The Vulnerable Phase of Heart Failure

Prognostic effect of the combined use of thiazides and loop diuretics at discharge following a hospitalization for acute heart failure

AIMS

There is limited information regarding the clinical impact of the concurrent use of thiazides and loop diuretics (LD) after an episode of acute heart failure (AHF) hospitalization. We aimed to evaluate the impact of thiazide prescription at discharge on top of LD on the short-term risk of AHF readmission.

METHODS

We included 3384 consecutive patients discharged from January 2008 to September 2021 after an admission for AHF in a single teaching center. The association between thiazides on discharge across the intensity of LD treatment and 30-day AHF readmission was explored by Cox regression analysis. A validation cohort of 622 patients was also examined.

RESULTS

The mean age of the patients was 73.8 ± 11.2 years, 1672 (47.5%) were women, and 1733 (51.2%) patients showed left ventricular ejection fraction > 50%. The median (IQR) NT-proBNP was 3409 (1829-6963) pg/mL. At discharge, 754 (22.3%) patients received high LD doses (> 80 mg/day) and 187 (5.5%) thiazides. At 30 days, we registered 76 (2.2%) deaths and 449 (13.3%) AHF readmissions. Thiazides at discharge were not associated with the risk of 30-day AHF readmission (HR = 0.92). However, this association was differentially influenced by the intensity of LD doses (p-value for interaction = 0.030), with a lower AHF-readmission risk in those with LD dose > 80 mg/day (p = 0.038), and a neutral association in those receiving low LD dose (≤ 80 mg/day) (p = 0.541).

CONCLUSIONS

In patients discharged after an episode of AHF, thiazide prescription was associated with a lower risk of 30-day AHF readmission when they were prescribed in patients receiving high LD doses.

Machine Learning-Based Prediction of Unplanned Readmission Due to Major Adverse Cardiac Events Among Hospitalized Patients with Blood Cancers

BackgroundHospitalized patients with blood cancer face an elevated risk for cardiovascular diseases caused by cardiotoxic cancer therapies, which can lead to cardiovascular-related unplanned readmissions.ObjectiveWe aimed to develop a machine learning (ML) model to predict 90-day unplanned readmissions for major adverse cardiovascular events (MACE) in hospitalized patients with blood cancers.DesignA retrospective population-based cohort study.MethodsWe analyzed patients aged ≥18 with blood cancers (leukemia, lymphoma, myeloma) using the Nationwide Readmissions Database. MACE included acute myocardial infarction, ischemic heart disease, stroke, heart failure, revascularization, malignant arrhythmias, and cardiovascular-related death. Six ML algorithms (L2-Logistic regression, Support Vector Machine, Complement Naïve Bayes, Random Forest, XGBoost, and CatBoost) were trained on 2017-2018 data and tested on 2019 data. The SuperLearner algorithm was used for stacking models. Cost-sensitive learning addressed data imbalance, and hyperparameters were tuned using 5-fold cross-validation with Optuna framework. Performance metrics included the Area Under the Receiver Operating Characteristics Curve (ROCAUC), Precision-Recall AUC (PRAUC), balanced Brier score, and F2 score. SHapley Additive exPlanations (SHAP) values assessed feature importance, and clustering analysis identified high-risk subpopulations.ResultsAmong 76 957 patients, 1031 (1.34%) experienced unplanned 90-day MACE-related readmissions. CatBoost achieved the highest ROCAUC (0.737, 95% CI: 0.712-0.763) and PRAUC (0.040, 95% CI: 0.033-0.050). The SuperLearner algorithm achieved slight improvements in most performance metrics. Four leading predictive features were consistently identified across algorithms, including older age, heart failure, coronary atherosclerosis, and cardiac dysrhythmias. Twenty-three clusters were determined with the highest-risk cluster (mean log odds of 1.41) identified by nonrheumatic/unspecified valve disorders, coronary atherosclerosis, and heart failure.ConclusionsOur ML model effectively predicts MACE-related readmissions in hospitalized patients with blood cancers, highlighting key predictors. Targeted discharge strategies may help reduce readmissions and alleviate the associated healthcare burden.

Prevalence and risk factors of mortality among heart failure patients in low resource setting hospitals: a multicenter prospective observational study

Background

Heart failure is a significant worldwide health problem that leads to mortality. Therefore, this study aimed to evaluate treatment outcomes and associated factors of heart failure patients who were admitted to hospitals in the southwest of Ethiopia.

Methods and participants

A multicenter prospective observational study was conducted from 1 February to 1 August 2021. Drug therapy problems were assessed as per the Cipolle, Strands, and Morley drug therapy problems classification method. The drug therapy was registered by using the drug-related problem registration format. The results of logistic regression analysis was interpreted as crude odds ratio and adjusted odds ratio (AOR) at 95% confidence interval (CI) to determine the association between dependent and independent variables.

Results

In our study settings, a total of 205 (85.1%) heart failure patients showed improvement and 36 (14.9%) died at hospital discharge. Being ≥65 years (AOR = 7.14, 95% CI: 2.04-.25.01, P = 0.002), a previous hospitalization (AOR = 6.20, 95% CI: 1.81-21.21, P = 0.004), and the presence of medication-related problems (AOR = 3.65, 95% CI: 1.13-11.73, P = 0.03) were the predictors of mortality.

Conclusion

The prevalence of in-hospital mortality among heart failure patients was found to be high. Previous hospitalization, older age, and the presence of drug therapy problems were the predictors of mortality among heart failure patients. Therefore, proper attention should be given to the management of elderly and re-admitted heart failure patients in addition to their regular care. In addition, hospitals should implement clinical pharmacy services to address any drug-related problems.

