Timing of previous heart failure hospitalization as a prognostic factor for emergency department heart failure patients

To investigate whether the timing of a previous hospital admission for acute heart failure (AHF) is a prognostic factor for AHF patients revisiting the emergency department (ED) in the subsequent 12-month follow-up. All ED AHF patients enrolled in the previously described EAHFE registry were stratified by the presence or absence of an AHF hospitalization admission in the prior 12 months. The primary outcome was 12-month all-cause mortality post ED visit. Secondary end points were hospital admission, prolonged hospitalization (> 7 days), mortality during hospitalization and a 90-day post-discharge adverse composite event (ACE) rate, defined as ED revisits due to AHF, hospitalizations due to AHF, or all-cause mortality. Outcomes were adjusted for baseline and AHF episode characteristics.Of 5,757 patients included, the median age was 84 years (IQR 77-88); 57% were women, and 3,759 (65.3%) had an AHF hospitalization in the previous 12 months. The 12-month mortality was 37% (41.7% vs. 28.3% p < 0.001), hospital admission was 76.1% (78.8% vs. 71.1% p < 0.001) ACE was 60.2% (65.1% vs. 50.5% p < 0.001). In the adjusted analysis, patients with AHF hospitalization in the prior 12 months had a higher mortality (HR = 1.41; 95% CI 1.27-1.56), 90-day ACE rate (HR = 1.45: 95% CI 1.32-1.59), and more hospital admissions (OR = 1.32; 95% CI 1.16-1.51), with shorter times since the previous hospitalization being related to the outcomes analyzed. One-year mortality, adverse events at 90 days, and readmission rates are increased in ED AHF patients previously admitted within the last 12 months.

Hyperkalemia in acute heart failure: Short term outcomes from the EAHFE registry

OBJECTIVE

Both hyperkalemia (HK) and Acute Heart Failure (AHF) are associated with increased short-term mortality, and the management of either may exacerbate the other. As the relationship between HK and AHF is poorly described, our purpose was to determine the relationship between HK and short-term outcomes in Emergency Department (ED) AHF.

METHODS

The EAHFE Registry enrolls all ED AHF patients from 45 Spanish ED and records in-hospital and post-discharge outcomes. Our primary outcome was all-cause in-hospital death, with secondary outcomes of prolonged hospitalization (>7 days) and 7-day post-discharge adverse events (ED revisit, hospitalization, or death). Associations between serum potassium (sK) and outcomes were explored using logistic regression by restricted cubic spline (RCS) curves, with sK =4.0 mEq/L as the reference, adjusting by age, sex, comorbidities, patient baseline status and chronic treatments. Interaction analyses were performed for the primary outcome.

RESULTS

Of 13,606 ED AHF patients, the median (IQR) age was 83 (76-88) years, 54% were women, and the median (IQR) sK was 4.5 mEq/L (4.3-4.9) with a range of 4.0-9.9 mEq/L. In-hospital mortality was 7.7%, with prolonged hospitalization in 35.9%, and a 7-day post-discharge adverse event rate of 8.7%. Adjusted in-hospital mortality increased steadily from sK ≥4.8 (OR = 1.35, 95% CI = 1.01-1.80) to sK = 9.9 (8.41, 3.60-19.6). Non-diabetics with elevated sK had higher odds of death, while chronic treatment with mineralocorticoid-receptor antagonists exhibited a mixed effect. Neither prolonged hospitalization nor post-discharge adverse events was associated with sK.

CONCLUSION

In ED AHF, initial sK >4.8 mEq/L was independently associated with in-hospital mortality, suggesting that this cohort may benefit from aggressive HK treatment.

Analysis of the relationship between ambient air pollution and the severity of heart failure decompensations in two Spanish metropolises (Barcelona and Madrid)

OBJECTIVES

To analyze whether the high levels of air pollutants are related to a greater severity of decompensated heart failure (HF).

