Predictors of Rehospitalization Among Adults With Congenital Heart Disease Are Lesion Specific

Incidence and Outcomes of Advanced Heart Failure in Adults With Congenital Heart Disease

BACKGROUND

There are limited data about the stage D heart failure (advanced HF) in adults with congenital heart disease. Our study objectives were (1) to determine the incidence of new-onset advanced HF in patients and the relationship between advanced HF and all-cause mortality and (2) to determine the relationship between therapies for advanced HF and all-cause mortality.

METHODS

Retrospective cohort study of adults with congenital heart disease at Mayo Clinic (2003-2019). We defined advanced HF using the European Society of Cardiology diagnostic criteria for advanced HF. Therapies received by the patients with advanced HF were classified into 3 mutually exclusive groups (treatment pathways): (1) conventional cardiac intervention, (2) transplant listing, and (3) palliative care.

RESULTS

Of 5309 patients without advanced HF at baseline assessment, 432 (8%) developed advanced HF during follow-up (1.1%/y), and the incidence of advanced HF was higher in patients with severe or complex congenital heart disease. Onset of advanced HF was associated with 6-fold increase in the risk of mortality. Conventional cardiac intervention was associated with significantly higher risk of mortality as compared to transplant listing. The longer the interval from the initial onset of advanced HF to transplant evaluation, the lower the odds of being listed for transplant.

CONCLUSIONS

Based on these data, we postulate that early identification of patients with advanced HF, and a timely referral for transplant evaluation (instead of conventional cardiac intervention) may offer the best chance of survival for these critically ill patients. Further studies are required to validate this postulation.

Burden of Pediatric Heart Failure in the United States

BACKGROUND

There are currently limited accurate national estimates for pediatric heart failure (HF).

OBJECTIVES

This study aims to describe the current burden of primary and comorbid pediatric HF in the United States.

METHODS

International Classification of Diseases, Clinical Modification codes were used to identify HF cases and comorbidities from the Kids' Inpatient Database, National Inpatient Sample, National Emergency Department (ED) Sample, and National Vital Statistics System for 2012 and 2016. To describe HF events, all visits/events among pediatric and adult subjects were included in the analysis. HF events were classified into 1 of 3 groups: 1) no HF; 2) primary HF; or 3) comorbid HF. We compared patients with and without HF and calculated unique event rates with age and sex standardization.

RESULTS

Congenital heart disease, conduction disorders/arrhythmias, and cardiomyopathy were responsible for the majority of pediatric HF-related ED visits and hospitalizations. Compared to 2012, in 2016, there was an increase in comorbid HF ED visits (rate ratio: 1.93; P < 0.001) and primary HF hospitalizations (rate ratio: 1.14; P = 0.002). Pediatric HF burden was lower compared to adult HF; however, deaths in the ED and in-hospital were significantly more likely in children presenting with HF than adults.

CONCLUSIONS

The burden of pediatric HF continues to increase. Compared to adults with HF presenting to the ED and in-hospital, outcomes are inferior and per patient resource use is higher for children hospitalized with HF. National initiatives to understand risk factors for morbidity and mortality in pediatric HF and continued surveillance and mitigation of preventable risk factors may attenuate this uptrend.

Hospitalizations in adult patients with congenital heart disease: an emerging challenge

The vast majority of patients with congenital heart disease (CHD) survive into adulthood, but many face lifelong complications, which often result in a hospital admission. The increasing number of hospitalizations in adults with CHD (ACHD) poses a significant challenge for healthcare systems globally, especially as heart failure (HF) is becoming increasingly common in this population and is the leading cause of morbidity and mortality. Besides HF, other major contributors to this increase in admission volume are hospitalizations related to mild lesions, comorbidities and pregnancies. Ιn-hospital mortality ranges between 0.8 and 6.1%, while hospitalizations related to HF predict medium-term mortality in ACHD population. Understanding the predictors of hospitalization and in-hospital mortality is, therefore, important for ACHD healthcare providers, who should identify patients at risk that require escalation of treatment and/or close monitoring. This article reviews the available literature on hospitalization patterns in ACHD patients, with a focus on HF-related hospital admissions and specific diagnostic subgroups.

Risk prediction models for heart failure admissions in adults with congenital heart disease

BACKGROUND

Heart failure (HF) is the leading cause of death in adult patients with congenital heart disease (ACHD). No risk prediction model exists for HF hospitalization (HFH) for ACHD patients. We aimed to develop a clinically relevant one-year risk prediction system to identify ACHD patients at high risk for HFH.