Evaluating a New Short Self-Management Tool in Heart Failure Against the Traditional Flinders Program

Background/Objective: Heart failure (HF) is a complex syndrome, with multiple causes. Numerous pathophysiological pathways are activated. Comprehensive and guideline-derived care is complex. A multidisciplinary approach is required. The current guidelines report little evidence for chronic disease self-management (CDSM) programs for reducing readmission and major adverse cardiovascular events (MACE). CDSM programs can be complex and are not user-friendly in clinical settings, particularly for vulnerable patients. The aim of this study was to investigate whether a simplified one-page CDSM tool, the SCReening in Heart Failure (SCRinHF), is comparable to a comprehensive Flinders Program of Chronic Disease Management, specifically in triaging self-management capabilities and in predicting readmission and MACE. Methods:SELFMAN-HF is a prospective, observational study based on community cardiology. Eligible patients, consecutively recruited, had HF with left ventricular ejection fraction <40% and were placed on sodium-glucose co-transporter-2 inhibitors (SGLT2-i) within 3 months of recruitment. SGLT2-i is the newest of the four HF treatment pillars; self-management skills are assessed at this juncture. CDSM was assessed and scored independently via the long-form (LF) and short-form (SF) tools, and concordance between forms was estimated. The primary endpoint is the 80% concordance across the two CDSM scales for predicting hospital readmission and MACE. Results: Of the 117 patients, aged 66.8 years (±SD 13.5), 88 (75%) were male. The direct comparisons for SF versus LF patient scores are as follows: "good self-managers", 13 vs. 30 patients (11.1% vs. 25.6%); "average", 46 vs. 21 patients (39.3% vs. 17.9%), "borderline", 20 vs. 31 patients (17.1% vs. 26.5%), and "poor self-managers" (vulnerable), 38 vs. 35 patients (32.5% vs. 29.9%). These findings underscore the possibility of SF tools in picking up patients whose scores infer poor self-management capabilities. This concordance of the SF with the LF scores for patients who have poor self-management capabilities (38 vs. 35 patients p = 0.01), alongside readmission (31/38 vs. 31/35 p = 0.01) or readmission risk for poor self-managers versus good self-managers (31/38 vs. 5/13 p = 0.01), validates the simplification of the CDSM tools for the vulnerable population with HF. Similarly, when concurrent and predictive validity was tested on 52 patients, the results were 39 (75%) for poor self-managers and 14 (27%) for good self-managers in both groups, who demonstrated significant correlations between SF and LF scores. Conclusions: Simplifying self-management scoring with an SF tool to improve clinical translation is justifiable, particularly for vulnerable populations. Poor self-management capabilities and readmission risk for poor self-managers can be significantly predicted, and trends for good self-managers are observed. However, correlations of SF to LF scores across an HF cohort for self-management abilities and MACE are more complex. Translation to patients of all skill levels requires further research.

Can Timely Outpatient Visits Reduce Readmissions and Mortality Among Heart Failure Patients?

BACKGROUND

Outpatient follow-up after a hospital discharge may reduce the risk of readmissions, but existing evidence has methodological limitations.

OBJECTIVES

To assess effect of outpatient follow-up within 7, 14, 21 and 30 days of a hospital discharge on 30-day unplanned readmissions or mortality among heart failure (HF) patients; and whether this varies for patients with different clinical complexities.

DESIGN

We analyzed medical records between January 2016 and December 2021 from a prospective cohort study. Using time varying mixed effects parametric survival models, we examined the association between not having an outpatient follow-up and risk of adverse events. We used interaction models to assess if the effect of outpatient follow-up visit on outcomes varies with patients' clinical complexity (comorbidities, grip strength, cognitive impairment and length of inpatient stay).

PARTICIPANTS

Two hundred and forty-one patients with advanced HF.

MAIN MEASURES

30-day all-cause (or cardiac) adverse event defined as all cause (or cardiac) unplanned readmissions or death within 30 days of an unplanned all-cause (or cardiac) admission or emergency department visit.

KEY RESULTS

We analyzed 1595 all-cause admissions, inclusive of 1266 cardiac admissions. Not having an outpatient follow-up (vs having an outpatient follow-up) significantly increased the risk of 30-day all-cause adverse event. (risk [95% CI] - 14 days: 35.1 [84.5,-1.1]; 21 days: 43.9 [48.2,6.7]; 30 days: 31.1 [48.5, 7.9]) The risk (at 21 days) was higher for those with one co-morbidity (0.25 [0.11,0.58]), mild (0.67 [0.45, 1.00]) and moderate cognitive impairment (0.38 [0.17, 0.84]), normal grip strength (0.57 [0.34, 0.96]) and length of inpatient stay 7-13 days (0.45 [0.23, 0.89]).

CONCLUSION

Outpatient follow-up within 30 days after a hospital discharge reduced risk of 30-day adverse events among HF patients, the benefit varying according to clinical complexity. Results suggest the need to prioritize patients who benefit from outpatient follow-up for these visits.

A simple and robust parametric shared frailty model for recurrent events with the competing risk of death: An application to the Carvedilol Prospective Randomized Cumulative Survival trial

Many non-fatal events can be considered recurrent in that they can occur repeatedly over time, and some researchers may be interested in the trajectory and relative risk of non-fatal events. With the competing risk of death, the treatment effect on the mean number of recurrent events is non-identifiable since the observed mean is a function of both the recurrent event and terminal event processes. In this paper, we assume independence between the non-fatal and the terminal event process, conditional on the shared frailty, to fit a parametric model that recovers the trajectory of, and identifies the effect of treatment on, the non-fatal event process in the presence of the competing risk of death. Simulation studies are conducted to verify the reliability of our estimators. We illustrate the method and perform model diagnostics using the Carvedilol Prospective Randomized Cumulative Survival trial which involves heart-failure events.

