CHARACTERISTICS AND OUTCOMES OF HOSPITALISED PATIENTS WITH HEART FAILURE AND SARCOIDOSIS: A PROPENISTY-MATCHED ANALYSIS OF THE NATIONWIDE READMISSIONS DATABASE 2010-2019

BACKGROUND

Sarcoidosis is associated with a poor prognosis. There is a lack of data examining the outcomes and readmission rates of sarcoidosis patients with heart failure (SwHF) and without heart failure (SwoHF). We aimed to compare the impact of non-ischemic heart failure on outcomes and readmissions in these two groups.

METHODS

The US Nationwide Readmission Database was queried from 2010-2019 for SwHF and SwoHF patients identified using the International Classification of Diseases, Ninth and Tenth Editions. Those with ischemic heart disease were excluded, and both cohorts were propensity matched for age, gender, and Charlson Comorbidity Index (CCI). Clinical characteristics, length of stay, adjusted healthcare-associated costs, 90-day readmission and mortality were analyzed.

RESULTS

We identified 97,961 hospitalized patients (median age 63 years, 37.9% male) with a diagnosis of sarcoidosis (35.9% SwHF vs. 64.1% SwoHF). On index admission, heart failure patients had higher prevalences of atrioventricular block (3.3% vs. 1.4%, p<0.0001), ventricular tachycardia (6.5% vs. 1.3%, p<0.0001), ventricular fibrillation (0.4% vs. 0.1%, p<0.0001) and atrial fibrillation (22.1% vs. 7.5%, p<0.0001). SwHF patients were more likely to be readmitted (hazard ratio 1.28, p<0.0001), had higher length of hospital stay (5 vs. 4 days, p<0.0001), adjusted healthcare-associated costs ($9,667.0 vs. $9,087.1, p<0.0001) and mortality rates on readmission (5.1% vs. 3.8%, p<0.0001). Predictors of mortality included heart failure, increasing age, male sex, higher CCI and liver disease.

CONCLUSION

SwHF is associated with higher rates of arrhythmia at index admission, as well as greater hospital cost, readmission and mortality rates compared to those without heart failure.

Expected vs Actual Outcomes of Elective Initiation of Inotropic Therapy During Heart Failure Hospitalization

Objective

To describe the intent and early outcomes of elective inotrope use during heart failure hospitalization.

Patients and Methods

A prospective multisite design was used to collect data for hemodynamically stable patients started electively on inotrope therapy between January 1 and August 31, 2018. We prospectively recorded data when intravenous inotropic therapy was initiated, including survey of the attending cardiologists regarding expectations for the clinical course. Patients were followed up for events through hospital discharge and an additional survey was administered at the end of hospitalization.

Results

For the 92 patients enrolled, average age was 60 years and ejection fraction was 24%±12%. At the time of inotrope initiation, attending heart failure cardiologists predicted that 50% (n=46) of the patients had a “high or very high” likelihood of becoming dependent on intravenous inotropic therapy and 58% (n=53) had a “high” likelihood of death, transplant, or durable ventricular assist device placement within the next 6 months. Provider predictions regarding death/hospice or need for continued home infusions were accurate only 51% (47 of 92) of the time. Only half the patients (n=47) had goals-of-care conversations before inotrope treatment initiation.

Conclusion

More than half the patients (51 of 92) electively started on inotrope treatment without present or imminent cardiogenic shock ultimately required home inotrope therapy, died during admission, or were discharged with hospice. Heart failure clinicians could not reliably identify those patients at the time of inotrope therapy initiation and goals-of-care discussions were not frequently performed.

High-Sensitivity Troponin I in Hospitalized and Ambulatory Patients With Heart Failure With Preserved Ejection Fraction: Insights From the Heart Failure Clinical Research Network