METHODS

Data source was the Quebec CHD Database. A retrospective cohort including all ACHD patients aged 18-64 (1995-2010) was constructed for assessing the cumulative risk of HFH adjusting for competing risk of death. To identify one-year predictors of incident HFH, multivariable logistic regressions were employed to a nested case-control sample of all ACHD patients aged 18-64 in 2009. The final model was used to create a risk score system based on adjusted odds ratios.

RESULTS

The cohort included 29,991 ACHD patients followed for 648,457 person-years. The cumulative HFH risk by age 65 was 12.58%. The case-control sample comprised 26,420 subjects, of whom 189 had HFHs. Significant one-year predictors were age ≥ 50, male sex, CHD lesion severity, recent 12-month HFH history, pulmonary arterial hypertension, chronic kidney disease, coronary artery disease, systemic arterial hypertension, and diabetes mellitus. The created risk score ranged from 0 to 19. The corresponding HFH risk rose rapidly beyond a score of 8. The risk scoring system demonstrated excellent prediction performance.

CONCLUSIONS

One eighth of ACHD population experienced HFH before age 65. Age, sex, CHD lesion severity, recent 12-month HFH history, and comorbidities constructed a risk prediction model that successfully identified patients at high risk for HFH.

Clinical Outcomes During Admissions for Heart Failure Among Adults With Congenital Heart Disease

Background

Heart failure (HF) admissions in adults with congenital heart disease (CHD) are becoming more common. We compared in‐hospital and readmission events among adults with and without CHD admitted for HF.

Methods and Results

We identified all admissions with the primary diagnosis of HF among adults in the California State Inpatient Database between January 1, 2005 and January 1, 2012. International Classification of Disease (ICD) codes identified the type of CHD lesion, comorbidities, and in‐hospital and 30‐day readmissions events. Adjusted odds ratio (AOR, 95% CI) was calculated after adjusting for admission year, age, sex, race, household income, primary payor, and Charlson comorbidity index. Of 203 759 patients admitted for HF, 539 had CHD other than atrial septal defect. Compared with patients admitted for HF without CHD, those with CHD were younger, more often male, and had fewer comorbidities as determined by Charlson comorbidity index. On multivariate analysis, CHD patients admitted for HF had higher odds of length of stay ≥7 days (AOR 2.5 [95% CI 2.0–3.1]), incident arrhythmias (AOR 2.8 [95% CI 1.7–4.5]), and in‐hospital mortality (AOR 1.9 [95% CI 1.1–3.1]). Also, CHD patients had lower odds of readmission for HF (AOR 0.6 [95% CI 0.3–0.9]), but similar odds of other 30‐day readmission events. Complex CHD patients had higher odds of length of stay ≥7 days (AOR 1.9 [95% CI 1.1–3.3]) than patients with noncomplex CHD lesions, but similar odds of all other clinical outcomes.

Conclusions

Among patients admitted with the primary diagnosis of HF in California, adults with CHD have substantially higher odds of longer length of stay, incident arrhythmias, and in‐hospital mortality compared with non‐CHD patients. These results suggest a need for HF risk stratification strategies and management protocols specific for patients with CHD.

Adults with congenital heart disease: ready for mobile health?

PURPOSE

Mobile health (mHealth) could improve the outcome of grown-up patients with congenital heart disease (GUCH) and reduce their emergency care utilisation. Inappropriate use of mHealth, however, can lead to data overload for professionals and unnecessary data collection for patients, increasing the burden for both. We aimed to determine the clinical characteristics of patients with high emergency care utilisation and to test whether these patients were willing to start using mHealth.

METHODS

Clinical characteristics and emergency care utilisation of consecutive GUCH patients who visited one of the two participating cardiologists at the outpatient clinic of the Academic Medical Centre in Amsterdam were studied retrospectively. All patients were approached to fill in an mHealth questionnaire. A frequency of three or more emergency visits in 5 years was defined as high emergency care utilisation.

RESULTS

In total, 202 consecutive GUCH patients who visited one of the two participating cardiologists were studied. Median age was 41 years, 47% were male, and 51% were symptomatic. In the previous 5 years, 134 emergency visits were identified. Of all patients, 8% had high emergency care utilisation. High emergency care utilisation was associated with patients being symptomatic, using antiarrhythmic drugs or diuretics. In total, 75% of all patients with high emergency care utilisation were willing to start using mHealth.

CONCLUSION

GUCH patients who are symptomatic, those on antiarrhythmic drug therapy and those on diuretics are suitable candidates for enrolment in future mHealth initiatives because of both high care utilisation and high motivation to start using mHealth.