The Congestion "Pandemic" in Acute Heart Failure Patients

Congestion not only represents a cardinal sign of heart failure (HF) but is also now recognized as the primary cause of hospital admissions, rehospitalization, and mortality among patients with acute heart failure (AHF). Congestion can manifest through various HF phenotypes in acute settings: volume overload, volume redistribution, or both. Recognizing the congestion phenotype is paramount, as it implies different therapeutic strategies for decongestion. Among patients with AHF, achieving complete decongestion is challenging, as more than half still experience residual congestion at discharge. Residual congestion is one of the strongest predictors of future cardiovascular events and poor outcomes. Through this review, we try to provide a better understanding of the congestion phenomenon among patients with AHF by highlighting insights into the pathophysiological mechanisms behind congestion and new diagnostic and management tools to achieve and maintain efficient decongestion.

Vulnerable period in heart failure: a window of opportunity for the optimization of treatment - a statement by Mexican experts

Acute heart failure (HF) is associated with poor prognosis. After the acute event, there is a vulnerable period during which the patient has a marked risk of readmission or death. Therefore, early optimization of treatment is mandatory during the vulnerable period. The objective of this article is to provide recommendations to address the management of patients with HF during the vulnerable period from a practical point of view. A group of Mexican experts met to prepare a consensus document. The vulnerable period, with a duration of up to 6 months after the acute event - either hospitalization, visit to the emergency department or the outpatient clinic/day hospital - represents a real window of opportunity to improve outcomes for these patients. To best individualize the recommendations, the management strategies were divided into three periods (early, intermediate and late vulnerable period), including not only therapeutic options but also evaluation and education. Importantly, the recommendations are addressed to the entire cardiology team, including physicians and nurses, but also other specialists implicated in the management of these patients. In conclusion, this document represents an opportunity to improve the management of this population at high risk, with the aim of reducing the burden of HF.

Formulation and application of the "hospital-to-home + online-to-offline" treatment scheme in caring for and supporting vulnerable patients with chronic heart failure

BACKGROUND

Chronic heart failure (CHF) is the terminal stage of cardiovascular disease.

OBJECTIVE

In this study, the "hospital-to-home + online-to-offline" (H2H + O2O) care scheme was implemented for patients with CHF during vulnerable periods, and its effect was evaluated.

METHODS

Patients with CHF in the cardiovascular department of a Class III/Grade A hospital in Jiangxi Province from January to December 2020 were selected using a convenience sampling method and randomly divided into a control and intervention group (n= 100 each). The patients in the control group received routine in-hospital treatment and out-of-hospital follow-up, while in the intervention group, a multi-disciplinary cooperation team with CHF specialist nurses evaluated and stratified the patients before discharge and formulated individualized prescriptions and care plans. Based on the "Health & Happiness" chronic disease follow-up application designed for this study, the specialist nurses provided patients with one-to-one guidance. After three months, the cardiac function, heart failure knowledge, self-care behavior, and re-hospitalization rate of the patients were compared between the two groups. Cardiac function was evaluated by the serum B-type natriuretic peptide (BNP), the left ventricular ejection fraction (LVEF), and a six-minute walking test (6MWT). Heart failure knowledge and self-care behavior was assessed using specific questionaries.

RESULTS

The level of cardiac function in the intervention group was significantly higher than that in the control group, and the difference was statistically significant (P< 0.001). The mastery of heart failure knowledge and self-care behavior in the intervention group were significantly higher than those in the control group, and the differences were statistically significant (P< 0.05). The re-hospitalization rate due to CHF in the intervention group was 21.0%, which was lower than that in the control group (35.0%), and the difference was statistically significant (P< 0.05).

CONCLUSION

The H2H + O2O care scheme can be used for the transition of vulnerable patients with CHF from the hospital to family care to improve the patients' level of cardiac function, elevate their knowledge level and self-care abilities, and improve their overall health outcomes.

Clinical efficacy and safety of adjunctive treatment of chronic ischemic heart failure with Qishen Yiqi dropping pills: a systematic review and meta-analysis

Objectives

Our study was to evaluate the effect of Qishen Yiqi Dropping Pills(QSYQ) on the prognosis of chronic ischemic heart failure(CIHF) and its safety.

Methods

Databases including CNKI, Wanfang, VIP, CBM, PubMed, Web of Science, The Cochrane Library and EMbase were searched from their inception to April 2023 to screen relevant randomized controlled trials (RCTs). Primary indicators included readmission rates, rates of major adverse cardiovascular events (MACE), and all-cause mortality rates. The quality of the literature was assessed according to the Cochrane Reviewers' Handbook 5.0 and the Modified Jadad Scale (with a score of 4-7 rated as high quality). Meta-analysis was performed using the meta-package created by R software version 4.2.3, continuous data were compared using SMDs, and dichotomous and ordered data were compared using ORs; and the I2 test was used to assess the heterogeneity.

Results

Fifty-nine studies out of 1,745 publications were finally included, totalling 6,248 patients. Most studies were poorly designed and had some publication bias, with only 26 high-quality papers (Jadad score ≥4). Meta-analysis showed that the combined application of QSYQ was able to reduce the readmission rate [OR = 0.42, 95% CI (0.33, 0.53), P < 0.001], all-cause mortality rate [OR = 0.43, 95% CI (0.27, 0.68), P < 0.001], and the incidence of MACE [OR = 0.42, 95% CI (0.31, 0.56), P < 0.001]. Also, the treatment method can improve clinical effectiveness [OR = 2.25, 95% CI (1.97, 2.58), P < 0.001], increase 6-min walking distance (6MWD) [SMD = 1.87, 95% CI (1.33, 2.41), P < 0.0001] and left ventricular ejection fraction (LVEF) [SMD = 1.08, 95% CI (0.83, 1.33), P < 0.0001], and decrease the Minnesota Living with Heart Failure Questionnaire (MLHFQ) scores [SMD = -2.03, 95% CI (-3.0, -1.07), P < 0.0001], BNP levels [SMD = -2.07, 95% CI (-2.81, -1.33), P < 0.0001] and NT-ProBNP levels [SMD = -2.77, 95% CI (-4.90, -0.63), P < 0.05]. A total of 21 studies (n = 2,742) evaluated their adverse effects, of which 13 studies reported no adverse effects and 8 studies reported minor adverse effects.