Background We sought to study the prevalence of high-sensitivity troponin and its association with cardiac structure and outcomes in ambulatory and hospitalized patients with heart failure with a preserved ejection fraction ( HF p EF ). Methods and Results A post hoc analysis utilized data from HF p EF patients: DOSE (Diuretic Optimization Strategies Evaluation) and CARRESS - HF (Cardiorenal Rescue Study in Acute Decompensated Heart Failure) enrolled patients hospitalized with acute HF p EF , and RELAX (Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in Heart Failure With Preserved Ejection Fraction) enrolled ambulatory patients with HF p EF . High-sensitivity troponin I (hs-TnI) was measured in hospitalized patients at baseline, at 72 to 96 hours, on day 7, and on day 60. In ambulatory patients hs-TnI was measured at baseline and at week 24. In the ambulatory cohort, correlations between hs-TnI and cardiac structure and function were assessed. The association between hs-TnI and a 60-day composite of emergency room visits, readmissions, and death was assessed for hospitalized patients using multivariable Cox proportional hazard models. The study population included 139 hospitalized and 212 ambulatory patients with HF p EF and hs-TnI measured at baseline. The median (25th, 75th percentiles) baseline troponin was 17.6 (11.1, 41.0) ng/L in hospitalized patients and 9.5 (5.3, 19.7) ng/L in ambulatory patients ( P<0.001). The prevalence of elevated hs-TnI (>99% percentile upper reference limit was 86% in hospitalized patients and 53% among ambulatory patients, with stable elevation in ambulatory patients during follow-up. HF p EF patients with a hs-TnI above the median were older with worse left ventricular hypertrophy and diastolic dysfunction. Continuously valued hs-TnI (per doubling) was associated with increased risk of composite end point (adjusted hazard ratio 1.20, 95% confidence interval 1.00-1.43; P=0.042). Conclusions Hs-TnI is commonly elevated among both hospitalized and ambulatory patients with HF p EF . Increased hs-TnI levels are associated with worse cardiac structure and increased risk of adverse events.

Comparing Measures to Assess Health-Related Quality of Life in Heart Failure With Preserved Ejection Fraction

OBJECTIVES

This study sought to compare the performance of 2 health-related quality of life (HRQOL) questionnaires in patients with heart failure with preserved ejection fraction (HFpEF).

BACKGROUND

The ability to accurately assess HRQOL over time is important in the care of patients with heart failure. The validity and reliability of HRQOL tools including the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the Kansas City Cardiomyopathy Questionnaire (KCCQ) has not been fully determined or compared in patients with HFpEF.

METHODS

Among patients with stable chronic HFpEF enrolled in the NEAT (Nitrate Effect on Activity Tolerance in Heart Failure) trial (n = 110), the study evaluated and compared reliability, validity, and responsiveness to change of the MLHFQ and KCCQ at baseline, 6 weeks, and 12 weeks.

RESULTS

Internal consistency was good and comparable for MLHFQ and KCCQ domains measuring similar aspects of HRQOL at baseline including the MLHFQ physical (Cronbach's α = 0.93) compared with the KCCQ clinical summary (α = 0.91), and the MLHFQ emotional (α = 0.92) compared with the KCCQ quality of life (α = 0.87). Correlations with New York Heart Association functional class (Spearman rho; r_s= -0.37 vs. 0.30) and 6-min walk test (6MWT) (r_s = 0.38 vs. -0.23) at baseline were slightly stronger for the KCCQ overall summary score than for the MLHFQ total score. The MLHFQ was more responsive to change in 6MWT based on responsiveness statistics.

CONCLUSIONS

These data suggest that both the MLHFQ and KCCQ are reliable and valid tools to assess HRQOL in HFpEF. The KCCQ was more strongly correlated with baseline functional status parameters, while the MLHFQ was more responsive to improvement in 6MWT.

Unanswered Questions in Contemporary Heart Failure

OBJECTIVE

The epidemiology of heart failure (HF) is changing. This study aimed to describe questions that arise during the routine care of HF patients that are unanswered by the current literature and describe how the type and focus of these questions has changed over time.

METHODS

Investigators from the National Heart, Lung, and Blood Institute-sponsored Heart Failure Apprentice Network collected and categorized questions from 5 academic hospitals over 12 months. A total of 174 unanswered questions were collected and analyzed.

RESULTS

Compared with 2004, there were more unanswered questions about "whether" to use therapies and fewer about "how" to use therapies. There were fewer questions about what therapeutic targets, therapy adjustment, and combination therapies. There were more questions about whether or how to stop therapies and how to add therapies back. Newly prominent topics, not observed in 2004, including novel therapeutics, refractory ventricular tachycardia, right heart failure, and nutrition/frailty, accounted for 24% of questions.

CONCLUSIONS

Compared with 2004, there are fewer unanswered questions about how to use, adjust, and combine therapies. There were more unanswered questions about whether and how to stop therapies. Almost 25% of unanswered questions dealt with topics indicative of more advanced disease which were not observed in 2004.