METHOD

Patients diagnosed with decompensated HF in the emergency department of 4 hospitals in Barcelona and 3 in Madrid were included. Clinical data (age, sex, comorbidities, baseline functional status), atmospheric (temperature, atmospheric pressure) and pollutant data (SO₂, NO₂, CO, O₃, PM₁₀, PM_2.5) were collected in the city on the day of emergency care. The severity of decompensation was estimated using 7-day mortality (primary indicator) and the need for hospitalization, in-hospital mortality, and prolonged hospitalization (secondary indicators). The association adjusted for clinical, atmospheric and city data between pollutant concentration and severity was investigated using linear regression (linearity assumption) and restricted cubic spline curves (no linearity assumption).

RESULTS

A total of 5292 decompensations were included, with a median age of 83 years (IQR=76-88) and 56% women. The medians (IQR) of the daily pollutant averages were: SO₂=2.5μg/m³ (1.4-7.0), NO₂=43μg/m³ (34-57), CO=0.48mg/m³ (0.35-0.63), O₃=35μg/m³ (25-48), PM₁₀=22μg/m³ (15-31) and PM_2.5=12μg/m³ (8-17). Mortality at 7 days was 3.9%, and hospitalization, in-hospital mortality, and prolonged hospitalization were 78.9, 6.9, and 47.5%, respectively. SO₂ was the only pollutant that showed a linear association with the severity of decompensation, since each unit of increase implied an OR for the need for hospitalization of 1.04 (95% CI 1.01-1.08). The restricted cubic spline curves study also did not show clear associations between pollutants and severity, except for SO₂ and hospitalization, with OR of 1.55 (95% CI 1.01-2.36) and 2.71 (95% CI 1.13-6.49) for concentrations of 15 and 24μg/m³, respectively, in relation to a reference concentration of 5μg/m³.

CONCLUSION

Exposure to ambient air pollutants, in a medium to low concentration range, is generally not related to the severity of HF decompensations, and only NO₂ may be associated with an increased need for hospitalization.

Impact of congestion and perfusion status in the emergency department on severity of decompensation and short-term prognosis in patients with acute heart failure

AIMS

To assess whether symptoms/signs of congestion and perfusion in acute heart failure (AHF) evaluated at patient arrival to the emergency department (ED) can predict the severity of decompensation and short-term outcomes.

METHODS AND RESULTS

We included patients from the Epidemiology of AHF Emergency Registry (EAHFE Registry). We registered seven clinical surrogates of congestion and five of hypoperfusion. Patients were grouped according to severity of congestion/hypoperfusion. We assessed the need for hospitalization, in-hospital all-cause mortality for patients needing hospitalization, and prolonged hospitalization for patients surviving the decompensation episode. Outcomes were adjusted for patient characteristics and the coexistence of congestion and hypoperfusion. We analysed 18 120 patients (median = 83 years, interquartile range = 76-88; women = 55.7%). Seventy-two per cent presented >2 signs/symptoms of congestion and 18% had at least 1 sign/symptom of hypoperfusion. Seventy-five per cent were hospitalized with in-hospital death in 9% and prolonged hospitalization in 47% discharged alive. The presence of congestion/hypoperfusion was independently associated with poorer outcomes. An increase in the number of signs/symptoms of congestion was associated with increased risk of hospitalization (P < 0.001) and prolonged stay (P = 0.011), but not mortality (P = 0.06). Increased signs/symptoms of hypoperfusion were associated with hospitalization (P < 0.001) and mortality (P < 0.001), but not prolonged stay (P = 0.227). In the combined model, including congestion and hypoperfusion, both had additive effects on hospitalization, in-hospital mortality was driven by hypoperfusion and no differences were observed for prolonged hospitalization.

CONCLUSION

The presence of congestion/hypoperfusion at ED arrival is a simple clinical marker associated with a higher risk of severity/adverse short-term outcomes.

Evaluation of the effect of intravenous nitroglycerine on short-term survival of patients with acute heart failure according to congestion and perfusion status at emergency department arrival

OBJECTIVES

We investigated if the phenotypic classification of acute heart failure (AHF) based on the number of signs/symptoms of congestion and hypoperfusion at emergency department (ED) arrival identifies subgroups in which intravenous (IV) nitroglycerine (NTG) use improves short-term survival.

METHODS

We included consecutive AHF patients diagnosed in 45 Spanish EDs, who were grouped according to phenotype severity. The main outcome was 30-day all-cause death. Propensity scores (PS) for NTG use were generated using variables associated with death. Analysis of interaction was performed in subgroups of patients based on congestion, hypoperfusion, age, sex, coronary artery disease (CAD), left ventricular ejection fraction (LVEF) and SBP.

