Frailty and Post-hospitalization Outcomes in Patients With Heart Failure With Preserved Ejection Fraction

Given the role of comorbid conditions in the pathophysiology of HFpEF, we aimed to identify and rank the importance of comorbid conditions associated with post-hospitalization outcomes of older adults hospitalized for HFpEF. We examined data from 4,605 Medicare beneficiaries hospitalized in 2007-2014 for HFpEF based on ICD-9-CM codes for acute diastolic heart failure (428.31 or 428.33). To identify characteristics with high importance for prediction of mortality, all-cause rehospitalization, rehospitalization for heart failure, and composite outcome of mortality or all-cause rehospitalization up to 1 year, we developed boosted decision tree ensembles for each outcome, separately. For interpretability, we estimated hazard ratios (HRs) and 95% confidence intervals (CI) using Cox proportional hazards models. Age and frailty were the most important characteristics for prediction of mortality. Frailty was the most important characteristic for prediction of rehospitalization, rehospitalization for heart failure, and the composite outcome of mortality or all-cause rehospitalization. In Cox proportional hazards models, a 1-SD higher frailty score (0.1 on theoretical range of 0 to 1) was associated with a HR of 1.27 (1.06 to 1.52) for mortality, 1.16 (1.07 to 1.25) for all-cause rehospitalization, 1.24 (1.14 to 1.35) for HF rehospitalization, and 1.15 (1.07 to 1.25) for the composite outcome of mortality or all-cause rehospitalization. In conclusion, frailty is an important predictor of mortality and rehospitalization in adults aged ≥66 years with HFpEF.

Attitudes toward deprescribing among adults with heart failure with preserved ejection fraction

BACKGROUND/OBJECTIVES

Attitudes toward deprescribing could vary among subpopulations. We sought to understand patient attitudes toward deprescribing among patients with heart failure with preserved ejection fraction (HFpEF).

DESIGN

Retrospective cohort study.

SETTING

Academic medical center in New York City.

PARTICIPANTS

Consecutive patients with HFpEF seen in July 2018-December 2019 at a program dedicated to providing care to older adults with HFpEF.

MEASUREMENTS

We assessed the prevalence of vulnerabilities outlined in the domain management approach for caring for patients with heart failure and examined data on patient attitudes toward having their medicines deprescribed via the revised Patient Attitudes Toward Deprescribing (rPATD).

RESULTS

Among 134 patients with HFpEF, median age was 75 (interquartile range 69-82), 60.4% were women, and 35.8% were nonwhite. Almost all patients had polypharmacy (94.0%) and 56.0% had hyperpolypharmacy; multimorbidity (80.6%) and frailty (78.7%) were also common. Overall, 90.3% reported that they would be willing to have one or more of their medicines deprescribed if told it was possible by their doctors; and 26.9% reported that they would like to try stopping one of their medicines to see how they feel without it. Notably, 91.8% of patients reported that they would like to be involved in decisions about their medicines. In bivariate logistic regression, nonwhite participants were less likely to want to try stopping one of their medicines to see how they feel without it (odds ratio 0.25, 95% confidence interval [0.09-0.62], p = 0.005).

CONCLUSIONS

Patients with HFpEF contend with many vulnerabilities that could prompt consideration for deprescribing. Most patients with HFpEF were amenable to deprescribing. Race may be an important factor that impacts patient attitudes toward deprescribing.

Complex and Potentially Harmful Medication Patterns in Heart Failure with Preserved Ejection Fraction

BACKGROUND

Complex medication regimens, often present in heart failure with preserved ejection fraction, may increase the risk of adverse drug effects and harm. We sought to characterize this complexity by determining the prevalence of polypharmacy, potentially inappropriate medications, and therapeutic competition (where a medication for 1 condition may worsen another condition) in 1 of the few dedicated heart failure with preserved ejection fraction programs in the United States.

METHODS

We conducted chart review on 231 patients with heart failure with preserved ejection fraction seen in the University of Michigan's Heart Failure with Preserved Ejection Fraction Clinic between July 2016 and September 2019. We recorded: 1) standing medications to determine the presence of polypharmacy, defined as ≥10 medications; 2) potentially inappropriate medications based on the 2016 American Heart Association Scientific Statement on drugs that pose a major risk of causing or exacerbating heart failure, the 2019 Beers Criteria update, or a previously described list of medications associated with geriatric syndromes; and 3) competing conditions and subsequent medications that could create therapeutic competition.

RESULTS

The prevalence of polypharmacy was 74%, and the prevalence of potentially inappropriate medications was 100%. Competing conditions were present in 81% of patients, of whom 49% took a medication that created therapeutic competition.

CONCLUSION

In addition to confirming that polypharmacy was highly prevalent, we found that potentially inappropriate medications and therapeutic competition were also frequently present. This supports the urgent need to develop patient-centered approaches to mitigate the negative effects of complex medication regimens endemic to adults with heart failure with preserved ejection fraction.

Prosthetic aortic graft replacement of the ascending thoracic aorta alters biomechanics of the native descending aorta as assessed by transthoracic echocardiography

Introduction

In patients with ascending aortic (AA) aneurysms, prosthetic graft replacement yields benefit but risk for complications in the descending aorta persists. Longitudinal impact of AA grafts on native descending aortic physiology is poorly understood.

Methods

Transthoracic echocardiograms (echo) in patients undergoing AA elective surgical grafting were analyzed: Descending aortic deformation indices included global circumferential strain (GCS), time to peak (TTP) strain, and fractional area change (FAC). Computed tomography (CT) was used to assess aortic wall thickness and calcification.

Results

46 patients undergoing AA grafting were studied; 65% had congenital or genetically-associated AA (30% bicuspid valve, 22% Marfan, 13% other): After grafting (6.4±7.5 months), native descending aortic distension increased, irrespective of whether assessed based on circumferential strain or area-based methods (both p<0.001). Increased distensibility paralleled altered kinetics, as evidenced by decreased time to peak strain (p = 0.01) and increased velocity (p = 0.002). Augmented distensibility and flow velocity occurred despite similar pre- and post-graft blood pressure and medications (all p = NS), and was independent of pre-surgical aortic regurgitation or change in left ventricular stroke volume (both p = NS). Magnitude of change in GCS and FAC was 5–10 fold greater among patients with congenital or genetically associated AA vs. degenerative AA (p<0.001), paralleling larger descending aortic size, greater wall thickness, and higher prevalence of calcific atherosclerotic plaque in the degenerative group (all p<0.05). In multivariate analysis, congenital/genetically associated AA etiology conferred a 4-fold increment in magnitude of augmented native descending aortic strain after proximal grafting (B = 4.19 [CI 1.6, 6.8]; p = 0.002) independent of age and descending aortic size.

Conclusions

Prosthetic graft replacement of the ascending aorta increases magnitude and rapidity of distal aortic distension. Graft effects are greatest with congenital or genetically associated AA, providing a potential mechanism for increased energy transmission to the native descending aorta and adverse post-surgical aortic remodeling.