Diagnosis and Management of Heart Failure in Elderly Patients from Hospital Admission to Discharge: Position Paper

Optimisation of treatments for heart failure with reduced ejection fraction in routine practice: a position statement from a panel of experts

Major international practice guidelines recommend the use of a combination of 4 medication classes in the treatment of patients with heart failure with reduced ejection fraction (HFrEF) but do not specify how these treatments should be introduced and up-titrated. Consequently, many patients with HFrEF do not receive an optimized treatment regimen. This review proposes a pragmatic algorithm for treatment optimization designed to be easily applied in routine practice. The first goal is to ensure that all 4 recommended medication classes are initiated as early as possible to establish effective therapy, even at a low dose. This is considered preferable to starting fewer medications at a maximum dose. The second goal is to ensure that the intervals between the introduction of different medications and between different titration steps are as short as possible to ensure patient safety. Specific proposals are made for older patients (> 75 years) who are frail, and for those with cardiac rhythm disorders. Application of this algorithm should allow an optimal treatment protocol to be achieved within 2-months in most patients, which should the treatment goal in HFrEF.

Patients with cardiac amyloidosis are at a greater risk of mortality and hospital readmission after acute heart failure

AIMS

Cardiac amyloidosis (CA) is an under-diagnosed cause of heart failure (HF) and has a worse prognosis than other forms of HF. The frequency of death or rehospitalization following discharge for acute heart failure (AHF) in CA (relative to other causes) has not been documented. The study aims to compare hospital readmission and death rates 90 days after discharge for AHF in patients with vs. without CA and to identify risk factors associated with these events in each group.

METHODS AND RESULTS

Patients with HF and CA (HF + CA+) were recruited from the ICREX cohort, after screening of their medical records. The cases were matched 1:5 by sex and age with control HF patients without CA (HF + CA-). There were 27 HF + CA + and 135 HF + CA- patients from the ICREX cohort included in the study. Relative to the HF + CA- group, HF + CA+ patients had a higher heart rate (P = 0.002) and N-terminal prohormone of brain natriuretic peptide levels (P < 0.001) and lower blood pressure (P < 0.001), weight, and body mass index values (P < 0.001) on discharge. Ninety days after discharge, the HF + CA+ group displayed a higher death rate, a higher all-cause hospital readmission rate, and a higher hospital readmission rate for AHF. Death and hospital readmissions occurred sooner after discharge in the HF + CA+ group than in the HF + CA- group.

CONCLUSIONS

The presence of CA in patients with HF was associated with a three-fold greater risk of death and a two-fold greater risk of all-cause hospital readmission 90 days after discharge. These findings emphasize the importance of close, active management of patients with CA and AHF.

Effect of Ghrelin Intervention on the Ras/ERK Pathway in the Regulation of Heart Failure by PTEN

Objective. To study the possible mechanism of ghrelin in heart failure and how it works. Method. In vitro results demonstrated that ghrelin alleviates cardiac function and reduces myocardial fibrosis in rats with heart failure. Moreover, ghrelin intervention increased PTEN expression level and reduced ERK, c-jun, and c-Fos expression level; in vivo experiments demonstrated that ghrelin intervention reduces mast memory expression and increases cardiomyocyte surface area, PTEN expression level, ERK, c-jun, c-Fos expression level, and cell surface area, while ERK blockade suppresses mast gene expression and reduces cell surface area. Results. In vitro experimental results prove that we have successfully constructed a rat model related to heart failure, and ghrelin can alleviate the heart function of heart failure rats and reduce myocardial fibrosis. In addition, ghrelin is closely related to the decrease of the expression levels of ERK, c-jun, and c-Fos, but it can also increase the expression of PTEN in the rat model; in vivo experiments proved that we successfully constructed an in vitro cardiac hypertrophy model, and the intervention of ghrelin would reduce the expression of hypertrophic memory and increase the surface area of cardiomyocytes, increase the expression level of PTEN, and reduce the expression levels of ERK, c-jun, and c-Fos, while the blockade of PTEN will increase the expression of hypertrophy genes and increase the cell surface area, while the blockade of ERK will increase the expression of hypertrophic genes, which in turn will make the cell surface area reducing. Conclusion. Ghrelin inhibits the phosphorylation and nuclear entry of ERK by activating PTEN, thereby controlling the transcription of hypertrophic genes, improving myocardial hypertrophy, and enhancing cardiac function.

Cost and Effectiveness of Long-Term Care Following Integrated Discharge Planning: A Prospective Cohort Study

Little is known about the effects of seamless hospital discharge planning on long-term care (LTC) costs and effectiveness. This study evaluates the cost and effectiveness of the recently implemented policy from hospital to LTC between patients discharged under seamless transition and standard transition. A total of 49 elderly patients in the standard transition cohort and 119 in the seamless transition cohort were recruited from November 2016 to February 2018. Data collected from medical records included the Multimorbidity Frailty Index, Activities of Daily Living Scale, and Malnutrition Universal Screening Tool during hospitalization. Multiple linear regression and Cox regression models were used to explore risk factors for medical resource utilization and medical outcomes. After adjustment for effective predictors, the seamless cohort had lower direct medical costs, a shorter length of stay, a higher survival rate, and a lower unplanned readmission rate compared to the standard cohort. However, only mean total direct medical costs during hospitalization and 6 months after discharge were significantly (p < 0.001) lower in the seamless cohort (USD 6192) compared to the standard cohort (USD 8361). Additionally, the annual per-patient economic burden in the seamless cohort approximated USD 2.9–3.3 billion. Analysis of the economic burden of disability in the elderly population in Taiwan indicates that seamless transition planning can save approximately USD 3 billion in annual healthcare costs. Implementing this policy would achieve continuous improvement in LTC quality and reduce the financial burden of healthcare on the Taiwanese government.