than 84 years. The aim of this study was to evaluate major comorbidities and 1-year survival in HF patients aged ≥85 years compared with younger age groups.

METHODS

Patients included in a prospective national registry of HF (RICA) were evaluated. Sociodemographic data, Charlson comorbidity index, cognitive status, basal functional status, body mass index, NYHA functional class, and left ventricle ejection fraction (LVEF) were recorded. Patients aged ≥85 years were compared with the rest using the Cox regression model to detect independent predictive factors of 1-year survival.

RESULTS

Of the 1172 patients included, 224 (19%) were aged over 84 years-old, mostly women, with hypertensive heart disease (46%, p<0.001) and preserved LVEF (68.7%; p<0.001). Diabetes (p<0.001), dyslipidemia (p=0.03) and obesity (p<0.001) were less prevalent in this group of patients. One-year mortality in the oldest old patients was 26.3%, which was higher than the rest (p<0.001). By multivariable analysis, a higher NYHA functional class (p=0.038), anemia (p=0.037), absence of obesity (p=0.002), and a worse functional status (p=0.049) were related to a worse 1-year survival in the oldest HF patients.

CONCLUSIONS

The oldest old HF patients have differential characteristics with lower prevalence of diabetes, dyslipidemia and obesity and a lower 1-year survival. Independent factors related to a worse 1-year survival in the oldest age group were a higher NYHA class, a worse functional status, presence of anemia and absence of obesity.

Worsening renal function defined as an absolute increase in serum creatinine is a biased metric for the study of cardio-renal interactions

OBJECTIVES

Worsening renal function (WRF) during the treatment of decompensated heart failure, frequently defined as an absolute increase in serum creatinine >or=0.3 mg/dl, has been reported as a strong adverse prognostic factor in several studies. We hypothesized that this definition of WRF is biased by baseline renal function secondary to the exponential relationship between creatinine and renal function.

METHODS

We reviewed consecutive admissions with a discharge diagnosis of heart failure. An increase in creatinine >or=0.3 mg/dl (WRF(CREAT)) was compared to a decrease in GFR >or=20% (WRF(GFR)).

RESULTS

Overall, 993 admissions met eligibility. WRF(CREAT) occurred in 31.5% and WRF(GFR) in 32.7%. WRF(CREAT) and WRF(GFR) had opposing relationships with baseline renal function (OR = 1.9 vs. OR = 0.51, respectively, p < 0.001). Both definitions had similar unadjusted associations with death at 30 days [WRF(GFR) OR = 2.3 (95% CI 1.1-4.8), p = 0.026; WRF(CREAT) OR = 2.1 (95% CI 1.0-4.4), p = 0.047]. Controlling for baseline renal insufficiency, WRF(GFR) added incrementally in the prediction of mortality (p = 0.009); however, WRF(CREAT) did not (p = 0.11).

CONCLUSIONS

WRF, defined as an absolute change in serum creatinine, is heavily biased by baseline renal function. An alternative definition of WRF should be considered for future studies of cardio-renal interactions.

Low-risk acute heart failure patients: external validation of the Society of Chest Pain Center's recommendations

INTRODUCTION

Risk-stratification in acute heart failure syndromes (AHFS) is problematic. A recent set of recommendations describes emergency department (ED) patients with AHFS who do not fulfill high-risk criteria and may be good candidates for observation unit (OU) management. The goal of this analysis was to report on the outcomes experienced by ED patients with AHFS who do not have any of these high-risk criteria.

METHODS

We performed a secondary analysis of the HEart failure and Audicor technology for Rapid Diagnosis and Initial Treatment (HEARD-IT) multinational study. HEARD-IT was a multicenter study designed to test the impact of acoustic cardiography on ED decision making in patients with possible AHFS. For the purposes of the current analysis we identified a subset of HEARD-IT patients who did not fulfill any high-risk criteria based on published data. The proportion of these patients who experienced an adverse outcome was determined.

RESULTS

The 201 subjects who fulfilled the inclusion criteria had a mean age of 64 years (SD: 13), 61% were male, 34% were Caucasian, and 55% were black. There were a total of 25 (12.4%) cardiac events, including 1 death due to AHFS. The majority of the cardiac events were 30-day readmissions related to AHFS (16/25, 64.0%).

CONCLUSION

AHFS patients at low-risk for subsequent morbidity and mortality based on recent consensus guidelines may be good candidates for early discharge after a brief period of observation in the OU or ED. Additional prospective research is needed to determine the impact of implementation of these criteria in ED patients with AHFS.

Can NT-proBNP predict risk of cardiovascular mortality within 10 years? Results from an epidemiological study of elderly patients with symptoms of heart failure

BACKGROUND

Heart failure has a serious prognosis. However, among elderly patients the panorama of concomitant diseases makes it difficult to implement the results from epidemiological studies. The aim of this study was to evaluate the influence of different clinical variables on cardiovascular mortality during a long-term follow-up.

METHODS AND RESULTS

In all, 474 elderly patients (age 65-82 years) in primary health care were evaluated and followed during a 10 year period. All patients had symptoms associated with heart failure and were examined by a cardiologist. Blood samples including NT-proBNP were analyzed, and ECG and Doppler echocardiography were assessed. Both the systolic and diastolic function was evaluated. Functional capacity was evaluated according to the NYHA classification. During the 10 years of follow-up those with the highest quartile of plasma concentration of NT-proBNP had almost four times increased risk of cardiovascular mortality. Impaired systolic function, diabetes and reduced functional capacity were all markers of increased risk of cardiovascular mortality. All variables were also evaluated after 5 years, with higher risk ratios for a majority of variables.

CONCLUSION

In this study 474 patients with symptoms of heart failure were followed during 10 years. High plasma concentration of NT-proBNP could predict almost four times increased risk of cardiovascular mortality up to 10 years. Also, impaired cardiac function according to echocardiography, and reduced functional capacity as well as diabetes all had influence on risk of cardiovascular mortality up to 10 years.