Conclusion

Our results suggest that the combined application of QSYQ can further improve patients' cardiac function and exercise tolerance, improve their quality of life, and ultimately improve patients' prognosis with a favorable safety profile. Nonetheless, limited by the quality and high heterogeneity of the literature, we must be conservative and cautious about the present results.

Systematic Review Registration

PROSPERO (CRD42023449251).

The Price of Explainability in Machine Learning Models for 100-Day Readmission Prediction in Heart Failure: Retrospective, Comparative, Machine Learning Study

BACKGROUND

Sensitive and interpretable machine learning (ML) models can provide valuable assistance to clinicians in managing patients with heart failure (HF) at discharge by identifying individual factors associated with a high risk of readmission. In this cohort study, we delve into the factors driving the potential utility of classification models as decision support tools for predicting readmissions in patients with HF.

OBJECTIVE

The primary objective of this study is to assess the trade-off between using deep learning (DL) and traditional ML models to identify the risk of 100-day readmissions in patients with HF. Additionally, the study aims to provide explanations for the model predictions by highlighting important features both on a global scale across the patient cohort and on a local level for individual patients.

METHODS

The retrospective data for this study were obtained from the Regional Health Care Information Platform in Region Halland, Sweden. The study cohort consisted of patients diagnosed with HF who were over 40 years old and had been hospitalized at least once between 2017 and 2019. Data analysis encompassed the period from January 1, 2017, to December 31, 2019. Two ML models were developed and validated to predict 100-day readmissions, with a focus on the explainability of the model's decisions. These models were built based on decision trees and recurrent neural architecture. Model explainability was obtained using an ML explainer. The predictive performance of these models was compared against 2 risk assessment tools using multiple performance metrics.

RESULTS

The retrospective data set included a total of 15,612 admissions, and within these admissions, readmission occurred in 5597 cases, representing a readmission rate of 35.85%. It is noteworthy that a traditional and explainable model, informed by clinical knowledge, exhibited performance comparable to the DL model and surpassed conventional scoring methods in predicting readmission among patients with HF. The evaluation of predictive model performance was based on commonly used metrics, with an area under the precision-recall curve of 66% for the deep model and 68% for the traditional model on the holdout data set. Importantly, the explanations provided by the traditional model offer actionable insights that have the potential to enhance care planning.

CONCLUSIONS

This study found that a widely used deep prediction model did not outperform an explainable ML model when predicting readmissions among patients with HF. The results suggest that model transparency does not necessarily compromise performance, which could facilitate the clinical adoption of such models.

The impact of informal caregivers' preparedness on short-term outcomes of heart failure patients with insufficient self-care

AIMS

Even though self-care is essential in the long-term management of heart failure (HF), it is often not performed adequately in HF populations. Mobilizing informal caregivers may be one way to help patients perform self-care, support individual needs, and maintain health. However, informal caregivers often face insufficient preparation for providing long-term care. This insufficient caregiver preparedness may lead to a decline in caregiver contributions and affect the outcomes of care in patients with HF. This study aimed to explore whether informal caregivers' preparedness is a predictor that influences short-term outcomes of HF patients; to analyse whether caregiver contribution to self-care of HF (CC-SCHF) plays a mediating role between informal caregivers' preparedness and HF short-term outcomes.

METHODS AND RESULTS

A prospective observational study was conducted in China. After controlling for covariates, higher levels of informal caregivers' preparedness were significantly associated with lower 3-month mortality [odds ratio (OR) = 0.919, 95% confidence interval (CI) = (0.855-0.988), P = 0.022] and 3-month readmission rate [OR = 0.883, 95% CI = (0.811-0.961), P = 0.004] and shorter length of hospital stay (β = -0.071, P < 0.001). The informal caregiver's preparedness was positively associated with CC-SCHF maintenance (r = 0.708, P < 0.01), CC-SCHF management (r = 0.431, P < 0.01), and CC-SCHF confidence (r = 0.671, P < 0.01). The CC-SCHF management was a mediator in the relationship between informal caregivers' preparedness and 3-month readmission rate [effect 95% CI = (-0.054 to -0.001)] and length of hospital stay [effect 95% CI = (-0.235 to -0.042)].

CONCLUSION

A higher level of informal caregivers' preparedness is associated with better short-term outcomes of HF patients with insufficient self-care.

Projected effectiveness of dapagliflozin in heart failure with reduced ejection fraction in clinical practice

Aim: To estimate the projected effectiveness of dapagliflozin in subjects with heart failure (HF) with reduced ejection fraction in clinical practice in Spain. Materials & methods: This multicenter cohort study included subjects aged 50 years or older consecutively hospitalized for HF in internal medicine departments in Spain. The projected clinical benefits of dapagliflozin were estimated based on results from the DAPA-HF trial. Results: A total of 1595 patients were enrolled, of whom 1199 (75.2%) were eligible for dapagliflozin. Within 1 year after discharge, 21.6% of patients eligible for dapagliflozin were rehospitalized for HF and 20.5% died. Full implementation of dapagliflozin led to an absolute risk reduction of 3.5% for mortality (number needed to treat = 28) and 6.5% (number needed to treat = 15) for HF readmission. Conclusion: Treatment with dapagliflozin in clinical practice may markedly reduce mortality and readmissions for HF.