RESULTS

We analyzed 16 437 AHF patients (median = 83 years; women = 56%); 1882 received NTG (11.4%). In the whole cohort, the cumulative 30-day mortality in patients receiving NTG was higher (11.5% vs. 9.6%; unadjusted HR, 1.19; 95% CI, 1.04-1.36), but not in the PS-matched cohorts (1698 pairs of patients; 11.5% vs. 10.5%; HR, 1.10; 95% CI, 0.90-1.35). Mortality was increased in NTG-treated patients with mild congestion (HR, 2.09; 95% CI, 1.19-3.67), especially in those without hypoperfusion (HR, 2.51; 95% CI, 1.24-5.10). Interaction analysis of the PS-matched cohorts confirmed detrimental effects of NTG use in less congested patients, whereas beneficial effects were only observed in patients with decreased LVEF (<50% subgroup: HR, 0.59; 95% CI, 0.37-0.92; ≥50% subgroup: HR, 1.30; 95% CI, 0.66-2.56; P = 0.002).

CONCLUSION

Phenotypical classification of AHF based on congestion/hypoperfusion at ED arrival does not identify subgroups of patients in whom IV-NTG would decrease mortality, although it could potentially be beneficial in those with LVEF of less than 50%. This hypothesis will have to be confirmed in the future. Conversely, our results suggest that IV-NTG may be harmful in patients with only mild clinical congestion.

Emergency department observation of patients with acute heart failure prior to hospital admission: impact on short-term prognosis

OBJECTIVES

To analyze whether short-term outcomes are affected when patients diagnosed with acute heart failure (AHF) spend time in an emergency department observation unit (EDOU) before hospital admission.

MATERIAL AND METHODS

Baseline and emergency episode data were collected for patients diagnosed with AHF in the EDs of 15 Spanish hospitals. We analyzed crude and adjusted associations between EDOU stay and 30-day mortality (primary outcome) and in-hospital mortality and a prolonged hospital stay of more than 7 days (secondary outcomes).

RESULTS

A total of 6597 patients with a median (interquartile range) age of 83 (76-88 years) were studied. Fifty-five percent were women. All were hospitalized for AHF (50% in internal medicine wards, 23% in cardiology, 11% in geriatrics, and 16 in other specialties. Of these patients, 3241 (49%) had had EDOU stays and 3350 (51%) had been admitted immediately, with no EDOU stay. Having an EDOU stay was associated with female sex, dementia or chronic obstructive pulmonary disease, long-term treatment with certain drugs for heart failure, greater baseline deterioration in function, and a higher degree of decompensation. Patients in the EDOU group were more often admitted to an internal medicine ward and had shorter stays; cardiology, geriatric, and intensive care admissions were less likely to have had an EDOU stay. Overall, 30-day mortality was 12.6% (13.7% in the EDOU group and 11.4% in the no-EDOU group; P = .004). In-hospital mortality was 10.4% overall (EDOU, 11.1% and no-EDOU, 9.6%; P = .044). Prolonged hospitalization occurred in 50.0% (EDOU, 48.7% and no-EDOU, 51.2%; P = .046). After adjusting for between-group differences, the EDOU stay was not associated with 30-day mortality (hazard ratio, 1.14; 95% CI, 0.99-1.31). Odds ratios for associations between EDOU stay and in-hospital mortality and prolonged hospital stay, respectively, were 1.09 (95% CI, 0.92-1.29) and 0.91 (95% CI, 0.82-1.01).

CONCLUSION

Although mortality higher in patients hospitalized for AHF who spend time in an EDO, the association seems to be accounted for by their worse baseline situation and the greater seriousness of the decompensation episode, not by time spent in the EDOU.

Outcomes of patients with heart failure with preserved ejection fraction discharged on treatment with neurohormonal antagonists after an episode of decompensation

AIMS

To analyze the frequency with which patients with heart failure with preserved ejection fraction (HFpEF) discharged after an acute heart failure (AHF) episode are treated with antineurohormonal drugs (ANHD), the variables related to ANHD prescription and their relationship with outcomes.

