Prognostic Impact of the Preservation of Activities of Daily Living on Post-Discharge Outcomes in Patients With Acute Heart Failure

Hospitalization-Associated Disability and 1-Year Mortality Risk in Older Patients With Heart Failure

OBJECTIVES

Hospitalization-associated disability (HAD) is the loss of the ability to perform one of the basic activities of daily living (ADLs) required for independent living during hospitalization. This study aimed to determine whether HAD is a significant prognostic risk factor in older patients with heart failure (HF) and independent ADLs.

DESIGN

Prospective, nationwide, multicenter registry study conducted between December 2020 and March 2022.

SETTING AND PARTICIPANTS

This study was conducted across 96 centers in Japan and included 6519 older patients (aged ≥65 years) with HF who were independent in ADL before hospitalization.

METHODS

HAD was defined as a drop of at least 5 points in the Barthel Index (BI) at discharge, relative to a stable score before hospitalization. Subgroup analysis classified HAD as mild (a decrease of 5-15 points in the BI) and severe (a decrease of ≥20 points in the BI). The primary outcome was all-cause mortality within 1 year after hospital discharge, and the secondary outcomes were HF-related mortality and rehospitalization.

RESULTS

All-cause mortality, HF-related mortality, and rehospitalization rates within 1 year were 12%, 5%, and 41%, respectively. Multivariate Cox regression analysis revealed that HAD increased the risk of 1-year all-cause mortality after hospital discharge (adjusted hazard ratio, 1.749; 95% CI, 1.475-2.075). Subgroup analysis showed a significantly higher risk of all-cause mortality among patients with severe HAD than among those with mild HAD (1.388; 1.109-1.739). HAD was a significant risk factor for HF-related mortality (1.556; 1.216-2.017). However, no relationship was observed between HAD and readmission (1.062; 0.970-1.163).

CONCLUSIONS AND IMPLICATIONS

The development of HAD was identified as a significant risk factor for 1-year post-discharge mortality among older patients with HF who were independent in ADLs before hospitalization. Preventing minor declines in ADL and mitigating any ADL impairments during hospitalization are crucial to avoiding a worsening prognosis.

Development and internal validation of a clinical prediction model to predict independence in daily living at discharge for patients with heart failure: analysis using a Japanese national inpatient database real-world dataset

PURPOSE

To develop a clinical prediction model (CPM) to predict independence in activities of daily living (ADLs) in patients with heart failure.

SUBJECTS AND METHODS

We collected the data of the individuals who were admitted and rehabilitated for heart failure from January 2017 to June 2022 from Japan's Diagnosis Procedure Combination database. We assessed the subjects' ADLs at discharge using the Barthel Index and classified them into independence, partial-independence, and total-dependence groups based on their ADLs at discharge. Two CPMs (an independence model and a partial-independence model) were developed by a binomial logistic regression analysis. The predictors included subject characteristics, treatment, and post-hospitalization disease onset. The CPMs' accuracy was validated by the area under the curve (AUC). Internal validation was performed using the bootstrap method. The final CPM is presented in a nomogram.

RESULTS

We included 96,753 patients whose ADLs could be traced at discharge. The independence model had a 0.73 mean AUC and a 1.0 slope at bootstrapping. We thus developed a simplified model using nomograms, which also showed adequate predictive accuracy in the independence model. The partial-independence model had a 0.65 AUC and inadequate predictive accuracy.

CONCLUSIONS

The independence model of ADLs in patients with heart failure is a useful CPM.

Clinical impacts of malnutrition based on the GLIM criteria using the MNA-SF for nutritional screening in patients with acute heart failure

The Global Leadership Initiative on Malnutrition (GLIM) suggested a two-step framework for the assessment of malnutrition based on screening and diagnosis. Malnutrition, as defined by the GLIM criteria, and the risk of malnutrition determined through nutritional screening are associated with adverse outcomes in patients with heart failure (HF). This study investigated the prognostic impact of malnutrition, as defined by the GLIM criteria, compared with the risk of malnutrition determined by the Mini Nutritional Assessment-Short Form (MNA-SF) screening tool among patients hospitalized for acute HF. A total of 446 patients with acute HF who underwent nutritional screening using the MNA-SF and were diagnosed with malnutrition based on the GLIM criteria were include in this study. The primary outcome was the incidence of all-cause death or HF-related readmission after discharge. Patients diagnosed with malnutrition based on both indices had a higher incidence of adverse events within one year post-discharge than patients diagnosed without malnutrition. However, a landmark analysis of years one to three post-discharge found that the incidence of the primary outcome was comparable between patients diagnosed with malnutrition and those that here not. Furthermore, although malnutrition as defined by the GLIM criteria was found to be an independent predictor of the 1 year incidence of all-cause death or rehospitalization for HF even after adjusting for other prognostic indicators (hazard ratio, 1.593; 95% confidence interval, 1.056-2.403; P = 0.026), the risk of malnutrition based on the MNA-SF was not. In conclusion, a diagnosis of malnutrition based on the GLIM criteria provides better prognostic stratification in the first year post-discharge in patients with acute HF as compared with nutritional screening based only on the MNA-SF.

Early prediction of functional impairment at hospital discharge in patients with osteoporotic vertebral fracture: a machine learning approach

Although conservative treatment is commonly used for osteoporotic vertebral fracture (OVF), some patients experience functional disability following OVF. This study aimed to develop prediction models for new-onset functional impairment following admission for OVF using machine learning approaches and compare their performance. Our study consisted of patients aged 65 years or older admitted for OVF using a large hospital-based database between April 2014 and December 2021. As the primary outcome, we defined new-onset functional impairment as a Barthel Index ≤ 60 at discharge. In the training dataset, we developed three machine learning models (random forest [RF], gradient-boosting decision tree [GBDT], and deep neural network [DNN]) and one conventional model (logistic regression [LR]). In the test dataset, we compared the predictive performance of these models. A total of 31,306 patients were identified as the study cohort. In the test dataset, all models showed good discriminatory ability, with an area under the curve (AUC) greater than 0.7. GBDT (AUC = 0.761) outperformed LR (0.756), followed by DNN (0.755), and RF (0.753). We successfully developed prediction models for new-onset functional impairment following admission for OVF. Our findings will contribute to effective treatment planning in this era of increasing prevalence of OVF.

Effect of basic activities of daily living independence on home discharge and long-term outcomes in patients hospitalized with heart failure

Patients hospitalized for heart failure (HF) experience impairments in functional status, primarily affecting basic activities of daily living (ADL). We investigated the independent effect of functional status for ADL on patient-centered outcomes (i.e., home discharge) and conventional clinical outcomes in HF. We analyzed 2936 consecutive hospitalized patients with HF from a prospective multicenter registry. The functional status of ADL was assessed before discharge by using the Barthel index (BI). Patients were categorized into the lower BI group (≤85; the lowest tertile) and higher BI group (>85). We evaluated the risk-adjusted association between BI and non-home discharge, as well as the two-year all-cause mortality. Exploratory subgroups included patients categorized by age, sex, HF hospitalization, left ventricular ejection fraction, body mass index, and estimated glomerular filtration rate (eGFR). Of the participants (age: 79 [69-85] years; 41.1% women), 86.3% were discharged home. A lower BI was independently associated with non-home discharge (OR: 5.12, 95% CI 3.86-6.80) and higher all-cause mortality rates (HR: 1.96, 95% CI 1.58-2.45). Two-year cardiac and non-cardiac mortality rates were higher in the lower BI group; however, the proportion of cardiac causes in two-year deaths did not differ between the lower and higher BI groups (48.8% vs. 49.5%, P = 0.891). Subgroup analyses consistently demonstrated an association between two-year mortality and lower BI; however, this association was stronger among patients with a higher eGFR (P-value for interaction = 0.004). A lower BI was independently associated with non-home discharge and higher mortality rates because of cardiac- and non-cardiac-related causes in hospitalized patients with HF.

