Clinical Predictors Influencing the Length of Stay in Emergency Department Patients Presenting with Acute Heart Failure

Meteorin-like protein plasma levels are associated with worse outcomes in de novo heart failure

BACKGROUND AND AIMS

Meteorin-like protein (Metrnl) has been recently suggested as a new adipokine with protective cardiovascular effects. Its circulating levels in patients seem to be associated with heart failure (HF), although with contradictory results. Our aim was to ascertain whether this adipokine could estimate the prognosis of HF in de novo HF (DNHF) patients.

METHODS

Metrnl plasma levels of 400 patients hospitalized with DNHF (55% of patients with HF with reduced ejection fraction, 17.3% HF with mid-range ejection fraction, 27.8% HF with preserved ejection fraction) were measured by enzyme-linked immunosorbent assay. We performed both sex-pooled and sex-specific analyses. A 12-month follow-up was conducted, during which clinical outcomes such as all-cause mortality, cardiovascular death and re-hospitalization due to HF were collected.

RESULTS

After a 12-month follow up, higher plasma Metrnl levels were associated with an increased risk for all-cause death and cardiovascular death after adjusting by sex, age, LVEF, hypertension, diabetes, ischemic aetiology, chronic renal failure, NT-proBNP and troponin (hazard ratio [HR] = 1.003, 95% confidence interval [CI] = 1.000-1.005; p-value<.05 and HR = 1.004, 95% CI = 1.001-1.007, p-value<.05, respectively). In line with this, DNHF patients with increased levels of circulating Metrnl had a higher number of occurrences of cardiovascular events. Regarding Metrnl associations with parameters implicated in the development and progression of HF, we found that Metrnl circulating levels were positively correlated with age (r = .322, p-value<.0001), NT-proBNP (r = .281, p-value<.0001) and with the renal dysfunction markers urea (r = .322, p-value<.0001) and creatinine (r = .353, p-value<.0001) and higher in women than men (473.7 [385.9-594.0] pg/mL vs. 428.7 [349.1-561.3] pg/mL, p-value<.006). Finally, concerning the subtype of HF, Metrnl plasma levels were higher in HF with preserved ejection fraction.

CONCLUSION

Patients with higher Metrnl levels have a worse prognosis in DNHF. Our results reinforce the association of Metrnl plasma levels with HF progression and outcomes.

Proposed Novel Heart Failure Biomarkers and Their Association with Length of Hospital Stay and Mortality: A Retrospective Observational Pilot Study

Background/Objectives: Chronic heart failure (CHF) remains a significant global health burden, with high morbidity, prolonged hospitalizations, and increased mortality. Traditional biomarkers such as NT-proBNP provide prognostic value; however, novel biomarker ratios may enhance risk stratification. This study evaluated the predictive utility of the NT-proBNP-to-albumin ratio (NTAR), red cell distribution width-to-eGFR ratio (RGR), and red cell distribution width-to-fibrinogen ratio (RFR) for hospital length of stay (LOS), extended hospitalization (ELOS), in-hospital mortality, and 6-month all-cause mortality. Methods: A retrospective observational pilot study was conducted on 382 CHF admissions (2022-2024) with comprehensive laboratory assessment. Biomarker performance was assessed through uni- and multivariate logistic regression, receiver operating characteristic curve, and Cox proportional hazards stepwise methods of analyses for refining predictive models. Results: NTAR and RGR emerged as significant predictors of hospitalization outcomes. NTAR demonstrated a moderate correlation with prolonged LOS (r = 0.45, p < 0.001) and was an independent predictor of ELOS (AUC = 0.697, OR = 2.438, p < 0.001), outperforming NT-proBNP. Additionally, NTAR significantly predicted in-hospital mortality (AUC = 0.768, OR = 4.461, p < 0.001) and 6-month all-cause mortality (AUC = 0.766, OR = 4.185, p < 0.001). RGR was the strongest predictor of in-hospital mortality (AUC = 0.785, HR = 2.18, p = 0.005), highlighting its role in renal dysfunction and erythropoietic alterations in CHF. The RFR observed prognostic value was minimal. Conclusions: In our study, NTAR and RGR offered valuable prognostic value underscoring the interplay of cardiac stress, nutritional status, and renal function in CHF prognosis. Further multicenter validation is warranted for these biomarkers.