METHODS

We included consecutive HFpEF patients (left ventricular ejection fraction ≥50%) discharged after an AHF episode from 45 Spanish hospitals whose chronic medications and treatment at discharge were available. Patients were classified according to whether they were discharged with or without ANHD, including beta-blockers (BB), renin-angiotensin-aldosterone-system inhibitors (RAASi) and mineralcorticosteroid-receptor antagonists (MRA). Co-primary outcomes consisted of 1-year all-cause mortality and 90-day combined adverse event (revisit to emergency department -ED-, hospitalization due to AHF or all-cause death). Secondary outcomes were 90-day adverse events taken individually. Adjusted associations of ANHD treatment with outcomes were calculated.

RESULTS

We analyzed 3,305 patients with HFpEF (median age: 83, 60% women), 2,312 (70%) discharged with ANHD. The ANHD most frequently prescribed was BB (45.8%). The 1-year mortality was 26.9% (adjusted HR for ANHD patients:1.17, 95%CI=0.98-1.38) and the 90-day combined adverse event was 54.4% (HR=1.14, 95%CI=0.99-1.31). ED revisit was significantly increased by ANHD (HR=1.15, 95%CI=1.01-1.32). MRA and BB were associated with worse results in some co-primary or secondary endpoints, while RAASi (alone) reduced 90-day hospitalization (HR=0.73, 98%CI=0.56-0.96).

CONCLUSION

70% of HFpEF patients are discharged with ANHD after an AHF episode. ANHD do not seem to reduce mortality or adverse events in HFpEF patients, only RAASi could provide some benefits, reducing the risk of hospitalization for AHF.

Influence of the length of hospitalisation in post-discharge outcomes in patients with acute heart failure: Results of the LOHRCA study

OBJECTIVE

To investigate the relationship between length of hospitalisation (LOH) and post-discharge outcomes in acute heart failure (AHF) patients and to ascertain whether there are different patterns according to department of initial hospitalisation.

METHODS

Consecutive AHF patients hospitalised in 41 Spanish centres were grouped based on the LOH (<6/6-10/11-15/>15 days). Outcomes were defined as 90-day post-discharge all-cause mortality, AHF readmissions, and the combination of both. Hazard ratios (HRs), adjusted by chronic conditions and severity of decompensation, were calculated for groups with LOH >6 days vs. LOH <6 days (reference), and stratified by hospitalisation in cardiology, internal medicine, geriatrics, or short-stay units.

RESULTS

We included 8563 patients (mean age: 80 (SD = 10) years, 55.5% women), with a median LOH of 7 days (IQR 4-11): 2934 (34.3%) had a LOH <6 days, 3184 (37.2%) 6-10 days, 1287 (15.0%) 11-15 days, and 1158 (13.5%) >15 days. The 90-day post-discharge mortality was 11.4%, readmission 32.2%, and combined endpoint 37.4%. Mortality was increased by 36.5% (95%CI = 13.0-64.9) when LOH was 11-15 days, and by 72.0% (95%CI = 42.6-107.5) when >15 days. Conversely, no differences were found in readmission risk, and the combined endpoint only increased 21.6% (95%CI = 8.4-36.4) for LOH >15 days. Stratified analysis by hospitalisation departments rendered similar post-discharge outcomes, with all exhibiting increased mortality for LOH >15 days and no significant increments in readmission risk.

CONCLUSIONS

Short hospitalisations are not associated with worse outcomes. While post-discharge readmissions are not affected by LOH, mortality risk increases as the LOH lengthens. These findings were similar across hospitalisation departments.

Effect of risk of malnutrition on 30-day mortality among older patients with acute heart failure in Emergency Departments

BACKGROUND

Little is known about the prevalence and impact of risk of malnutrition on short-term mortality among seniors presenting with acute heart failure (AHF) in emergency setting. The objective was to determine the impact of risk of malnutrition on 30-day mortality risk among older patients who attended in Emergency Departments (EDs) for AHF.

MATERIAL AND METHODS

We performed a secondary analysis of the OAK-3 Registry including all consecutive patients ≥65 years attending in 16 Spanish EDs for AHF. Risk of malnutrition was defined by the Mini Nutritional Assessment Short Form (MNA-SF) < 12 points. Unadjusted and adjusted logistic regression models were used to assess the association between risk of malnutrition and 30-day mortality.