Benefits of dapagliflozin in the whole spectrum of heart failure in clinical practice: the RICA registry

Aims: To determine the projected benefits of dapagliflozin after an acute heart failure (HF) event in Spain. Methods: A multicenter and prospective study that included subjects aged 50 years or older consecutively admitted with HF to internal medicine departments in Spain. The projected clinical benefits of dapagliflozin were calculated via pooled analysis of the DAPA-HF and DELIVER trials. Results: A total of 5644 subjects were analyzed, of whom 79.2% were eligible for dapagliflozin, according to criteria of the DAPA-HF and DELIVER trials. Full implementation of dapagliflozin would imply a 1-year absolute risk reduction of 2.3% for death (number needed to treat = 43) and 5.7% (number needed to treat = 17) for HF rehospitalization. Conclusion: Treatment with dapagliflozin could significantly reduce HF burden in clinical practice.

Burden of Illness beyond Mortality and Heart Failure Hospitalizations in Patients Newly Diagnosed with Heart Failure in Spain According to Ejection Fraction

OBJECTIVE

The objective of this study was to describe the rates of adverse clinical outcomes, including all-cause mortality, heart failure (HF) hospitalization, myocardial infarction, and stroke, in patients newly diagnosed with HF to provide a comprehensive picture of HF burden.

METHODS

This was a retrospective and observational study, using the BIG-PAC database in Spain. Adults, newly diagnosed with HF between January 2013 and September 2019 with ≥1 HF-free year of enrolment prior to HF diagnosis, were included.

RESULTS

A total of 19,961 patients were newly diagnosed with HF (43.5% with reduced ejection fraction (EF), 26.3% with preserved EF, 5.1% with mildly reduced EF, and 25.1% with unknown EF). The mean age was 69.7 ± 19.0 years; 53.8% were men; and 41.0% and 41.5% of patients were in the New York Heart Association functional classes II and III, respectively. The baseline HF treatments included beta-blockers (70.1%), renin-angiotensin system inhibitors (56.3%), mineralocorticoid receptor antagonists (11.8%), and SGLT2 inhibitors (8.9%). The post-index incidence rates of all-cause mortality, HF hospitalization, and both combined were 102.2 (95% CI 99.9-104.5), 123.1 (95% CI 120.5-125.7), and 182 (95% CI 178.9-185.1) per 1000 person-years, respectively. The rates of myocardial infarction and stroke were lower (26.2 [95% CI 25.1-27.4] and 19.8 [95% CI 18.8-20.8] per 1000 person-years, respectively).

CONCLUSIONS

In Spain, patients newly diagnosed with HF have a high risk of clinical outcomes. Specifically, the rates of all-cause mortality and HF hospitalization are high and substantially greater than the rates of myocardial infarction and stroke. Given the burden of adverse outcomes, these should be considered targets in the comprehensive management of HF. There is much room for improving the proportion of patients receiving disease-modifying therapies.

A Suggested Model for the Vulnerable Phase of Heart Failure: Assessment of Risk Factors, Multidisciplinary Monitoring, Cardiac Rehabilitation, and Addressing the Social Determinants of Health

The vulnerable phase (VP) of heart failure (HF) is 30 to 90 days after hospital discharge and is associated with increased rehospitalization and mortality rates. The pathophysiological mechanism that drives the VP is due to the progressive increase in left ventricular filling pressure, which can cause hemodynamic congestion and long-term multiorgan injury. Our team analyzed English-written, peer-reviewed research through PubMed from 2018 to 2022, to gather current information on the VP and generate a multipronged approach toward the assessment and intervention of patients with posthospitalization HF. It is our opinion that a structured approach using remote vital monitoring and risk-stratifying tools will be best to identify patients at risk for decompensatory HF during the VP. Medical management can then be targeted toward these high-risk patients by using an organized multidisciplinary team and a disease management program, which includes remote patient-monitoring systems, addressing social determinants of health, and cardiac rehabilitation, to improve rehospitalization and mortality rates.

Clinical characteristics at hospital discharge that predict cardiovascular readmission within 100 days in heart failure patients - An observational study

Background

After a heart failure (HF) hospital discharge, the risk of a cardiovascular (CV) related event is highest in the following 100 days. It is important to identify factors associated with increased risk of readmission.

Method

This retrospective, population-based study examined HF patients in Region Halland (RH), Sweden, hospitalized with a HF diagnosis between 2017 and 2019. Data regarding patient clinical characteristics were retrieved from the Regional healthcare Information Platform from admission until 100 days post-discharge. Primary outcome was readmission due to a CV related event within 100 days.

Results

There were 5029 included patients being admitted for HF and discharged and 1966 (39%) were newly diagnosed. Echocardiography was available for 3034 (60%) patients and 1644 (33%) had their first echocardiography while admitted. The distribution of HF-phenotypes was 33% HF with reduced ejection fraction (EF), 29% HF with mildly reduced EF and 38% HF with preserved EF. Within 100 days, 1586 (33%) patients were readmitted, and 614 (12%) died. A Cox regression model showed that advanced age, longer hospital length of stay, renal impairment, high heart rate and elevated NT-proBNP were associated with an increased risk of readmission regardless of HF-phenotype. Women and increased blood pressure are associated with a reduced risk of readmission.

Conclusions

One third had a CV-readmission within 100 days. This study found clinical factors already present at discharge that are associated with increased risk of readmission which should be considered at discharge.

The clinical value of the Controlling Nutritional Status score for predicting prognosis in systolic heart failure cases in the vulnerable phase

Background

Malnutrition, a commonly encountered complication of heart failure, has an association with poor prognosis. The vulnerable phase of heart failure constitutes the most vulnerable stage of heart failure cases after discharge (usually within 3 months). At present, the prognostic value of Controlling Nutritional Status (CONUT) score in the vulnerable phase of systolic heart failure is unclear.

