Impact of Triggering Events on Outcomes of Acute Heart Failure

Hospital Variability in the Use of Vasoactive Agents in Patients Hospitalized for Acute Decompensated Heart Failure for Clinical Phenotypes

BACKGROUND

The absence of practice standards in vasoactive agent usage for acute decompensated heart failure has resulted in significant treatment variability across hospitals, potentially affecting patient outcomes. This study aimed to assess temporal trends and institutional differences in vasodilator and inotrope/vasopressor utilization among patients with acute decompensated heart failure, considering their clinical phenotypes.

METHODS

Data were extracted from a government-funded multicenter registry covering the Tokyo metropolitan area, comprising consecutive patients hospitalized in intensive/cardiovascular care units with a primary diagnosis of acute decompensated heart failure between January 2013 and December 2021. Clinical phenotypes, that is, pulmonary congestion or tissue hypoperfusion, were defined through a comprehensive assessment of clinical signs and symptoms, vital signs, and laboratory findings. We assessed the frequency and temporal trends in phenotype-based drug utilization of vasoactive agents and investigated institutional characteristics associated with adopting the phenotype-based approach using generalized linear mixed-effects models, with random intercepts to account for hospital-level variability.

RESULTS

Among 37 293 patients (median age, 80 years; 43.7% female), 88.6% and 21.2% had pulmonary congestion and tissue hypoperfusion status, respectively. Throughout the study period, both overall and phenotype-based vasodilator utilizations showed significant declines, with overall usage dropping from 61.4% in 2013 to 48.6% in 2021 (Ptrend<0.001). Conversely, no temporal changes were observed in overall inotrope/vasopressor utilization from 24.6% in 2013 to 25.8% in 2021 or the proportion of phenotype-based utilization. Notably, there was considerable variability in phenotype-based drug utilization among hospitals, with a median ranging from 48.3% to 77.8%. In multivariable-adjusted models, a higher number of board-certified cardiologists were significantly associated with lower rates of phenotype-based vasodilator utilization and reduced inappropriate inotrope/vasopressor utilization, while tertiary care hospitals were linked to more appropriate inotrope/vasopressor utilization.

CONCLUSIONS

Substantial variability existed among hospitals in phenotype-based drug utilization of vasoactive agents for patients with acute decompensated heart failure, highlighting the need for standardized treatment protocols.

REGISTRATION

URL: https://www.umin.ac.jp/ctr/index.htm; Unique identifier: UMIN000013128.

Association Between Complementary Use of Daikenchuto (a Japanese Herbal Medicine) and Readmission in Older Patients With Heart Failure and Constipation

Background

Constipation commonly coexists with heart failure (HF) and can increase blood pressure because of straining during defecation and accompanying mental stress. Daikenchuto, a Japanese herbal medicine to ameliorate gastrointestinal motility, may be effective as a complement to laxatives in improving outcomes in patients with HF and constipation.

Methods and Results

We used the Diagnosis Procedure Combination database to identify patients aged ≥65 years who were admitted for HF, had constipation, and were discharged alive between April 2016 and March 2022. We divided the 115,544 eligible patients into 2 groups according to the prescription of Daikenchuto in addition to laxatives at discharge and compared the incidence of 1-year HF readmission using 1 : 4 propensity score matching. Daikenchuto was prescribed at discharge in 3,315 (2.9%) patients. In the unmatched cohort, patients treated with Daikenchuto were more often male and had a higher prevalence of malignancy than those treated without Daikenchuto. In the 1 : 4 propensity score-matched cohort (3,311 and 13,243 patients with and without Daikenchuto, respectively), no significant difference was noted in 1-year HF readmission between the groups (22.2% vs. 21.9%; hazard ratio=1.02, 95% confidence interval=0.94-1.11). This result was consistent across clinically relevant subgroups except for renal disease.

Conclusions

Complementary use of Daikenchuto in combination with laxatives was not associated with a lower incidence of HF readmission in patients with HF and constipation.

Association Between Coexisting Constipation and Heart Failure Readmission in Patients With Heart Failure - A Nationwide Database Study

Background

Constipation often coexists with heart failure (HF) and can cause increased blood pressure variability, which may increase the risk of repeated HF admissions. However, large-scale contemporary data regarding the prognostic effect of constipation in patients with HF are lacking.