Association between changes in nutritional status and ability to perform activities of daily living in older patients with heart failure: A stratified analysis by frailty status

OBJECTIVES

We aimed to determine the association between changes in nutritional status and the activities of daily living (ADL) at discharge, considering frailty status of older patients with heart failure (HF).

METHODS

This study included 491 older inpatients with HF categorized into the following groups based on their clinical frailty scale (CFS) scores: low, intermediate, and high. Changes in nutritional status were assessed using the Controlling Nutritional Status score at admission and discharge. The outcome variable was Barthel Index (BI) at discharge.

RESULTS

Multivariate logistic regression analysis indicated an association between improvement in nutritional status and high BI at discharge in both the low and intermediate CFS groups (odds ratio [OR], 2.18 [95% confidence interval, 1.04-4.58]), (OR, 2.45 [1.21-4.95]), respectively.

CONCLUSIONS

Improvement in the ADL at discharge in older patients with HF was associated with improved nutritional status during hospitalization in the low and intermediate CFS groups.

Prognostic impact of polypharmacy and discharge medications in octogenarians and nonagenarian patients with acute heart failure

With the increasing frequency of heart failure (HF) in elderly patients, polypharmacy has become a major concern owing to its adverse outcomes. However, reports on the clinical impact of polypharmacy and discharge medications in hospitalized super-aged patients with acute HF are rare. Data from 682 patients aged 80 years or older, hospitalized for treating acute HF, were analyzed. We recorded the number of medications at discharge and classified them into three groups: HF, non-HF cardiovascular, and non-cardiovascular medications. We investigated the correlation of polypharmacy, defined as daily administration of 10 or more medications at discharge, and the use of discharge medications with post-discharge prognosis. Polypharmacy was recorded in 24.3% of enrolled patients. Polypharmacy was not an independent predictor of all-cause mortality, the incidence of cardiac-related death, or HF-associated rehospitalization; however, the number of non-cardiovascular medications, multiple usage of potentially inappropriate medications, use of mineralocorticoid receptor antagonists, and doses of loop diuretics were associated with poor prognosis. Polypharmacy was significantly associated with higher mortality in patients with Barthel index ≥ 60 at discharge; hence, physical function at discharge was useful for the stratification of prognostic impacts of polypharmacy. The current study demonstrated that polypharmacy was not essentially associated with poor prognosis in super-aged patients with acute HF. Appropriate medications that consider the patient's physical function, rather than polypharmacy itself, are important for the management of HF.

Impact of the Barthel Index Score and Prognosis on Patients Undergoing Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement

BACKGROUND

Few studies have compared the Barthel Index (BI) score and postoperative outcomes of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). We aimed to examine the relationship between the BI score and postoperative outcomes in patients who underwent TAVR and SAVR.

METHODS AND RESULTS

The study included patients who underwent SAVR between January 2014 and December 2022 (n=293) and patients who underwent TAVR between January 2016 and December 2022 (n=312). We examined the risk factors for long-term mortality in the 2 groups. The mean (±SD) preoperative BI score was 88.7±18.0 in the TAVR group and 95.8±12.3 in the SAVR group. The home discharge rate was significantly lower in the SAVR than TAVR group. The BI score at discharge was significantly higher in the SAVR than in TAVR group (86.2 vs. 80.2; P<0.001). Significant risk factors for long-term mortality in the TAVR group were sex (P<0.001) and preoperative hemoglobin level (P=0.008), whereas those in the SAVR group were preoperative albumin level (P=0.04) and postoperative BI score (P=0.02). The cut-off point of the postoperative BI score determined by receiver operating characteristic curve analysis was 60.0.

CONCLUSIONS

The BI score at discharge was a significant risk factor for long-term mortality in the SAVR group, with a cut-off value of 60.0.

The association of serum adiponectin level with activities of daily living in hospitalized elderly patients with heart failure

BACKGROUND

Several studies have reported a relationship between elevated serum adiponectin levels and poor outcomes in patients with heart failure (HF). However, data on the activities of daily living (ADL) in elderly patients with HF are limited.

METHODS

We evaluated 218 hospitalized elderly (≥65 years) patients with HF who underwent a comprehensive cardiac rehabilitation (CR) program during hospitalization. Serum adiponectin levels were measured before discharge. The Barthel index (BI) score was evaluated at discharge. Low ADL was defined as a BI score < 85.

RESULTS

Serum adiponectin levels were significantly associated with low ADL [p = 0.03; odds ratio (OR), 1.024, per 1.0 μg/mL increase]. In logistic or regression analyses adjusted for age, sex, body mass index, and estimated glomerular filtration rate, high adiponectin levels (≥16.2 μg/mL) were significantly associated with low ADL (p = 0.04; OR, 2.53), malnutrition (p < 0.01; OR, 2.88), and 6-min walk distance (p = 0.04; β = -17.5). In the multivariate analysis adjusted for conventional risk factors of low ADL, high adiponectin levels were also significantly associated with low ADL (p = 0.03; OR, 2.68). In the stepwise forward selection procedure, a high adiponectin level was an independent determinant of low ADL (p = 0.02; R2 = 0.0262). Both net reclassification improvement (0.53; p < 0.01) and integrated discrimination improvement (0.02; p = 0.01) improved significantly after the addition of high adiponectin level to conventional risk factors. In the regression analysis adjusted for age and sex, serum adiponectin levels were significantly (p < 0.0025) negatively associated with abdominal visceral and subcutaneous adipose tissue areas, body weight, body mass index, and serum triglyceride levels.

CONCLUSIONS

High serum adiponectin levels were not only significantly associated with an increased risk of low ADL, but also with an increased risk of malnutrition and low physical activity in elderly patients with HF after the in-hospital CR program.

The association between oral health status and physical function in elderly patients with acute heart failure

OBJECTIVES

Oral health problems are common and are associated with various geriatric conditions in older adults. The importance of oral health has not been fully highlighted in the assessment and management of patients with heart failure. Here, we investigated the association between oral health status and the decline in physical function during hospitalization in elderly patients with acute heart failure.

MATERIALS AND METHODS

We evaluated oral health using the revised oral assessment guide in 77 patients aged 65 years or older who were admitted to hospital for acute heart failure. Oral health problems were defined as a revised oral assessment guide score ≥9.

RESULTS

Oral health problems were identified in 66.2% of the patients. Patients with oral health problems had high prevalence of decreased physical function, undernutrition, and cognitive impairment. A reduction in the Barthel Index, as an indicator of activities of daily living during hospitalization, was significant in the enrolled patients. The Barthel Index decreased more in patients with oral health problems than those with normal oral health. Furthermore, the revised oral assessment guide score on admission was found to be the only independent predictor of changes in the Barthel Index during hospitalization in the multivariate analyses.

CONCLUSIONS

Oral assessment using the revised oral assessment guide during hospitalization could provide useful information for the management of elderly heart failure patients.

