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Wong KYK, Hughes DA, Debski M, Latt N, Assaf O, Abdelrahman A, Taylor R, Allgar V, McNeill L, Howard S, Wong SYS, Jones R, Cassidy CJ, Seed A, Galasko G, Clark A, Wilson D, Davis GK, Montasem A, Lang CC, Kalra PR, Campbell R, Lip GYH, Cleland JGF. Effectiveness of out-patient based acute heart failure care: a pilot randomised controlled trial. Acta Cardiol 2023; 78:828-837. [PMID: 37694719 DOI: 10.1080/00015385.2023.2197834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 03/21/2023] [Accepted: 03/25/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVES Acute heart failure (AHF) hospitalisation is associated with 10% mortality. Outpatient based management (OPM) of AHF appeared effective in observational studies. We conducted a pilot randomised controlled trial (RCT) comparing OPM with standard inpatient care (IPM). METHODS We randomised patients with AHF, considered to need IV diuretic treatment for ≥2 days, to IPM or OPM. We recorded all-cause mortality, and the number of days alive and out-of-hospital (DAOH). Quality of life, mental well-being and Hope scores were assessed. Mean NHS cost savings and 95% central range (CR) were calculated from bootstrap analysis. Follow-up: 60 days. RESULTS Eleven patients were randomised to IPM and 13 to OPM. There was no statistically significant difference in all-cause mortality during the index episode (1/11 vs 0/13) and up to 60 days follow-up (2/11 vs 2/13) [p = .86]. The OPM group accrued more DAOH {47 [36,51] vs 59 [41,60], p = .13}. Two patients randomised to IPM (vs 6 OPM) were readmitted [p = .31]. Hope scores increased more with OPM within 30 days but dropped to lower levels than IPM by 60 days. More out-patients had increased total well-being scores by 60 days (p = .04). OPM was associated with mean cost savings of £2658 (95% CR 460-4857) per patient. CONCLUSIONS Patients with acute HF randomised to OPM accrued more days alive out of hospital (albeit not statistically significantly in this small pilot study). OPM is favoured by patients and carers and is associated with improved mental well-being and cost savings.
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Affiliation(s)
- K Y K Wong
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
- Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - D A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - M Debski
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - N Latt
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - O Assaf
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - A Abdelrahman
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - R Taylor
- Research and Development Department, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - V Allgar
- Peninsula Clinical Trials Unit, University of Plymouth, Plymouth, UK
| | - L McNeill
- Accountant, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - S Howard
- Financial Information And Costing Manager, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - S Y S Wong
- Department of Care of the Older Person, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - R Jones
- Public Involvement Group, Research and Development Department, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - C J Cassidy
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - A Seed
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - G Galasko
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - A Clark
- Peninsula Clinical Trials Unit, University of Plymouth, Plymouth, UK
| | - D Wilson
- Department of Cardiology, Worcestershire Royal Hospital (Worcestershire Acute Hospital NHS Trust), Worcester, UK
| | - G K Davis
- Cardiorespiratory Research Centre, Edge Hill University Medical School, Ormskirk, UK
| | - A Montasem
- Institute of Life Course and Medical Sciences, School of Dental Sciences, Liverpool University Dental Hospital, University of Liverpool, Liverpool, UK
| | - C C Lang
- Department of Cardiology, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - P R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - R Campbell
- Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - G Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - J G F Cleland
- Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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Wong KYK, Wong SYS, Fraser HW, Ersoy Y, Ogston S, Wolfson D, Malek M, Struthers AD, Tunstall-Pedoe H, MacWalter RS. Effect of social deprivation on mortality and the duration of hospital stay after a stroke. Cerebrovasc Dis 2006; 22:251-7. [PMID: 16788298 DOI: 10.1159/000094012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2005] [Accepted: 03/02/2006] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We aim to assess whether social deprivation independently predicts case fatality after a stroke patient has been admitted to hospital, and to assess whether social deprivation affected duration of hospital stay. METHODS Cohort study in a tertiary teaching hospital included consecutive patients admitted to hospital within 48 h of their stroke between 1988 and 1994. Outcome measures were case fatality at 1 year and length of hospital stay. The socioeconomic category was derived from the postcode sector of residence for the patients (Carstairs index). Cause of death was determined by data linkage to the Registrar General data for Scotland. RESULTS 2,042 stroke patients were included. A significant age difference existed between the deprivation categories (76.0 +/- 10.9 years in the affluent cohort vs. 71.4 +/- 10.7 years in the deprived cohort). Smoking was more common in the deprived group. ECG findings and neurological score on admission were similar between the groups. No difference existed between groups for length of hospital stay (p = 0.793), and in the proportions remaining alive at 1 year (p = 0.416). When entered into a multivariate Cox regression analysis, the deprivation categories did not predict mortality. Age, sex, Philadelphia Geriatric Center Instrumental Activities of Daily Living (IADL) Scale Score, Orgogozo neurological score on admission, and ECG abnormalities were the significant predictors. CONCLUSIONS Stroke patients living in more socially deprived areas had their strokes at an earlier age but were not at a greater risk of dying or longer hospital stay once they had been admitted to hospital.