Association Between Serum Albumin and the Length of Hospital Stay Among Patients With Acute Heart Failure

Introduction: Albumin plays a vital role in improving osmotic pressure and hemodynamics. A lower serum albumin level may cause pulmonary congestion and edema and contribute to myocardial dysfunction, diuresis resistance, and fluid retention in acute heart failure. Hypothesis: We hypothesized that AHF patients with normal serum albumin have shorter hospital stays. Methods: Using Electronic Medical Records, patients admitted from May 2020 through May 2021 aged >18, ICD-10, and positive Framingham Heart Failure Diagnostic Criteria were included. We excluded patients without albumin records and eGFRs less than 30 mL/min/1.73 m2. Prolonged hospitalization was defined as >8 days of hospitalization. Results: During index emergency department visits, patients were symptomatic (New York Heart Association), aged median of 70 years (Interquartile range (IQR) 18), 59% (n = 103) were male, predominantly White (73%, n = 128), and had a high Charleston Comorbidity index score [5, IQR (4-7)]. Nearly one-fourth (23%, n = 41) of the patients had <3.5 g/dL albumin levels. The median length of hospital stay was eight days (IQR of 11). Comparing differences between lengths of hospital stays (<8 vs. >8 days), there was different serum albumin (3.9 + 0.48 vs. 3.6 + 0.53, p < .001) and left ventricular ejection fraction (45% (range 26-63) versus 30% (range 24-48), p = .004). An increased serum albumin decreased prolonged hospitalization (odds ratio (OR), 0.28; 95% confidence interval (CI), 0.14-0.55, p = <0.001). Patients in the lower albumin group had higher NT-proBNP (median: 8521 (range 2025-9134) versus 5147 (range 2966-14,795) pg/ml, p = .007) and delay in administering intravenous diuretics (391 (167-964) minutes versus 271 (range 157-533) minutes, p = .02). Conclusion: Hypoalbuminemia is strongly associated with prolonged hospitalization. Timely and effective diuretic therapy may reduce hospital stay durations, particularly with albumin supplementation.

Impact of intravenous antibiotics for unconfirmed pulmonary infections in patients with acute decompensated heart failure at a community health system

PURPOSE

Patients with acute decompensated heart failure (ADHF) present similarly to those with respiratory infections, which may lead to administration of unnecessary intravenous (IV) antibiotics. This study was conducted to assess outcomes in patients admitted for ADHF who received IV antibiotics vs those who did not.

METHODS

This retrospective cohort study evaluated adults admitted with ADHF who received IV antibiotics for at least 48 hours or did not receive IV antibiotics. Patients with an active infection were excluded. The primary outcome was hospital length of stay in the unmatched cohort; secondary outcomes included 30-day readmission, all-cause mortality, amount of loop diuretic administered, total sodium and fluids received, Clostridioides difficile infection, IV antibiotic agents administered, and duration of therapy.

RESULTS

The unmatched cohort included 38 patients who received IV antibiotics and 123 patients who did not receive IV antibiotics, while the matched cohort included 33 patients in each arm. In the unmatched and matched cohorts, patients receiving IV antibiotics had a longer median hospital length of stay (5 vs 3 days; P < 0.01 and 5 vs 4 days; P < 0.01) and received a greater median amount of total sodium (9.22 vs 0.28 g; P < 0.01 and 10.24 vs 0 g; P < 0.01) and median total volume from IV antibiotics and fluids (1,788 vs 50 mL; P < 0.01 and 1,825 vs 0 mL; P < 0.01). No significant differences were found for the other secondary outcomes. Ceftriaxone and azithromycin were the most frequently administered IV antibiotics, with a median duration of therapy of 4 days.

CONCLUSION

Use of IV antibiotics in patients with ADHF was associated with longer hospital length of stay and should be avoided in patients without evidence of infection.

Models to predict length of stay in the emergency department: a systematic literature review and appraisal

INTRODUCTION

Prolonged Length of Stay (LOS) in ED (Emergency Department) has been associated with poor clinical outcomes. Prediction of ED LOS may help optimize resource utilization, clinical management, and benchmarking. This study aims to systematically review models for predicting ED LOS and to assess the reporting and methodological quality about these models.

METHODS

The online database PubMed, Scopus, and Web of Science (10 Sep 2023) was searched for English language articles that reported prediction models of LOS in ED. Identified titles and abstracts were independently screened by two reviewers. All original papers describing either development (with or without internal validation) or external validation of a prediction model for LOS in ED were included.

RESULTS

Of 12,193 uniquely identified articles, 34 studies were included (29 describe the development of new models and five describe the validation of existing models). Different statistical and machine learning methods were applied to the papers. On the 39-point reporting score and 11-point methodological quality score, the highest reporting scores for development and validation studies were 39 and 8, respectively.

CONCLUSION

Various studies on prediction models for ED LOS were published but they are fairly heterogeneous and suffer from methodological and reporting issues. Model development studies were associated with a poor to a fair level of methodological quality in terms of the predictor selection approach, the sample size, reproducibility of the results, missing imputation technique, and avoiding dichotomizing continuous variables. Moreover, it is recommended that future investigators use the confirmed checklist to improve the quality of reporting.