Effect of in-patient cardiac rehabilitation at rehabilitation hospital for cardiology patients: two-center trial

The effectiveness of cardiac rehabilitation (CR) in patients with cardiovascular disease requiring continuous CR from an acute care hospital to a convalescent rehabilitation hospital is unknown. Therefore, we compared the effect of CR in a rehabilitation hospital for patients with cardiovascular disease with that of those who underwent cardiovascular surgery. Sixty-nine consecutive patients were admitted to two rehabilitation hospitals for CR. Patients were classified by primary disease into two groups: patients with cardiovascular disease (cardiology group, 26 patients) and patients who underwent cardiovascular surgery (surgery group, 43 patients). Clinical information, physical function, cognitive function, activities of daily living (ADL), quality of life (QOL), amount of CR, and length of hospital stay were compared between the two groups. Compared with clinical features, age was significantly higher in the cardiology group (P < 0.001), and the preadmission Barthel index was significantly lower in the cardiology group (P = 0.025). Physical function at the time of transfer was significantly lower in the cardiology group than in the surgery group for the short physical performance battery (P < 0.001), gait speed (P = 0.005), and 6-min walking distance (P = 0.042). No significant difference was found in the amount of CR performed or the length of hospital stay, and no interaction effects were observed in improvements in physical function, exercise tolerance, or QOL. In conclusion, in rehabilitation hospitals, patients with cardiovascular disease were older, had lower preadmission ADL, and had lower a physical function at transfer than those who underwent cardiovascular surgery, but CR improved physical function and QOL to the same extent. The results suggest that the recovery of patients with cardiovascular disease may be similar to those who undergo cardiovascular surgery.

Geriatric Nutritional Risk Index Predicts High Activities of Daily Living at Discharge in Older Patients with Heart Failure after Cardiac Rehabilitation

BACKGROUND

Hospitalization often leads to a decline in activities of daily living (ADL) in older patients with heart failure. Although cardiac rehabilitation (CR) improves ADL, it can be difficult to perform CR due to the deconditioning of these patients. This study aimed to examine the factors associated with ADL at discharge in older patients with heart failure who underwent CR.

METHODS

A total of 86 of 110 older heart failure patients aged ≥ 75 years (average age, 86.9 ± 5.7 years) transferred to our institution for CR were enrolled and classified into high ADL at discharge (n = 54) and low ADL at discharge (n = 32) groups. Physical characteristics, comorbidities, medications, blood test data, echocardiographic data, and nutritional status (Geriatric Nutritional Risk Index [GNRI]) were retrospectively examined from medical records. ADL were assessed using the Barthel Index (BI) at admission and discharge. Considering multicollinearity, the relationship between high ADL (BI ≥ 60) at discharge and these assessments at admission was analyzed using multiple logistic regression analysis. The receiver operating characteristic curve was analyzed to calculate the cutoff values for the parameters identified by the multiple logistic regression analysis.

RESULTS

The GNRI was the only independent factor predicting high ADL at discharge (p = 0.041; odds ratio [OR], 1.125; 95% confidence interval [CI], 1.005-1.260). The area under the receiver operating characteristic curve for the GNRI was 0.770 (95% CI, 0.664-0.876). The cutoff value for the GNRI was 83.4 (sensitivity, 85.2%; specificity, 62.5%).

CONCLUSION

These findings suggest that the GNRI score at admission predicts high ADL at discharge in older patients with heart failure who underwent CR.

Predictive Value of the Hemoglobin-Geriatric Nutritional Risk Index in Patients with Heart Failure

Malnutrition prevails among patients with heart failure (HF), increasing the likelihood of functional decline. We assessed the predictive value of the Hemoglobin-Geriatric Nutritional Risk Index (H-GNRI)—combining hemoglobin and the Geriatric Nutritional Risk Index (GNRI)—on prognosis in older patients with HF. We used the JMDC multicenter database to examine the potential associations between malnutrition risk and other outcome measures. The patients were categorized as low- (H-GNRI score = 2), intermediate- (H-GNRI score = 1), or high-risk (H-GNRI score = 0) based on their H-GNRI scores. The primary outcome measure was the Barthel Index (BI) gain; the secondary outcomes included the BI at discharge, the BI efficiency, length of hospital stay, in-hospital mortality, discharge to home or a nursing home, and hospitalization-associated disability. We analyzed 3532 patients, with 244 being low-risk, 952 being intermediate-risk, and 2336 being high-risk patients. The high-risk group of patients had significantly lower BI values at discharge, lower BI gains, reduced BI efficiency values, and prolonged hospital stays compared to those in the low-risk group. The high-risk patients also had higher in-hospital mortality rates, lower rates of discharge to home or a nursing home, and greater incidences of a hospitalization-associated disability in comparison to the low-risk group. The H-GNRI may serve as a valuable tool for determining prognoses for patients with HF.

Association of preoperative clinical frailty and clinical outcomes in elderly patients with stable coronary artery disease after percutaneous coronary intervention

There are few reports on the long-term clinical outcome after percutaneous coronary intervention (PCI) in patients with stable coronary artery disease (CAD) complicated with frailty. This novel study investigated the association between pre-PCI frailty and long-term clinical outcomes in elderly patients aged 65 years or older with stable CAD who underwent elective PCI. We assessed 239 consecutive patients aged 65 years or older with stable CAD who underwent successful elective PCI at Kagoshima City Hospital between January 1st, 2017 and December 31st, 2020. Frailty was retrospectively assessed using the Canadian Study and Aging Clinical Frailty Scale (CFS). Based on the pre-PCI CFS, patients were divided into two groups: the non-frail (CFS < 5) and the frail (CFS ≥ 5) group. We investigated the association between pre-PCI CFS and major adverse cardiovascular events (MACEs) defined as the composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, and heart failure requiring hospitalization. Additionally, we assessed the association between pre-PCI CFS and major bleeding events defined as Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding. The mean age was 74.8 ± 7.0 years, and 73.6% were men. According to the pre-PCI frailty assessment, 38 (15.9%) and 201 (84.1%) were classified as frail and non-frail groups, respectively. During a median follow-up of 962 (607-1284) days, 46 patients developed MACEs and 10 patients developed major bleeding events. Kaplan-Meier curves showed a significantly higher incidence of MACE in the frail group compared to those in the non-frail group (Log-rank p < 0.001). Even in multivariate analysis, pre-PCI frailty (CFS ≥ 5) was independently associated with MACE (HR 4.27, 95% CI 1.86-9.80, p-value: < 0.001). Additionally, the cumulative incidence of major bleeding events was significantly higher in the frail group than in the non-frail group (Log-rank p = 0.001). Pre-PCI frailty was an independent risk factor for MACE and bleeding events in elderly patients with stable CAD who underwent elective PCI.

Effects of early mobilisation program on functional capacity, daily living activities, and N-terminal prohormone brain natriuretic peptide in patients hospitalised for acute heart failure. A randomised controlled trial

Background

Patients hospitalised for acute decompensated heart failure (ADHF) show reduced functional capacity, limited activities of daily living (ADL), and elevated N-terminal prohormone of brain natriuretic peptide (NT-proBNP). The management of these patients focuses mainly on medical therapy with little consideration for in-patient cardiac rehabilitation. There has been a growing interest in evaluating the efficacy of early mobilisation, as the core for in-hospital rehabilitation, in ADHF patients in the last decade; however, the randomised trials on this topic are few.

Objective

This randomised-controlled study, therefore, aimed to further test the hypothesis that early supervised mobilisation would have beneficial effects on functional capacity, ADL, and NT-proBNP in stabilised patients following ADHF.

Methods

This is a single-centered, randomised-controlled, parallel-group trial in which 30 patients hospitalised for ADHF were randomly assigned to two groups; the study group (age = 55 . 4 ± 5 . 46 years, n 1 = 15 ) and the control group (age = 55 . 73 ± 5 . 61 years, n 2 =15). Inclusion criteria were ADHF on top of chronic heart failure independent of etiology or ejection fraction, clinical/hemodynamic stability, age from 40 to 60 years old, and both genders. Exclusion criteria were cardiogenic shock, acute coronary ischemia, or significant arrhythmia. Both groups received the usual medical care, but only the study group received an early structured mobilisation protocol within 3 days of hospital admission till discharge. The outcome measures were the 6-min walk distance (6-MWD) and the rating of perceived exertion (RPE) determined from the 6-min walk test at discharge, the Barthel index (BI), NT-proBNP, and the length of hospital stays (LOS).