Methods

Totally 187 systolic heart failure cases were retrospectively assessed at the Second Affiliated Hospital of Dalian Medical University. Based on CONUT score at admission, cases were assigned to 3 groups, including the normal nutrition, and mild and moderate or severe malnutrition groups. The primary endpoint was all-cause death in the 90 days following discharge. The secondary, composite outcome encompassed all-cause death and rehospitalization due to heart failure. Kaplan-Meier method and log-rank test were performed to compare outcome event rates between groups. The independent risk factors for outcome events were obtained by multivariate COX regression analysis. The receiver operating characteristic (ROC) curve analysis and the Delong test were used to compare the prediction performance of the CONUT score and other independent risk factors for all-cause death.

Results

During the 90 days of follow-up, 8.6% of HF patients had the primary endpoint and 23.5% had the secondary outcome. All-cause mortality was markedly elevated in the moderate or severe malnutrition group (Logrank: p < 0.001). Compared with the normal nutrition group, composite endpoint events had starkly increased incidence rates in both malnutrition groups, and the incidence increased with the severity of malnutrition (Logrank: p < 0.05). Multivariate COX risk analysis revealed higher CONUT score [hazard ratio (HR) = 1.791, 95% confidence interval (CI) 1.379-2.327], age (HR = 1.08, 95% CI 1.028-1.134), B-type natriuretic peptide (BNP) (HR = 1.001, 95% CI 1.000-1.001), and aspartate aminotransferase (AST) (HR = 1.008, 95% CI 1.001-1.015) at admission as independent predictive factors of all-cause mortality. And higher CONUT score (HR = 1.162, 95% CI 1.024-1.318) and lower estimated glomerular filtration rate (eGFR) (HR = 0.98, 95% CI 0.966-0.993) for the secondary endpoint. The addition of the CONUT score significantly increased the predictive performance of age, BNP and AST, as well as their combination for all-cause death (Delong test: all p < 0.05).

Conclusion

The CONUT score at admission independently predicts poor prognosis during the vulnerable phase in patients with systolic heart failure and may be combined with conventional risk factors to further improve the predictive efficacy.

Improvement in Heart Failure Self-Care and Patient Readmissions with Caregiver Education: A Randomized Controlled Trial

Caregivers support heart failure (HF) self-care with little HF education. The purpose of this study was to evaluate the effectiveness of a caregiver-only educational intervention aimed at improving caregiver self-efficacy, perceived control, and HF knowledge, as well as patient self-care and 30-day cardiac readmission. In total, 37 patients and their caregivers were randomly assigned to a control condition or a caregiver-only educational intervention with telephone follow-up. Outcomes included patient 30-day cardiac readmission, patient self-care, caregiver self-efficacy, caregiver perceived control, and caregiver HF knowledge. Linear mixed model, Kaplan–Meier, and Cox regression analyses were used to determine the effects of the intervention on outcomes. Self-care maintenance ( p = 0.002), self-care management ( p = 0.005), 30-day cardiac readmission ( p = 0.003), and caregiver perceived control ( p < 0.001) were significantly better in the intervention group. The results suggest that interventions targeting caregiver HF education could be effective in improving HF patients’ 30-day cardiac readmissions, patient self-care, and caregiver perceived control.

Reduction in 90 day readmission rates utilizing ambulatory pulmonary pressure monitoring

AIMS

In the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in New York Heart Association Functional Class III Heart Failure Patients) trial, heart failure hospitalization (HFH) rates were lower in patients with ambulatory pulmonary artery pressure (PAP) monitoring guidance. We investigated the effect of ambulatory haemodynamic monitoring on 90 day readmission rates after HFH.

METHODS AND RESULTS

We retrospectively analysed patients across the Advocate Aurora Health hospital network who had undergone PAP sensor implantation between 1 October 2015 and 31 October 2019. Patients with a ventricular assist device (VAD) or transplant prior to implantation were excluded. Rates of total HFH and 30 and 90 day all-cause readmission up to 12 months after implantation were collected, while censoring for an endpoint of heart transplantation, VAD, or death. Event rates were compared using Poisson regression. Of 459 patients included, there were 404 HFHs before and 179 after implantation. Compared with pre-implantation, 30 day all-cause readmission [incidence rate ratio (IRR): 0.55 (0.39-0.77), P = 0.0006] and 90 day all cause readmission rates were lower post-implantation [IRR: 0.45 (0.35-0.58), P < 0.0001]. The effect of PAP sensor implantation on 90 day all-cause readmission incidence rates was consistent across multiple subgroups.

CONCLUSIONS

Across a large hospital network, ambulatory haemodynamic monitoring was associated with lower HFH rates, as well as 30 and 90 day all-cause readmission rates. This supports the utility of ambulatory PAP monitoring to improve HF management in the era of value-based medicine.

Design and rationale of the inferior vena CAVA and Lung UltraSound-guided therapy in Acute Heart Failure (CAVAL US-AHF Study): a randomised controlled trial

Background

Between 25% and 30% of patients hospitalised for acute heart failure (AHF) are readmitted within 90 days after discharge, mostly due to persistent congestion on discharge. However, as the optimal evaluation of decongestion is not clearly defined, it is necessary to implement new tools to identify subclinical congestion to guide treatment.

Objective

To evaluate if inferior vena cava (IVC) and lung ultrasound (CAVAL US)-guided therapy for AHF patients reduces subclinical congestion at discharge.

Methods

CAVAL US-AHF is a single-centre, single-blind randomised controlled trial designed to evaluate if an IVC and lung ultrasound-guided healthcare strategy is superior to standard care to reduce subclinical congestion at discharge. Fifty-eight patients with AHF will be randomised using a block randomisation programme that will assign to either lung and IVC ultrasound-guided decongestion therapy (‘intervention group’) or clinical-guided decongestion therapy (‘control group’), using a quantitative protocol and will be classified in three groups according to the level of congestion observed: none or mild, moderate or severe. The treating physicians will know the result of the test and the subsequent adjustment of treatment in response to those findings guided by a customised therapeutic algorithm. The primary endpoint is the presence of more than five B-lines and/or an increase in the diameter of the IVC, with and without collapsibility. The secondary endpoints are the composite of readmission for HF, unplanned visit for worsening HF or death at 90 days, variation of pro-B-type natriuretic peptide at discharge, length of hospital stay and diuretic dose at 90 days. Analyses will be conducted as between-group by intention to treat.