Association of Hypoalbuminemia With Clinical Outcomes in Patients Admitted With Acute Heart Failure

Albumin is a protein produced by the liver essential for maintaining blood volume and regulating fluid balance. Hypoalbuminemia is characterized by low levels of albumin in the blood. It is also a marker of malnutrition-inflammatory syndrome. Several studies have demonstrated its prognostic role in patients with chronic heart failure; however, data regarding hypoalbuminemia in acute heart failure admissions are scarce. This study aims to analyze the relationship between hypoalbuminemia and heart failure. We used a retrospective cohort study surveying data from the 2016-2018 combined National Inpatient Sample (NIS) database. Adult hospitalizations for heart failure patients were identified using the ICD-10 codes, stratified into cohorts with and without hypoalbuminemia. Primary outcomes were (1) in-patient mortality, (2) length of stay, and total hospital charge. We also reclassified the HF admissions with hypoalbuminemia to those with systolic or diastolic heart failure to compare any differences in mortality and other in-patient complications. Multivariate linear and logistic regression were used to adjust for confounders and to analyze the outcomes. There were 1,365,529 adult hospitalizations for Congestive Heart Failure (CHF), and among them 1,205,990 (88 %) had secondary diagnoses of hypoalbuminemia. Patients with comorbid hypoalbuminemia were, on average, 8 years older (P < 0.001), predominantly white race, and males (P-value <0.001). HF hospitalizations with hypoalbuminemia had double in-hospital mortality than those without (4.8% vs 2.7%, P < 0.001). However, there was no difference in mortality between patients with Systolic heart failure and Diastolic heart failure with concomitant low albumin levels (from 4.9 % vs 4.7%, P 0.13). We found that patients admitted with HF and concomitant Hypoalbuminemia (HA) had nearly twice the odds of in-patient mortality than those with normal albumin levels. The Length of Stay (LOS) was higher between comparison groups. THC remained statistically indifferent in patients regardless of albumin levels but was greater in hypoalbuminemic patients with Systolic heart failure than Diastolic heart failure ones.

Body composition, lipid profile and clinical parameters are predictors of prognosis in patients with heart failure: Two-year follow-up

BACKGROUND

Heart failure (HF) is a complex syndrome that leads to changes in body composition and eventually results in unfavorable outcomes.

AIM

This study aimed to evaluate body composition, lipid profiles and clinical parameters of patients with HF, and their associations with both survival and unfavorable clinical outcomes.

METHODS

This prospective cohort study included 94 adults and older people with HF. Body composition was assessed by bioelectrical impedance analysis (BIA). Anthropometric variables and lipid profile were also evaluated. Electronic medical records were checked to collect information on clinical outcomes (mortality and hospitalization), considering a follow-up period of 24 months. Survival was calculated using the Kaplan-Meier estimate, and the curves compared using Log-Rank. The death risk rate (Hazard Ratio, HR) was calculated using Cox's univariate models.

RESULTS

Mean age was 55.1 (13.9) years and there was a higher frequency of males. There was a predominance of HF with reduced ejection fraction, and ischemic etiology. Patients with New York Heart Association (NYHA) functional classification I/II had a better overall survival rate at 24 months than those with NYHA III/IV (univariate HR 4.93 (1.76-13.82); p = 0.001). Greater survival rates were found in patients without chronic kidney disease (CKD) (univariate HR 2.93 (1.59-5.39); p = 0.01). In the multivariate analyses, both dyslipidemia (adjusted HR 3.84 (1.22-12.00); p = 0.021) and increased fat mass index (FMI) were associated with overall survival rate (adjusted HR 3.59 (1, 10-11.74); p = 0.034).

CONCLUSION

The severity of HF symptoms and the presence of chronic kidney disease are associated with higher mortality. Increased fat mass index and dyslipidemia are predictors of favorable outcomes in this population.

Prognostic Factors for Prolonged In-Hospital Stay in Patients with Heart Failure

Background and Objectives: Heart failure (HF) is a threatening health condition that is associated with an increasing prevalence and high expenses because of frequent patient hospitalizations. The purpose of this study was to evaluate the factors that influence the length of in-hospital stay in HF patients. Materials and Methods: A total of 220 patients (43.2% men), admitted to the Department of Cardiology, Kaunas Hospital of Lithuanian University of Health Sciences from the 1st of January 2021 to the 31st of May 2021, were included in this study. According to the length of in-hospital stay, patients were stratified into two groups: the first group's length of stay (LOS) was from 1 to 8 days, and the second group's LOS was 9 days or more. Results: The median LOS was 8 (6-10) days. Multivariate logistic regression analysis revealed five predictors as independent factors associated with prolonged hospitalization. These predictors included treatment interruption (OR 3.694; 95% CI 1.080-12.630, p = 0.037), higher value of NT-proBNP (OR 3.352; 95% CI 1.468-7.659, p = 0.004), estimated glomerular filtration rate (eGFR) ≤ 50 mL/min/1.73 m2 (OR 2.423; 95% CI 1.090-5.383, p = 0.030), systolic blood pressure (BP) ≤ 135 mmHg (OR 3.100; 95% CI 1.421-6.761, p = 0.004) and severe tricuspid valve regurgitation (OR 2.473; 95% CI 1.086-5.632, p = 0.031). Conclusions: Several variables were identified as significant clinical predictors for prolonged length of in-hospital stay in HF patients where treatment interruption, higher NT-proBNP value and lower systolic BP at admission were the most important.