Results

The study group showed significantly greater improvements compared to the controls in the 6-MWD (252 . 28 ± 92 . 32 versus 106 . 35 ± 56 . 36 m, P < 0 . 001 ), the RPE (12 . 53 ± 0 . 91 versus 15 . 4 ± 1 . 63 , P < 0 . 001 ), and the LOS (10 . 42 ± 4 . 23 versus 16 . 85 ± 6 . 87 days, p = 0 . 009 ) at discharge. Also, the study group showed significant improvements in the BI compared to baseline [100 (100-100) versus 41.87 (35-55), p = 0 . 009 ] and the controls [100 (100-100) versus 92.5(85-95), p = 0 . 006 ]. The mean value of NT-proBNP showed a significant reduction only compared to baseline (786 . 28 ± 269 . 5 versus 1069 . 03 ± 528 . 87 pg/mL, p = 0 . 04 ) following the intervention. The absolute mean change (Δ ) of NT-proBNP showed an observed difference between groups in favor of the study group (i.e., Δ = ↓ 282 . 75 ± 494 . 13 pg/mL in the study group versus ↓ 26 . 42 ± 222 . 21 pg/mL in the control group, p = 0 . 077 ).

Conclusion

Early structured mobilisation under the supervision of a physiotherapist could be strongly suggested in combination with the usual medical care to help improve the functional capacity and daily living activities, reduce NT-proBNP levels, and shorten the hospital stay in stabilised patients following ADHF. Trial registration number: PACTR202202476383975.

Differences in clinical outcomes between octogenarian and nonagenarian patients with acute heart failure

AIM

The number of hospitalized super-elderly patients with heart failure (HF) has increased with aging of the population. These patients are associated with poor clinical outcomes with the advance of age; however, few reports regarding acute HF have compared the clinical outcomes of nonagenarians with those of octogenarians.

METHODS

This study enrolled 683 patients aged ≥80 years who were admitted to our institution for acute HF between 2016 and 2020. The outcomes of interest were the 1-year all-cause mortality, incidence of cardiac events (cardiac-related death or HF-related readmission), and physical function during hospitalization of patients with survival-to-discharge. Physical function was evaluated using the Barthel index.

RESULTS

Post-discharge all-cause mortality, particularly non-cardiac mortality, was significantly higher in nonagenarians than octogenarians. Conversely, the incidence of cardiac death or rehospitalization for HF after discharge was comparable between the two groups. On admission, the Barthel index score was significantly lower in nonagenarians than octogenarians, and further decreased during hospitalization. Nonagenarians required social support at discharge more often than octogenarians (67.4% vs. 44.4%; P < 0.001).

CONCLUSIONS

The current study demonstrated that nonagenarians have poorer non-cardiac outcomes and were more vulnerable regarding physical activities than octogenarians among patients with acute HF. Holistic medical care, including palliative care and social support, will be increasingly required with increasing age. Geriatr Gerontol Int 2023; 23: 227-233.

Dysphagia is an independent predictor of hospital-acquired disability in older patients with heart failure: a propensity score-matched analysis : Predictors of HAD in older HF patients

This study aims to identify the relationship between dysphagia and developing hospital-acquired disability (HAD) in older patients with heart failure (HF). This single-center retrospective cohort study included 360 patients (median age, 84 years: 58.1% female, 41.9% male) who had undergone rehabilitation and were aged 65 years and older. Patients were divided into dysphagia and non-dysphagia groups and compared based on the Functional Oral Intake Scale score. HAD was defined as a decline in the Barthel Index score (indication of daily activity levels) at discharge relative to that before admission. The relationship between dysphagia and HAD was analyzed using bivariate analysis after adjusting for age, sex, body mass index, medical history, clinical and laboratory data, short physical performance battery (SPPB), and cognitive function at the start of rehabilitation, using propensity score matching. HAD was observed in 38.1% of the patients. Patients with dysphagia were significantly older, and had lower body mass index and physical and cognitive function than those without. After propensity score matching, the prevalence of HAD was significantly higher in the dysphagia group than in the non-dysphagia group (61.9% vs. 42.9%, P = 0.032). Dysphagia at the start of rehabilitation was an independent predictor of HAD. The results of this study may contribute to risk stratification of HAD.

A Comparative Study of Three Nutritional Risk/Screening Indices for Predicting Cardiac Events and Physical Functioning Among Patients with Acute Heart Failure

Undernutrition is very common among patients with heart failure (HF). This study evaluated the prognostic values of three nutritional risk/screening indices among patients with acute HF. We retrospectively calculated scores for 465 patients with acute HF using the Controlling Nutritional Status (CONUT) tool, the Geriatric Nutritional Risk Index (GNRI), and the Mini-Nutritional Assessment Short Form (MNA-SF). The outcomes of interest were the 1-year rate of cardiac events (cardiac-related death or HF-related readmission) and the Barthel index as an index of physical function during hospitalization. The CONUT, GNRI, and MNA-SF scores were significantly correlated, although the proportions of a normal nutritional state varied (CONUT: 18.3%, GNRI: 32.9%, and MNA-SF: 43.9%). Kaplan-Meier estimates revealed that cardiac events were more common among patients with undernutrition based on the CONUT score, and multivariable regression analysis revealed that only the CONUT score independently predicted poor outcomes. Furthermore, changes in the Barthel index during hospitalization were significantly correlated with the CONUT score but not with the GNRI and MNA-SF scores. In receiver operating characteristic analyses, the CONUT score had the most powerful predictive values on both the postdischarge incidence of cardiac events and the decline of physical function during hospitalization compared with the GNRI and the MNA-SF. These results indicate that the CONUT score might provide useful information for predicting poor outcomes in patients with acute HF.

Development and validation of early prediction models for new-onset functional impairment at hospital discharge of ICU admission

PURPOSE

We aimed to develop and validate models for predicting new-onset functional impairment after intensive care unit (ICU) admission with predictors routinely collected within 2 days of admission.

METHODS

In this multi-center retrospective cohort study of acute care hospitals in Japan, we identified adult patients who were admitted to the ICU with independent activities of daily living before hospitalization and survived for at least 2 days from April 2014 to October 2020. The primary outcome was functional impairment defined as Barthel Index ≤ 60 at hospital discharge. In the internal validation dataset (April 2014 to March 2019), using routinely collected 94 candidate predictors within 2 days of ICU admission, we trained and tuned the six conventional and machine-learning models with repeated random sub-sampling cross-validation. We computed the variable importance of each predictor to the models. In the temporal validation dataset (April 2019 to October 2020), we measured the performance of these models.

RESULTS

We identified 19,846 eligible patients. Functional impairment at discharge was developed in 33% of patients (n = 6488/19,846). In the temporal validation dataset, all six models showed good discrimination ability with areas under the curve above 0.86, and the differences among the six models were negligible. Variable importance revealed newly detected early predictors, including worsened neurologic conditions and catabolism biomarkers such as decreased serum albumin and increased blood urea nitrogen.

CONCLUSION

We successfully developed early prediction models of new-onset functional impairment after ICU admission that achieved high performance using only data routinely collected within 2 days of ICU admission.