Methods and Results

We retrospectively identified 556,792 patients admitted for HF for the first time and discharged alive in the fiscal years 2016-2021 using the Japanese Diagnosis Procedure Combination database. Constipation was defined as continued use of laxatives after discharge. We examined the association between constipation and 1-year HF readmission. The prevalence of constipation was 22.0% (n=122,670), which remained stable over the 6 years. Patients with constipation were older (82.7±10.1 vs. 79.3±12.8 years), more often female (53.5% vs. 48.0%), and received medications for HF more frequently at discharge compared with those without constipation. In the multivariable Cox proportional hazards model, constipation was significantly associated with a higher incidence of 1-year HF readmission (24.0% vs. 18.6%; adjusted hazard ratio [HR] 1.08; 95% confidence interval [CI] 1.06-1.10). This result was consistent with the result from the Fine-Gray model accounting for competing risk of death (subdistribution HR 1.08; 95% CI 1.06-1.09).

Conclusions

Constipation was associated with a higher risk of HF readmission after the first episode of HF hospitalization. Given the detrimental effect of constipation, further efforts are warranted to decrease constipation-related risk in patients with HF.

Association of pre-hospital precipitating factors with short- and long-term outcomes of acute heart failure patients: A report from the WET-HF2 registry

BACKGROUND

Interest in clinical course preceding heart failure (HF) exacerbation has grown, with a greater emphasis placed on patients' clinical factors including precipitant factor (PF). Large-scale studies with precise PF documentation and temporal-outcome variation remain limited.

METHODS

We reviewed prospectively collected 2412 consecutive patient-level records from a multicenter Japanese registry of hospitalized patients with HF (West Tokyo Heart Failure2 Registry: 2018-2020). Patients were categorized based on PFs: behavioral (i.e., poor adherence to physical activity, medicine, or diet regimen), treatment-required (i.e., anemia, arrhythmia, ischemia, infection, thyroid dysfunction or other conditions as suggested exacerbating factors), and no-PF. The composite outcomes of HF rehospitalization and death within 1 year after discharge and HF rehospitalization were individually assessed.

RESULTS

Median patient age was 78 years (interquartile range: 68-85 years), and 1468 (61%) patients had documented PFs, of which 356 (15%) were considered behavioral. The behavioral PF group were younger, more male and had past HF hospitalization history compared to those in the other groups (all p < 0.05). Although risk of in-hospital death was lower in the behavioral PF group, their risk of composite outcome was not significantly different from the treatment-required group (hazard ratio [HR] 1.19 [95% confidence interval {CI} 0.93-1.51]) and the no-PF group (HR 1.28 [95%CI 1.00-1.64]). Furthermore, the risk of HF rehospitalization was higher in the behavioral PF group than in the other two groups (HR 1.40 [95%CI 1.07-1.83] and HR 1.39 [95%CI 1.06-1.83], respectively).

CONCLUSION

Despite a better in-hospital prognosis, patients with behavioral PFs were at significantly higher risk of HF rehospitalization.

Association of ambient temperature and acute heart failure with preserved and reduced ejection fraction

AIMS

Evidence on the association between ambient temperature and the onset of acute heart failure (AHF) is scarce and mixed. We sought to investigate the incidence of AHF admissions based on ambient temperature change, with particular interest in detecting the difference between AHF with preserved (HFpEF), mildly reduced (HFmrEF), and reduced ejection fraction (HFrEF).

METHODS AND RESULTS

Individualized AHF admission data from January 2015 to December 2016 were obtained from a multicentre registry (Tokyo CCU Network Database). The primary event was the daily number of admissions. A linear regression model, using the lowest ambient temperature as the explanatory variable, was selected for the best-estimate model. We also applied the cubic spline model using five knots according to the percentiles of the distribution of the lowest ambient temperature. We divided the entire population into HFpEF + HFmrEF and HFrEF for comparison. In addition, the in-hospital treatment and mortality rates were obtained according to the interquartile ranges (IQRs) of the lowest ambient temperature (IQR1 <5.5°C; IQR25.5-13.3°C; IQR3 13.3-19.7°C; and IQR4 >19.7°C). The number of admissions for HFpEF, HFmrEF and HFrEF were 2736 (36%), 1539 (20%), and 3354 (44%), respectively. The lowest ambient temperature on the admission day was inversely correlated with the admission frequency for both HFpEF + HFmrEF and HFrEF patients, with a stronger correlation in patients with HFpEF + HFmrEF (R²  = 0.25 vs. 0.05, P < 0.001). In the sensitivity analysis, the decrease in the ambient temperature was associated with the greatest incremental increases in HFpEF, followed by HFmrEF and HFrEF patients (3.5% vs. 2.8% vs. 1.5% per -1°C, P < 0.001), with marked increase in admissions of hypertensive patients (systolic blood pressure >140 mmHg vs. 140-100 mmHg vs. <100 mmHg, 3.0% vs. 2.0% vs. 0.8% per -1°C, P for interaction <0.001). A mediator analysis indicated the presence of the mediator effect of systolic blood pressure. The in-hospital mortality rate (7.5%) did not significantly change according to ambient temperature (P = 0.62).