Using health administrative data to model associations and predict hospital admissions and length of stay for people with eating disorders

BACKGROUND

Eating disorders are serious mental illnesses requiring a whole of health approach. Routinely collected health administrative data has clinical utility in describing associations and predicting health outcome measures. This study aims to develop models to assess the clinical utility of health administrative data in adult eating disorder emergency presentations and length of stay.

METHODS

Retrospective cohort study on health administrative data in adults with eating disorders from 2014 to 2020 in Sydney Local Health District. Emergency and admitted patient data were collected with all clinically important variables available. Multivariable regression models were analysed to explore associations and to predict admissions and length of stay.

RESULTS

Emergency department modelling describes some clinically important associations such as decreased odds of admission for patients with Bulimia Nervosa compared to Anorexia Nervosa (Odds Ratio [OR] 0.31, 95% Confidence Interval [95%CI] 0.10 to 0.95; p = 0.04). Admitted data included more predictors and therefore further significant associations including an average of 0.96 days increase in length of stay for each additional count of diagnosis/comorbidities (95% Confidence Interval [95% CI] 0.37 to 1.55; p = 0.001) with a valid prediction model (R² = 0.56).

CONCLUSIONS

Health administrative data has clinical utility in adult eating disorders with valid exploratory and predictive models describing associations and predicting admissions and length of stay. Utilising health administrative data this way is an efficient process for assessing impacts of multiple factors on patient care and predicting health care outcomes.

Association between the Length of Hospital Stay and 30-Day Outcomes in Patients Admitted with Acute Decompensated Heart Failure

Method

This study is performed in the context of the Persian Registry of Cardiovascular Disease/Heart Failure (PROVE/HF). We included all patients admitted with ADHF regardless of the etiology of heart failure (HF). LOS was classified in tertiles (<4 days, >4 and <6 days, and >6 days). Our outcomes were 30-day all-cause mortality and rehospitalization. Baseline characteristics and outcomes are reported according to the tertiles of LOS. A binary logistic regression and cox regression analysis were performed to evaluate the association between LOS and rehospitalization and death, respectively.

Results

Between April 2019 and March 2020, 385 patients with ADHF were registered in our study. The mean length of hospitalization was 6.35 ± 5.46 days, varying from a minimum of 0 days to a maximum of 47 days. One hundred patients had a hospital stay lower than 4 days; 151 individuals had an intermediate LOS (4-6 days); and 134 were hospitalized for more than 6 days. Our analysis indicated no association between LOS and 30-day rehospitalization and death in multivariable or univariable models.

Conclusion

This study found no association between LOS and rehospitalization or death in patients admitted with ADHF; however, further investigations are warranted.

Factors Associated with Emergency Department Length of Stay in Critically Ill Patients: A Single-Center Retrospective Study

BACKGROUND Length of stay (LOS) in the emergency department (ED) should be measured and evaluated comprehensively as an important indicator of hospital emergency service. In this study, we aimed to analyze clinical characteristics of critically ill patients admitted to the ED and identify the factors associated with LOS. MATERIAL AND METHODS All patients with level 1 and level 2 of the Emergency Severity Index who were admitted to the ED from January 2018 to December 2019 were included in this retrospective study. The patients were divided into 2 groups: LOS ≥4 h and LOS <4 h. Variables were comprehensively analyzed and compared between the 2 groups. RESULTS A total of 19 616 patients, including 7269 patients in the LOS ≥4 h group and 12 347 patients in the LOS <4 group, were included. Advanced age, admission in winter and during the night shift, and diseases excluding nervous system diseases, cardiovascular diseases, and trauma were associated with higher risk of LOS. Nervous system diseases, cardiovascular diseases, trauma, and procedures including tracheal intubation, surgery, percutaneous coronary intervention, and thrombolysis were associated with lower risk of LOS. CONCLUSIONS Prolonged LOS in the ED was associated with increased age and admission in winter and during the night shift, while shortened LOS was associated with nervous system diseases, cardiovascular diseases, and trauma, as well as with procedures including tracheal intubation, surgery, percutaneous coronary intervention, and thrombolysis. Our findings can serve as a guide for ED physicians to individually evaluate patient condition and allocate medical resources more effectively.