Ethics and dissemination

Ethical approval was obtained from the Institutional Review Board and registered in the PRIISA.BA platform of the Ministry of Health of the City of Buenos Aires.

Trial registration number

NCT04549701.

911 Calls for Emergency Medical Services in Heart Failure: A Descriptive Qualitative Study

BACKGROUND

Heart failure (HF) is a common condition leading to activation of emergency medical services (EMS).

OBJECTIVE

The aim of this study was to describe reasons given by persons with HF, family members, or other caregivers for requesting EMS activation during 911 calls.

METHODS

In this descriptive qualitative study, a content analysis was performed on transcribed audio files of 383 EMS requests involving 383 persons with HF in the community.

RESULTS

One hundred forty-seven calls (38.4%) were placed by the family members, 75 (19.6%) were placed by the patients, 56 (14.6%) were placed by healthcare workers or personnel from living facilities, and the remaining calls (n = 105, 27.4%) were placed by others (eg, friends, neighbors, officers). Three broad categories of symptoms, signs, and events were identified as the reasons for an EMS request. Frequently reported symptoms were breathing problems (55.4%), chest pain (18.3%), and other pain (eg, head, extremities) (16.7%). Signs included decreased consciousness (15.4%), swelling (5.7%), and bleeding (5.0%). The reported events involved falls (8.1%), heart attack (6.3%), hypoxic episodes (6.0%), stroke (5.2%), and post-hospital-discharge complications (4.7%). In most calls (74.9%), multiple reasons were reported and a combination of symptoms, signs, and events were identified. Heart failure diagnosis was mentioned in fewer than 10% of the calls.

CONCLUSIONS

Overall, symptoms and signs of HF exacerbation were common reasons to activate 911 calls. Falls were frequently reported. Under the duress of the emergent situations surrounding the 911 call, callers rarely mentioned the existence of HF. Interventions are needed to guide patients with HF and their family members to promote the management of HF to reduce EMS activation as well as to activate EMS quickly for acute changes in HF conditions.

Incidence and Prognostic Implications of Readmissions Caused by Thrombotic Events After a Heart Failure Hospitalization

Background Readmission occurs in 1 out of 3 patients with heart failure (HF). We aimed to study the incidence and prognostic implications of rehospitalizations because of arterial thromboembolism events (ATEs) and venous thromboembolism events (VTEs) after discharge in patients with HF. Methods and Results We identified Medicare beneficiaries who were admitted with a primary diagnosis of HF from 2014 to 2019, with a hospital stay ranging between 3 and10 days, followed by discharge to home. We calculated incidence of ATEs (myocardial infarction, ischemic stroke, or systemic embolism) and VTEs (deep venous thrombosis and pulmonary embolism) up to 90 days after discharge. Out of 2 953 299 patients admitted with HF during the study period, a total of 585 353 patients met the inclusion criteria, and 36.6% were readmitted within 90 days of discharge. The incidence of readmission due ATEs, VTEs, HF, and all other reasons was 3.4%, 0.5%, 13.2%, and 19.5%, respectively. Incidence of thromboembolic events was highest within 14 days after discharge. Factors associated with ATEs included prior coronary, peripheral, or cerebrovascular disease and for VTEs included malignancy and prior liver or lung disease. ATE/VTE readmission had a 30-day mortality of 19.9%. After a median follow-up period of 25.6 months, ATE and VTE readmissions were associated with higher risk of mortality (hazard ratio, 2.76 [95% CI, 2.71-2.81] and 2.17 [95% CI, 2.08-2.27], respectively; P<0.001 for both) compared with no readmission on time-dependent Cox regression. Conclusions After a HF hospitalization, 3.9% of patients were readmitted with a thromboembolic event that was associated with 2- to 3-fold greater risk of mortality in follow-up.

New therapeutic options for patients with heart failure with reduced ejection fraction and acute decompensated heart failure

BACKGROUND

Patients with acute decompensated heart failure (ADHF) are at severe risk of death and rehospitalization. Several clinical studies have been designed to evaluate the efficacy and safety of new molecules administered before discharge or shortly after ADHF. The aim of this article is to summarize current knowledge on recently published findings on treatment of patients with heart failure with reduced ejection fraction (HFrEF) and ADHF.

METHODS

We performed a thorough search for literature pertaining to our review via the PubMed database.

RESULTS

In this review, we summarize original papers concerning the efficacy and safety of new molecules in patients with HFrEF and ADHF.

CONCLUSIONS

Peri-discharge initiation of treatment with new molecules is possible and safe for patients with HFrEF and ADHF. New molecules, if administered before discharge or shortly after, reduce the risk of cardiovascular death or worsening heart failure within the vulnerable phase, and are also nephroprotective.

Posthospitalization Follow-Up of Patients With Heart Failure Using eHealth Solutions: Restricted Systematic Review

BACKGROUND

Heart failure (HF) is a clinical syndrome with high incidence rates, a substantial symptom and treatment burden, and a significant risk of readmission within 30 days after hospitalization. The COVID-19 pandemic has revealed the significance of using eHealth interventions to follow up on the care needs of patients with HF to support self-care, increase quality of life (QoL), and reduce readmission rates during the transition between hospital and home.

OBJECTIVE

The aims of this review are to summarize research on the content and delivery modes of HF posthospitalization eHealth interventions, explore patient adherence to the interventions, and examine the effects on the patient outcomes of self-care, QoL, and readmissions.