CONCLUSIONS

Lower ambient temperature was associated with higher frequency of AHF admissions, and the effect was more pronounced in HFpEF and HFmrEF patients than in those with HFrEF.

Time-sensitive approach in the management of acute heart failure

Acute heart failure (AHF) has become a global public health burden largely because of the associated high morbidity, mortality, and cost. The treatment options for AHF have remained relatively unchanged over the past decades. Historically, clinical congestion alone has been considered the main target for treatment of acute decompensation in patients with AHF; however, this is an oversimplification of the complex pathophysiology. Within the similar clinical presentation of congestion, significant differences in pathophysiological mechanisms exist between the fluid accumulation and redistribution. Tissue hypoperfusion is another vital characteristic of AHF and should be promptly treated with appropriate interventions. In addition, recent clinical trials of novel therapeutic strategies have shown that heart failure management is ‘time sensitive’ and suggested that treatment selection based on individual aetiologies, triggers, and risk factor profiles could lead to better outcomes. In this review, we aim to describe the specifics of the ‘time‐sensitive’ approach by the clinical phenotypes, for example, pulmonary/systemic congestion and tissue hypoperfusion, wherein patients are classified based on pathophysiological conditions. This mechanistic classification, in parallel with the comprehensive risk assessment, has become a cornerstone in the management of patients with AHF and thus supports effective decision making by clinicians. We will also highlight how therapeutic modalities should be individualized according to each clinical phenotype.

Feasibility of the deep learning method for estimating the ventilatory threshold with electrocardiography data

Regular aerobic physical activity is of utmost importance in maintaining a good health status and preventing cardiovascular diseases (CVDs). Although cardiopulmonary exercise testing (CPX) is an essential examination for noninvasive estimation of ventilatory threshold (VT), defined as the clinically equivalent to aerobic exercise, its evaluation requires an expensive respiratory gas analyzer and expertize. To address these inconveniences, this study investigated the feasibility of a deep learning (DL) algorithm with single-lead electrocardiography (ECG) for estimating the aerobic exercise threshold. Two hundred sixty consecutive patients with CVDs who underwent CPX were analyzed. Single-lead ECG data were stored as time-series voltage data with a sampling rate of 1000 Hz. The data of preprocessed ECG and time point at VT calculated by respiratory gas analyzer were used to train a neural network. The trained model was applied on an independent test cohort, and the DL threshold (DLT; a time of VT estimated through the DL algorithm) was calculated. We compared the correlation between oxygen uptake of the VT (VT-VO2) and the DLT (DLT-VO2). Our DL model showed that the DLT-VO2 was confirmed to be significantly correlated with the VT-VO2 (r = 0.875; P < 0.001), and the mean difference was nonsignificant (-0.05 ml/kg/min, P > 0.05), which displayed strong agreements between the VT and the DLT. The DL algorithm using single-lead ECG data enabled accurate estimation of VT in patients with CVDs. The DL algorithm may be a novel way for estimating aerobic exercise threshold.

Benefit and harm of intravenous vasodilators across the clinical profile spectrum in acute cardiogenic pulmonary oedema patients

BACKGROUND

The absence of high quality, large-scale data that indicates definitive mortality benefits does not allow for firm conclusions on the role of intravenous vasodilators in acute heart failure. We aimed to investigate the associations between intravenous vasodilators and clinical outcomes in acute heart failure patients, with a specific focus on patient profiles and type of vasodilators.

METHODS

Data of 26,212 consecutive patients urgently hospitalised for a primary diagnosis of acute heart failure between 2009 and 2015 were extracted from a government-funded multicentre data registration system. Propensity scores were calculated with multiple imputations and 1:1 matching performed between patients with and without vasodilator use. The primary endpoint was inhospital mortality.

RESULTS

On direct comparison of the vasodilator and non-vasodilator groups after propensity score matching, there were no significant differences in the inhospital mortality rates (7.5% vs. 8.8%, respectively; P=0.098) or length of intensive/cardiovascular care unit stay and hospital stay between the two groups. However, there was a substantial difference in baseline systolic blood pressure by vasodilator type; favourable impacts of vasodilator use on inhospital mortality were observed among patients who had higher systolic blood pressures and those who had no atrial fibrillation on admission. Furthermore, when compared to nitrates, the use of carperitide (natriuretic peptide agent) was significantly associated with worse outcomes, especially in patients with intermediate systolic blood pressures.

CONCLUSIONS

In acute heart failure patients, vasodilator use was not universally associated with improved inhospital outcomes; rather, its effect depended on individual clinical presentation: patients with higher systolic blood pressure and no atrial fibrillation seemed to benefit maximally from vasodilators.

TRIAL REGISTRATION

UMIN-CTR identifier, UMIN000013128.