Early initiation of tolvaptan is associated with early discharge in patients with heart failure regardless of age

BACKGROUND

Elderly patients with heart failure (HF) have been observed to decrease activities of daily living (ADL) during hospitalization. Prevention of ADL decline from shortening of hospital stays is especially important in the elderly, because decreasing ADL is associated with poor prognosis. We investigated the relationship between the early initiation of tolvaptan (TLV) after hospitalization and the length of hospital stay in patients with HF aged younger than 80 years and aged 80 years and older.

METHODS

We analyzed 146 patients younger than 80 years (< 80) and 101 patients aged 80 years and older (≥ 80) who were hospitalized with HF from February 2011 to June 2016 and had initiated TLV. The relationship between the time until commencement of TLV and the length of hospital stay was assessed. Additionally, a comparison made between the TLV early start group (within the median) and the delayed start group (over the median) for both groups. Multivariate analysis was also performed on factors that required hospital stays below the median.

RESULTS

A significant correlation was observed between time to TLV initiation and the length of hospital stay (< 80: r = 0.382, P < 0.001; ≥ 80: r = 0.395, P < 0.001). The length of hospital stay in the early group was significantly longer than that in the delayed group for both groups (< 80: early 21.0 ± 13.0 days and 33.0 ± 22.7 days, respectively, P < 0.001; ≥ 80: early 21.3 ± 12.5 days and 32.9 ± 17.9 days, respectively, P < 0.001). Conversely, no statistically significant difference found in the length of hospital stay after initiation of TLV. Moreover, no increase in adverse events in the elderly observed. A multivariate analysis revealed that a predictive factor for short-term hospitalization was early administration of TLV regardless of age.

CONCLUSIONS

The early initiation of TLV after hospitalization was associated with a shorter length of hospital stay in patients with HF regardless of age.

Usefulness of 2D Video Analysis for Evaluation of Shoulder Range of Motion during Upper Limb Exercise in Patients with Psychiatric Disorders

Aging and its associated problems related to movement impacts the care of people with psychiatric disorders. This study sought to clarify the usefulness of 2D video analysis for evaluating shoulder range of motion (ROM) during upper limb exercises in patients with psychiatric disorders. Subjects (N=54) were patients with psychiatric disorders categorized as the following:having either a high or low activities of daily living (ADL) score using the Barthel Index;experiencing shoulder ROM limitation, and whether or not compensatory movements were exhibited. Compensatory movement was also considered in patients with Parkinsonism, cerebrovascular disease, and cognitive dysfunction. Shoulder joint ROM was measured using a goniometer and active ROM was captured using ImageJ. No significant difference between passive ROM measured by a goniometer and active ROM measured by ImageJ considering disease groups, ADL level, and shoulder ROM limitation was found. Factoring in compensatory movements, however, significant differences were found between passive and active ROM:existence compensatory movement group, left side (z=-2.30, p=0.02);nonexistence compensatory movement group, right side (z=-2.63, p<0.001). Image-evaluating devices help assess ROM in patients with psychiatric disorders, enhancing the development of physical rehabilitation programs to regain critical ADL, sustaining self-care capabilities. J. Med. Invest. 69 : 70-79, February, 2022.

Discharge disposition and 1-year readmission in acute-phase hospitalized patients with heart failure: a retrospective observational multi-center study

Patients hospitalized for acute heart failure (HF) tend to experience declines in physical function and activities of daily living (ADL) due to bed rest and restricted mobilization. This could result in some patients being transferred to rehabilitation hospitals. This study aims to examine the relationship between discharge disposition and 1-year readmission and mortality rates in HF patients. Nine hundred fifty six consecutive HF patients who were hospitalized for acute decompensated HF and underwent rehabilitation were divided into two groups: home (returned home) or transfer (transferred to rehabilitative or long-term care hospital units due to decline in physical function and/or ADL) groups. The primary and secondary outcomes were 1-year readmission and mortality rates after discharge, respectively. Of the 956 patients, 8.6% (n = 82) were transferred to rehabilitative or long-term care hospital units. Over a 1-year follow-up period, all-cause and HF readmission rates were 50.1% (n = 479) and 27.2% (n = 260), respectively. The transfer group had significantly lower readmission rates compared to home group after adjusting for the pre-existing risk factors (hazard ratio for all-cause and HF readmission: 0.600 and 0.552, 95% CI 0.401-0.897 and 0.314-0.969; P = 0.013 and P = 0.038, respectively). There was no significant relationship between discharge disposition and all-cause mortality rate. Low ADL defined as Barthel index < 60 points was identified as a predictor of all-cause and HF readmission among the home group (odds ratio for all-cause and HF readmission rates: 2.156 and 1.847, 95% CI 1.026-4.531 and 1.036-2.931; P = 0.043 and P = 0.037, respectively). This multi-center study demonstrated that HF patients transferred to rehabilitative or long-term care hospital units after an acute hospitalization had a significantly decreased 1-year all-cause and HF readmission rates compared to patients who returned to their home. These findings may help in selecting a discharge disposition for older HF patients with ADL decline.

Associations of body mass index and hospital-acquired disability with post-discharge mortality in older patients with acute heart failure

OBJECTIVES

To investigate the effect of hospital-acquired disability (HAD) on all-cause mortality after discharge according to the body mass index (BMI) in older patients with acute decompensated heart failure.

METHODS

We included 408 patients aged ≥ 65 years who were hospitalized for acute decompensated heart failure and had undergone an acute phase of cardiac rehabilitation at the Sakakibara Heart Institute between April 2013 and September 2015 (median age: 82 years, interquartile range (IQR): 76-86; 52% male). Patients were divided into three groups based on BMI at hospital admission: underweight (< 18.5 kg/m²), normal weight (18.5 to 25 kg/m²), and overweight (≥ 25 kg/m²). HAD was defined as a decrease of at least five points at discharge compared to before hospitalization according to the Barthel Index.

RESULTS

The median follow-up period was 475 (IQR: 292-730) days, and all-cause mortality during the follow-up period was 84 deaths (21%). According to multivariate Cox regression analysis, being underweight (HR: 1.941, 95% CI: 1.134-3.321,P = 0.016) or overweight (HR: 0.371, 95% CI: 0.171-0.803,P = 0.012), with normal BMI as the reference, and HAD (HR: 1.857, 95% CI: 1.062-3.250,P = 0.030) were independently associated with all-cause mortality. Patients with HAD exhibited a significantly lower cumulative survival rate in the underweight group (P = 0.001) and tended to have a lower cumulative survival rate in the normal weight group (P = 0.072). HAD was not significantly associated with cumulative survival in the overweight group (P = 0.392).

CONCLUSIONS

BMI and HAD independently predicted all-cause mortality after discharge in older patients with acute decompensated heart failure. Furthermore, HAD was significantly associated with higher all-cause mortality after discharge, especially in the underweight group.

Acute-Phase Initiation of Cardiac Rehabilitation for Short-Term Improvement in Activities of Daily Living in Patients Hospitalized for Acute Heart Failure

BACKGROUND

Whether acute-phase cardiac rehabilitation (CR) is beneficial for short-term improvement in activities of daily living (ADL) in patients hospitalized for acute heart failure (AHF) remains unclear.

AIM

To investigate the association of acute-phase initiation of CR with short-term improvement in ADL in patients hospitalized for AHF.

METHODS

We retrospectively analyze data from the Diagnosis Procedure Combination Database, a nationwide inpatient database. Patients hospitalized for HF between January 2010 and March 2018 are included. Propensity score matching and generalized linear models are built to examine the association between improvement in ADL and acute-phase CR initiation, defined as the initiation of CR within two days of admission.