RESULTS

We included 749 patients (mean age: 85 (SD 6); 55.8% females). Risk of malnutrition was observed in 594 (79.3%) patients. The rate of 30-day mortality was 8.8%. After adjusting for MEESSI-AHF risk score clinical categories (model 1) and after adding all variables showing a significantly different distribution among groups (model 2), the risk of malnutrition was an independent factor associated with 30-day mortality (adjusted OR by model 1 = 3.4; 95%CI 1.2-9.7; p = .020 and adjusted OR by model 2 = 3.1; 95%CI 1.1-9.0; p = .033) compared to normal nutritional status.

CONCLUSIONS

The risk of malnutrition assessed by the MNA-SF is associated with 30-day mortality in older patients with AHF who were attended in EDs. Routine screening of risk of malnutrition may help emergency physicians in decision-making and establishing a care plan.

Assessment of the knowledge and perception of support of patients with heart failure SOPICA study IN SPAIN

OBJECTIVE

To understand the perceptions of patients with heart failure (HF) concerning their disease, treatment and support, as well as the specialists who provide care after a decompensation, and to determine whether there is a relationship between the type of specialist involved in the follow-up and the medium-term prognosis.

METHODS

A multicentre, prospective cohort study consecutively included patients with acute HF in the emergency department. The patients were interviewed by telephone 91-180days after their emergency department visit. We investigated the relationship between the type of specialist who performed the follow-up and the emergency department visits or hospitalisations using Cox regression models, with progressive adjustment by groups of potential confounders of these relationships.

RESULTS

We interviewed 785 patients. Thirty-three percent (95%CI: 30%-36%) considered their disease mild, 64% (60%-67%) required help from third parties for daily activities, 65% (61%-68%) had no recent therapeutic changes, and 69% (67%-72%) received the same treatment in the exacerbations. The perceived support varied significantly depending on the factor under consideration (from greater to lesser: family, hospital, emergency department, health centre, religion and patient associations; p<.05 in all comparisons). Thirty-nine percent (36%-43%) of the patients with decompensations consulted directly with the emergency department, with no prior changes in treatment. At discharge, general practitioners (74%, 71%-77%) and cardiologists (74%, 70%-77%) were the most involved in the follow-up, although the specialty was not related to the prognosis.

CONCLUSION

There are various aspects of the perception of patients with HF concerning their disease that are susceptible to future interventions. Patient follow-up involves various specialties, but all achieve similar results in the medium term.

[Patients' perception of quality of emergency department care for acute heart failure: the CALPERICA study]

OBJECTIVES

To determine perception of quality of care for acute heart failure (AHF) of patients discharged from the emergency department in comparison with the perception of admitted patients; to explore the variables associated with perception of quality.

MATERIAL AND METHODS

Prospective, cross-sectional case-control study in 7 emergency departments. Consecutive patients diagnosed with AHF were recruited to answer a telephone survey assessing their view of quality of physician care, nurse care, overall treatment, and degree of resolution of their problem in the emergency department. Discharged patients were also asked to state their level of agreement with the decision to send them home from the emergency department. The answers of patients who were discharged home were compared with patients who were admitted to the ward. The results were analyzed according to whether or not adverse events occurred within 30 days.

RESULTS

A total of 1147 patients were enrolled and 1003 (87.4%) were interviewed; 253 of the patients (25.2%) were discharged home. We found no significant differences in any of the assessments (on physician or nurse care, overall treatment, or degree of resolution) between patients who were discharged home and those who were admitted. The mean (SD) overall satisfaction assessments (on a scale of 0 to 10) were 7.34 (1.38) and 7.38 (1.52), respectively, in the 2 groups (P=.66). Over 90% of those discharged home agreed with or strongly agreed with the decision. Evaluations were unrelated to whether or not adverse events occurred in the next 30 dyas.

CONCLUSION

Patients with AHF have high opinions of the different components of care received in the emergency department, and their evaluations are unrelated to whether they were admitted or discharged home. Those discharged home agree with the decision and their opinion remains firm regardless of whether adverse events occur later.