METHODS

A restricted systematic review study design was used. Literature searches and reviews followed the (PRISMA-S) Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search extension checklist, and the CINAHL, MEDLINE, Embase, and Cochrane Library databases were searched for studies published between 2015 and 2020. The review process involved 3 groups of researchers working in pairs. The Mixed Methods Appraisal Tool was used to assess the included studies' methodological quality. A thematic analysis method was used to analyze data extracted from the studies.

RESULTS

A total of 18 studies were examined in this review. The studies were published between 2015 and 2019, with 56% (10/18) of them published in the United States. Of the 18 studies, 16 (89%) were randomized controlled trials, and 14 (78%) recruited patients upon hospital discharge to eHealth interventions lasting from 14 days to 12 months. The studies involved structured telephone calls, interactive voice response, and telemonitoring and included elements of patient education, counseling, social and emotional support, and self-monitoring of symptoms and vital signs. Of the 18 studies, 11 (61%) provided information on patient adherence, and the adherence levels were 72%-99%. When used for posthospitalization follow-up of patients with HF, eHealth interventions can positively affect QoL, whereas its impact is less evident for self-care and readmissions.

CONCLUSIONS

This review suggests that patients with HF should receive prompt follow-up after hospitalization and eHealth interventions have the potential to improve these patients' QoL. Patient adherence in eHealth follow-up trials shows promise for successful future interventions and adherence research. Further studies are warranted to examine the effects of eHealth interventions on self-care and readmissions among patients with HF.

Trends in 30- and 90-Day Readmission Rates for Heart Failure

BACKGROUND

The impact of hospital readmission reduction program (HRRP) on heart failure (HF) outcomes has been debated. Limited data exist regarding trends of HF readmission rates beyond 30 days from all-payer sources. The aim of this study was to investigate temporal trends of 30- and 90-day HF readmissions rates from 2010 to 2017 in patients from all-payer sources.

METHODS

The National Readmission Database was utilized to identify HF hospitalizations between 2010 and 2017. In the primary analysis, a linear trend in 30-day and 90-day readmissions from 2010 to 2017 was assessed. While in the secondary analysis, a change in aggregated 30- and 90-day all-cause and HF-specific readmissions pre-HRRP penalty phase (2010-2012) and post-HRRP penalties (2013-2017) was compared. Subgroup analyses were performed based on (1) Medicare versus non-Medicare insurance, (2) low versus high HF volume, and (3) HF with reduced versus preserved ejection fraction (heart failure with reduced ejection fraction and heart failure with preserved ejection fraction). Multiple logistic and adjusted linear regression analyses were performed for annual trends.

RESULTS

A total of 6 669 313 index HF hospitalizations for 30-day, and 5 077 949 index HF hospitalizations for 90-day readmission, were included. Of these, 1 213 402 (18.2%) encounters had a readmission within 30 days, and 1 585 445 (31.2%) encounters had a readmission within 90 days. Between 2010 and 2017, both 30 and 90 days adjusted HF-specific and all-cause readmissions increased (8.1% to 8.7%, P trend 0.04, and 18.3% to 19.9%, P trend <0.001 for 30-day and 14.8% to 16.0% and 30.9% to 34.6% for 90-day, P trend <0.001 for both, respectively). Readmission rates were higher during the post-HRRP penalty period compared with pre-HRRP penalty phase (all-cause readmission 30 days: 18.6% versus 17.5%, P<0.001, all-cause readmission 90 days: 32.0% versus 29.9%, P<0.001) across all subgroups except among the low-volume hospitals.

CONCLUSIONS

The rates of adjusted HF-specific and all-cause 30- and 90-day readmissions have increased from 2010 to 2017. Readmissions rates were higher during the HRRP phase across all subgroups except the low-volume hospitals.

Opioid Use and Outcomes in Hospitalized Older Patients With Heart Failure Receiving and Not Receiving Hospice Referrals

BACKGROUND

The use of opioids is associated with poor outcomes. Less is known about this association in patients with heart failure (HF) and whether it varies by the receipt of hospice care.

METHODS

Of the 7467 patients hospitalized for HF without previous opioid use, 124 received discharge opioids. We matched 123 of these patients with 123 not receiving opioids based on their propensity scores for opioid use, thus assembling a matched cohort of 246 patients balanced on 30 baseline characteristics (mean age, 76 years, 60% women, and 11% African American). We repeated the process in hospice (n = 155; 20 received opioids) and nonhospice (n = 7298; 104 received opioids) subgroups, thus assembling 2 matched cohorts of 22 and 208 patients, respectively. Hazard ratios (HRs) and 95% confidence intervals (CIs) associated with opioid use were estimated from matched cohorts.

RESULTS

During 8.6 (median, 1.4) years of follow-up, all-cause mortality occurred in 80% and 68% of matched patients in the opioid and nonopioid groups, respectively (HR, 1.49; 95% CI, 1.11-1.99; P = 0.008). There was evidence of heterogeneity in this association between hospice and nonhospice patients (P for interaction, 0.027). Among matched hospice and nonhospice patients, HRs (95% CIs) for mortality were 6.37 (2.06-19.69; P = 0.001) and 1.42 (1.03-1.96; P = 0.035), respectively. HRs (95% CIs) for 30-day and 1-year mortality were 1.98 (1.06-3.70; P = 0.033) and 1.72 (1.18-2.49; P = 0.004), respectively. HRs (95% CIs) for all-cause, HF, and non-HF readmissions were 1.31 (0.97-1.76; P = 0.079), 1.03 (0.71-1.49; P = 0.866), and 1.75 (1.05-2.91; P = 0.031), respectively. Readmission associations were similar among matched nonhospice patients. There was no readmission among matched hospice patients receiving opioids.

CONCLUSIONS

In older patients with HF, opioid use is associated with a higher risk of mortality, which is greater in the hospice subgroup, and a higher risk of non-HF readmission in the nonhospice subgroup.