RESULTS

Among 306,826 eligible patients, CR is initiated in 45,428 patients (14.8%) within two days of hospital admission. Propensity score matching creates 45,427 pairs. CR initiation within two days of hospital admission is associated with ADL improvement (risk ratio: 1.018; 95% confidence interval: 1.004-1.032), particularly in elderly patients, females, and individuals with low ADL at admission, body mass index of 18.5-24.9 kg/m2, and New York Heart Association class IV.

CONCLUSIONS

Our analyses highlight the possibility that acute-phase CR initiation may result in short-term improvement in ADL in patients hospitalized for AHF.

What is the optimal nutritional assessment tool for predicting decline in the activity of daily living among older patients with heart failure?

The clinical importance of nutritional management in activities of daily living (ADL) among older inpatients with heart failure (HF) is greatly increasing. We determined the optimal nutritional assessment tool that can predict ADL decline among older inpatients with HF. We prospectively investigated 91 inpatients aged ≥ 65 years with HF in an acute hospital. We measured their nutritional status at admission using nutrition indices: the controlling nutritional status (CONUT), the geriatric nutritional risk index, the prognostic nutritional index, and the mini nutritional assessment. Logistic regression analysis was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of the relationships between the malnutrition status assessed by each nutritional index category and the ADL decline measured by the Barthel index (BI) in the univariate and multivariate analyses. Among the participants, 28.6% (n = 26; median age 81.5 years; 69.2% men) of the participants were included in the Reduced BI group and 71.4% (n = 65; median age 79.0 years; 67.7% men) in the Maintained BI group. The Reduced BI group showed a significantly higher CONUT value than the Maintained BI group, but there were no significant differences in other nutritional indices. In the multivariate logistic regression analysis, a higher CONUT score was associated with a significantly elevated risk of Reduced BI (adjusted OR 0.24; 95%CI 0.08-0.75; p = 0.014). We found that CONUT is an appropriate nutritional assessment tool for predicting ADL decline among older inpatients with HF in the early phase of hospitalization.

Barthel Index Score Predicts Mortality in Elderly Heart Failure - A Goal of Comprehensive Cardiac Rehabilitation

BACKGROUND

A strategy to predict mortality in elderly heart failure (HF) patients has not been established.

METHODS AND RESULTS

We retrospectively enrolled 413 HF patients aged ≥65 years (mean age 78 years) who had received comprehensive cardiac rehabilitation (CR) during hospitalization. Basic activities of daily life were assessed before discharge using the Barthel index (BI). Of 413 HF patients, 116 (28%) died during a median follow-up period of 1.90 years (interquartile range 1.20-3.23 years). An adjusted dose-dependent association analysis showed that the hazard ratio (HR) of mortality increased in an almost linear manner as the BI score decreased, and that a BI score of 85 corresponded to an HR of 1.0. Kaplan-Meier survival curves showed that the survival rate was lower for patients with a low BI (<85) than for those with a high BI (≥85; 65% vs. 74%, respectively; P=0.007). In multivariate Cox regression analyses, low BI was independently associated with higher mortality after adjusting for predictors, including B-type natriuretic peptide. Inclusion of the BI into the adjusted model improved the accuracy of the prediction of mortality.

CONCLUSIONS

A BI score <85 at the time of discharge is associated with increased mortality independent of known prognostic markers, and achieving functional status with a BI score ≥85 by comprehensive CR during hospitalization may contribute to favorable outcomes in elderly HF patients.

Clinical Characteristics and Outcomes of Hospitalized Patients With Heart Failure From the Large-Scale Japanese Registry Of Acute Decompensated Heart Failure (JROADHF)

BACKGROUND

With aging population, the prevalence and incidence of heart failure (HF) have been increasing worldwide. However, the characteristics and outcomes of patients with HF in an era of aging are not well established in Japan.

METHODS AND RESULTS

The Japanese Registry Of Acute Decompensated Heart Failure (JROADHF), a retrospective, multicenter, nationwide registry, was designed to study the clinical characteristics and outcomes of patients hospitalized with HF throughout Japan in 2013. One hundred and twenty-eight hospitals were selected by cluster random sampling and 13,238 hospitalized patients with HF were identified by medical record review. Demographics, medical history, severity, treatment, and in-hospital and long-term outcome data were collected from the Diagnostic Procedure Combination and medical charts. Data were analyzed using univariate and multivariate logistic regression or Cox regression analysis. The mean age of registered patients was 78.0±12.5 years and 52.8% were male. Elderly patients (age >75 years) accounted for 68.9%, and HF with preserved ejection fraction (HFpEF) accounted for 45.1%. Median length of hospital stay was 18 days and in-hospital mortality was 7.7%. The median follow-up period was 4.3 years, and the incidence rates for cardiovascular death and rehospitalization for HF were 7.1 and 21.1 per 100 person-years, respectively.

CONCLUSIONS

A contemporary nationwide registry demonstrated that hospitalized HF patients were very elderly, HFpEF was common, and their prognosis was still poor in Japan.

Decreased activities of daily living at discharge predict mortality and readmission in elderly patients after cardiac and aortic surgery: A retrospective cohort study

Recently, activities of daily living (ADL) were identified as a prognostic factor among elderly patients with heart disease; however, a specific association between ADL and prognosis after cardiac and aortic surgery is not well established. We aimed to clarify the impact of ADL capacity at discharge on prognosis in elderly patients after cardiac and aortic surgery.This retrospective cohort study included 171 elderly patients who underwent open operation for cardiovascular disease in a single center (median age: 74 years; men: 70%). We used the Barthel Index (BI) as an indicator for ADL. Patients were classified into 2 groups according to the BI at discharge, indicating a high (BI ≥ 85) or low (BI < 85) ADL status. All-cause mortality and unplanned readmission events were observed after discharge.Thirteen all-cause mortality and 44 all-cause unplanned readmission events occurred during the median follow-up of 365 days. Using Kaplan-Meier analysis, a low ADL status was determined to be significantly associated with all-cause mortality and unplanned readmission. In the multivariable Cox proportional hazard models, a low ADL status was an independent predictor of all-cause mortality and unplanned readmission after adjusting for age, sex, length of hospital stay, and other variables (including preoperative status, surgical parameter, and postoperative course).A low ADL status at discharge predicted all-cause mortality and unplanned readmission in elderly patients after cardiac and aortic surgery. A comprehensive approach from the time of admission to postdischarge to improve ADL capacity in elderly patients undergoing cardiac and aortic surgery may improve patient outcomes.

Acute heart failure in elderly patients: a review of invasive and non-invasive management

Acute heart failure (AHF) is a major cause of unplanned hospitalisations in the elderly and is associated with high mortality. Its prevalence has grown in the last years due to population aging and longer life expectancy of chronic heart failure patients. Although international societies have provided guidelines for the management of AHF in the general population, scientific evidence for geriatric patients is often lacking, as these are underrepresented in clinical trials. Elderly have a different risk profile with more comorbidities, disability, and frailty, leading to increased morbidity, longer recovery time, higher readmission rates, and higher mortality. Furthermore, therapeutic options are often limited, due to unfeasibility of invasive strategies, mechanical circulatory support and cardiac transplantation. Thus, the in-hospital management of AHF should be tailored to each patient's clinical situation, cardiopulmonary condition and geriatric assessment. Palliative care should be considered in some cases, in order to avoid unnecessary diagnostics and/or treatments. After discharge, a strict follow-up through outpatient clinic or telemedicine is can improve quality of life and reduce rehospitalisation rates. The aim of this review is to offer an insight on current literature and provide a clinically oriented, patient-tailored approach regarding assessment, treatment and follow-up of elderly patients admitted for AHF.

Clinical Frailty Score Predicts Long-Term Mortality and Hospitalization Due to Heart Failure After Implantation of Cardiac Implantable Electric Device

BACKGROUND

Although patients with poor ability to perform activities of daily living, such as those with high Clinical Frailty Score (CFS), will often receive a cardiac implantable electric device (CIED), the indications for implantation in these patients have not been clearly defined. We investigated the association between CFS and prognosis in patients with a CIED.

METHODS AND RESULTS

We retrospectively enrolled 323 consecutive patients who underwent initial device implantation (age, 77 (70-83) years; male, 181 [56%] patients; high-voltage device, 49 [15%] patients), and the CFS was retrospectively estimated. Primary outcome was all-cause death, and the secondary outcome was hospitalization due to heart failure (HF). Median CFS was 4 (3-5) points. During 2 years' follow-up, all-cause death occurred in 32 patients (10%). Freedom from all-cause death was significantly lower in patients with a high CFS than in those with a low score (1-2 points: 100%, 3-4 points: 92.9%, 5-9 points: 77.3%, P<0.01). After adjustment for age and sex, the CFS was an independent predictor of the primary outcome (hazard ratio [HR] 2.0, 95% confidence interval [CI] 1.6-2.5, P<0.01), and of the secondary outcome (HR 1.6 [95% CI 1.2-2.0], P<0.01).

CONCLUSIONS

The CFS is an independent predictor of both death and hospitalization due to HF in patients with a CIED.

Predictors of Functional Decline in Activities of Daily Living at Discharge in Patients After Cardiovascular Surgery

BACKGROUND

This study aimed to investigate the trajectory of functional recovery of activities of daily living (ADL) from the time of admission up to hospital discharge, and explored which preoperative and postoperative variables were independently associated with functional decline in ADL at discharge of patients after cardiovascular surgery.

METHODS AND RESULTS

In this observational study, we evaluated ADL preoperatively and at discharge using the Functional Independence Measure (FIM) in patients after cardiovascular surgery. Functional decline in ADL was defined as scoring 1-5 on any one of the FIM items at discharge. Multiple logistic regression was performed to predict the functional decline in ADL at discharge. We found that 18.8% of elective cardiovascular surgery patients suffered from decreased ADL at discharge. The Mini-Mental State Examination (odds ratio (OR): 0.573, 95% confidence interval (CI): 0.420-0.783), gait speed (OR: 0.032, 95% CI: 0.003-0.304) and initiation of walking around the bed (OR: 1.277, 95% CI: 1.103-1.480) were independently associated with decreased ADL at discharge.

CONCLUSIONS

A functional decline in ADL at discharge can be predicted using preoperative measures of cognitive function, preoperative gait speed and postoperative day of initiation of walking. These results show that preoperative cognitive screening and gait speed assessments can be used to identify patients who might require careful postoperative planning, and for whom early postoperative rehabilitation is needed to prevent serious functional ADL deficits.

Characteristics of Elderly Patients with Heart Failure and Impact on Activities of Daily Living: A Registry Report from Super-Aged Society

BACKGROUND

To assess the health care burden of elderly patients with heart failure (HF) in an aging Japanese community-based hospital, we investigated the outcomes of cardiac rehabilitation.

METHODS AND RESULTS

We enrolled all patients with HF aged ≥65 years admitted to 3 hospitals in the Niigata Prefecture. We prospectively collected data on their hospital stays and for 2 years postdischarge. The cohort comprised 617 patients (46.5% men; mean age 84.7 years), 76.2% of whom were aged ≥80 years. Among these patients, 15.6% were nursing home residents, 57.7% required long-term care insurance, only 37.6% could walk unaided at the time of admission, and 70.5% required cardiac rehabilitation; age had no significant rehabilitative effect on the degree of improvement in activities of daily living (ADLs). Two years postdischarge, all-cause mortality, and HF rehospitalization were 41.1% and 38.6%, respectively. The ADL score at discharge was an independent prognostic factor for mortality. The incidence of mortality and rehospitalization was lower in elderly patients with preserved ADLs at discharge.

CONCLUSIONS

Elderly patients with HF in our super-aged society were mainly octogenarians who required disease management and personalized care support. Although their ADL scores increased with comprehensive cardiac rehabilitation, improved scores at discharge were closely associated with prognosis.

Prognostic impact of hospital-acquired disability in elderly patients with heart failure

Aims

Functional decline is associated with worse outcomes in patients with elderly heart failure (HF), but little is known about the prognostic impact of hospital‐acquired disability (HAD) during hospital stay after acute HF. The present study examines the prognostic significance of HAD in the prediction of all‐cause mortality in elderly patients who admitted for acute HF.

Methods and results

This retrospective study was performed in 1941 elderly patients aged ≥65 years or older from the cardiovascular physiotherapy for acute HF patients in the Tokyo metropolitan area registry and excluded those who died in hospital. HAD was defined as any decline in the Barthel index (BI) before discharge compared with the BI within 1 month before hospital admission. The primary outcome of this study was all‐cause death and HF readmission. A total of 565 (29%) deaths and 789 (41%) HF readmission occurred over a median follow‐up period of 1.7 years. A total of 476 patients (25%) had HAD during hospital stay after acute HF. In multivariable analysis, HAD predicted all‐cause death [hazard ratio (HR): 1.772; 95% confidence interval (CI): 1.450–2.167; P < 60; 0.001] and with risk of HF readmission (HR: 1.193; 95% CI: 1.005–1.416; P = 0.043) after adjusting for the Meta‐analysis Global Group in Chronic Heart Failure risk score.

Conclusions

Hospital‐acquired disability is associated with an increased risk of all‐cause death and readmission for HF in elderly patients with acute HF.

Serial Changes in Clinical Presentations and Outcomes of 5,740 Patients Requiring Repeated Hospital Admissions (Four or More Times) due to Worsened Heart Failure

Heart failure (HF) is a major cause of death and hospitalization worldwide. In particular, hospital readmission due to worsened HF occurs frequently after the onset of HF. However, the association of repeated hospital admission with clinical manifestations and outcomes is unclear. The aim of this study was to clarify the serial changes in presentation and clinical course of patients requiring repeated hospital admission due to worsened HF. Among 466,921 patients who were admitted and discharged between January 2010 and March 2018, with the main discharge diagnosis of HF, we studied 5,740 patients who were hospitalized 4 times or more, using the Diagnosis Procedure Combination database. We evaluated serial changes in continuous data using the Jonckheere trend test, and categorical data using the Cochran-Armitage trend test. The median age of the patients was 78 years, and 3,326 patients (58%) were male. Body mass index and Barthel Index decreased with increased numbers of admissions. Patients requiring respiratory support and hemodialysis increased, whereas patients undergoing intra-aortic balloon pumping decreased with increased numbers of admissions. The length of hospital stay was prolonged and the interval between hospitalizations was shortened with increased numbers of hospital admissions. The in-hospital mortality rate was 8.8% at the fourth admission. In conclusion, this is the first large-scale real-world study on the serial changes in characteristics and outcomes of HF patients requiring repeated hospitalization, suggesting that repeated hospitalization might adversely affect the general status of patients with HF and result in a vicious clinical cycle.

Acupressure therapy and Liu Zi Jue Qigong for pulmonary function and quality of life in patients with severe novel coronavirus pneumonia (COVID-19): a study protocol for a randomized controlled trial

BACKGROUND

In December 2019, pneumonia associated with the 2019 novel coronavirus (COVID-19) emerged in Wuhan, China. The number of cases has increased rapidly. Patients with severe disease have a poor prognosis, and there are no effective therapies for COVID-19. Only rapid advice guidelines for symptomatic supportive care have been used. A traditional Chinese medicine rehabilitation (TCMR) program consisting of acupressure therapy and Liu Zi Jue Qigong can be used as a complementary therapy for COVID-19. Hence, we designed a randomized trial to evaluate the efficacy and advantages of TCMR for treating patients with severe COVID-19.

METHODS/DESIGN

This is a parallel-design, two-arm, analyst assessor-blinded, randomized controlled trial. A total of 128 patients with COVID-19 aged from 20 to 80 years will be recruited and assigned randomly into a guideline therapy group and a guideline therapy plus TCMR group at a 1:1 ratio. Patients in both groups will receive guideline therapy. The patients in the intervention group will perform acupressure therapy and Liu Zi Jue Qigong exercises in addition to conventional treatments twice a day and will be persistent from admission to discharge. The primary outcome will be measured with the Modified Medical Research Council Dyspnea Scale, and the secondary outcomes will include the Activities of Daily Living Barthel Index Scale, Patient Health Questionnaire-9 Scale, and the Respiratory Symptoms Scale. The assessments of the clinical scales will be performed at three points (before treatment, the 7th day during hospitalization, and the discharge day). Adverse events will be noted and recorded for the safety evaluation.

DISCUSSION

This trial will provide high-quality evidence of the value of TCMR, which consists of acupressure therapy and Liu Zi Jue Qigong exercises, for treating patients with severe COVID-19.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000029994 . Registered on 18 February 2020.

Statistics of heart failure and mechanical circulatory support in 2020

Heart failure is increasing in prevalence, with approximately 26 million patients affected worldwide. This represents a significant cause of morbidity and mortality. Statistics regarding heart failure patient age, hospitalization likelihood, and mortality differ significantly by country. Heart failure patients are typically classified by ejection fraction, with distinct phenotypes associated with reduced ejection fraction (rEF) or preserved ejection fraction (pEF). Heart failure has a significant financial impact related to hospitalization, medication, and procedural expenses. The costs of heart failure also extend to the reduced quality of life conferred by heart failure symptoms. Management of heart failure includes a variety of interventions, including mechanical circulatory support (MCS). MCS, including left ventricular assist devices (LVADs), right ventricular assist devices (RVADs) and extracorporeal membrane oxygenation (ECMO), has been a means of managing end stage heart failure. Given the relative scarcity of transplant organs, the utilization of MCS, particularly as a bridge to transplantation (BTT) has grown significantly. In this review, we discuss statistics related to heart failure and MCS. We evaluate how patients are classified and examine global trends and regional differences. We then address MCS therapies, the costs associated with heart failure, the impact of heart failure on patient quality of life, and data regarding morbidity and mortality.

Main Risk Factors Related to Activities of Daily Living in Non-Dialysis Patients with Chronic Kidney Disease Stage 3-5: A Case-Control Study

Introduction

Elderly people are at increased risk of falls, disability and death due to reduced functional reserve, decline in multiple systems functions, which affects their activities of daily living (ADL) and eventually develop into frailty. The ADL assessment is conducive to early detection to avoid further serious situations. Previous studies on patients’ activities of daily living with chronic kidney disease (CKD) are mainly focused on dialysis patients. Little information is available on non-dialysis patients.

Patients and Methods

A total of 303 elderly patients with CKD stage 3–5 who were admitted to our hospital were selected. ADL evaluation was performed on patients at admission, with Barthel index (BI) as the evaluation tool. They were divided into two groups based on BI (≥60 and <60). Demographic information, lifestyle and clinical profile were collected. The risk factors related to ADL were analyzed by univariate and multivariate models.

Results

The data of 303 patients enrolled in this study were analyzed. The average age of patients was 84.48± 7.14 years and 62.05% were male. There were 88 patients (29.04%) in BI <60 group and 215 patients (70.96%) in the BI ≥60 group. The average age of subjects in the two groups was 87.47 ± 5.85 years and 83.26± 7.28 years, respectively. On univariate analysis, ADL impairment was associated with many factors, such as age, body mass index, blood lipid, heart rate, smoking history, Charlson comorbidity index (CCI), hemoglobin, serum albumin, BNP, eGFR, etc. Multivariate logistic regression showed that age (OR 1.08, 95% CI 1.00–1.17, P=0.0390), Charlson comorbidity index (OR 4.75, 95% CI 1.17–19.30, P=0.0295), and serum albumin (OR 0.80, 95% CI 0.70–0.92, P=0.0012) were the independent risk factors of ADL impairment.

Conclusion

Decline of ADL in CKD patients was independently correlated with age, Charlson comorbidity index and serum albumin. ADL and its influential factors in the elderly CKD patients deserve further attention.

Efficacy of Tolvaptan in Elderly Patients with Heart Failure and Preserved Ejection Fraction

Background: There is no known therapy with proven efficacy for improving clinical outcomes in elderly patients with heart failure (HF) and preserved ejection fraction (HFpEF). In this study, we aimed to evaluate the efficacy of tolvaptan (TLV) in elderly HFpEF patients. Methods: This retrospective observational study involved 100 consecutive elderly HFpEF patients hospitalized at the Nagoya Heart Center, Japan. Inclusion criteria were: (1) patients aged ≥75 years; (2) first hospitalization secondary to HF; (3) received medical therapy for HF, without invasive treatment; and (4) clinical follow-up for >6 months after discharge. The primary endpoint was rehospitalization due to worsening HF, and the secondary endpoint was worsening renal function (WRF) during hospitalization and at 6 months after discharge. Sixty background-matched HFpEF patients were divided into 2 groups: with TLV therapy (TLV (+), n = 29) and without TLV therapy (TLV (–), n = 31). In the TLV (+) group, TLV therapy was continued after discharge. Clinical outcomes of these patients were evaluated. Results: Bed rest period and length of hospital stay were significantly shorter in the TLV (+) group than in the TLV (−) group. The dose of loop diuretics, mean serum creatinine levels, and incidence of WRF development were significantly lower in the TLV (+) group. Incidence of rehospitalization was also significantly lower in the TLV (+) group (log-rank test; p = 0.018). The multivariate logistic regression analysis demonstrated that TLV therapy reduces the incidence of rehospitalization in elderly patients with HFpEF. Conclusions: TLV therapy reduced the bed rest period, length of hospital stay, and rate of rehospitalization without WRF in elderly HFpEF patients, suggesting that TLV could represent an effective therapy for this group of patients.

Progressive Mobilization Program for Patients With Acute Heart Failure Reduces Hospital Stay and Improves Clinical Outcome

Background: Early ambulation has been shown to be associated with shorter hospital stay and better clinical outcomes in patients with acute heart failure (HF). Early mobilization program in combination with structured exercise training is recommended, but has yet to be developed and implemented in HF. Methods and Results: We developed a progressive mobilization program for HF patients that classifies the mobilization process into 7 stages based on disease condition and physical function. We retrospectively analyzed 136 patients with acute HF (80±11 years), who were assigned either to the mobilization program (intervention group, n=75) or to usual care (control group, n=61). The program was safely implemented without any adverse events. Hospital stay was significantly reduced in the intervention group compared with the control group (33±25 vs. 51±36 days, P<0.01). The intervention group had higher activities of daily living (ADL) score at discharge evaluated using the Barthel index (64±38 vs. 49±36, P<0.05). The intervention group also had a higher percentage of discharge to home (71% vs. 52%, P<0.05) and a lower rate of HF-related readmission (16% vs. 36%, P<0.05) compared with the control group. Conclusions: The progressive mobilization program for acute HF was feasible and was associated with better ADL and reduced hospital stay, leading to improvement of clinical outcome.