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Affiliation(s)
- K Y K Wong
- Department of Clinical Pharmacology and Therapeutics, Ninewells Hospital Dundee, Dundee, UK
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Abstract
OBJECTIVE To test the hypothesis that B-type natriuretic peptide (BNP) predicts reversible myocardial ischaemia in stroke survivors who do not have chest pain or previous myocardial infarction. METHODS 56 stroke survivors (mean (SE) age 68 (8) years) underwent tetrofosmin myocardial perfusion scanning with dipyridamole as the stressor. The degree of ischaemia was assessed by a scoring system (out of 64) by an experienced observer blinded to the results of BNP. RESULTS In the whole cohort, BNP was significantly correlated with the degree of myocardial ischaemia on stress scanning (Spearman's r = -0.475, p < 0.001). BNP also correlated with the degree of reversible ischaemia (stress score - rest score; Spearman's r = 0.28, two tailed p = 0.049). In the cohort who did not have left ventricular systolic dysfunction (n = 44), BNP remained higher in patients with relevant myocardial ischaemia (mean (SE) BNP 20.9 pg/ml, 95% confidence interval (CI) 15.2 to 26.5 v 12.2 pg/ml, 95% CI 5.95 to 18.5; p = 0.046); 33 of the 44 patients had no chest pain or history of myocardial infarction. The relation between resting BNP and both inducible ischaemia and dipyridamole stress score remained significant (Spearman's r = 0.37 and -0.38, respectively). CONCLUSIONS BNP correlates with the degree of reversible myocardial ischaemia in patients who do not have chest pain or a history of myocardial infarction or evidence of left ventricular systolic dysfunction. Stroke survivors with a high BNP deserve further investigations to rule out significant reversible myocardial ischaemia, in order to reduce their risk of cardiac death.
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Affiliation(s)
- K Y K Wong
- Division of Medicine and Therapeutics, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.
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Abstract
OBJECTIVES To find out what spectrum of cardiac abnormalities are found in those stroke survivors who can be deemed to be at high cardiac risk by their having long QT. METHODS 202 patients with good recovery from a cerebrovascular event occurring at least one month previously were recruited into a prospective epidemiological study. These stroke survivors underwent a battery of cardiac investigations including 12 lead ECG, echocardiography, myocardial perfusion scanning, and heart rate variability assessment. The ECGs were digitised by a single observer blinded to the blood pressure and other investigations of the patients. The maximum heart rate corrected QT interval (QTc max) in the 12 lead ECG was derived by Bazett's formula. RESULTS Prolonged QTc max significantly correlated with increasing blood pressure, left ventricular mass index, and depressed heart rate variability. As the number of cardiac abnormalities increased, QTc max became more prolonged. CONCLUSIONS Long QT is significantly associated with left ventricular mass index even after adjustment for both systolic and diastolic blood pressures. Long QT was also associated with the total cardiac disease burden. These two observations may explain why stroke survivors with long QTc max were at greater risk of cardiac death.
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Affiliation(s)
- K Y K Wong
- Division of Medicine and Therapeutics, University of Dundee, Dundee, UK.
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Abstract
OBJECTIVES To test the hypothesis that the QTc of any lead of the ECG predicts death after stroke, and to determine which lead of the ECG carries the greatest risk of cardiac death when its QTc is measured. DESIGN Standard 12 lead ECGs were analysed by one observer who was blind to patient outcome. SETTING A major teaching hospital in Scotland. PATIENTS 404 stroke survivors were studied at approximately one year after the cerebrovascular event and followed for up to 6.3 years. OUTCOME MEASURES Death from any cause and cardiac mortality. RESULTS The QTc measured from any lead of the ECG (except aVR) was associated with death from any cause. A prolonged QTc in limb lead III and chest lead V6 carried the highest relative risk of cardiac death (a 3.1-fold incease). After adjusting for overt ischaemic heart disease, pulse pressure, glucose, and cholesterol, a prolonged QTc in lead V6 was associated with a relative risk of cardiac death of 2.8 (95% confidence interval (CI) 1.1 to 7.3) (p = 0.028) and of death from all causes of 2.9 (95% CI 1.6 to 5.3) (p < 0.001). If the QTc in V6 exceeded 480 ms, then the specificity of predicting cardiac death within five years after the stroke was 94%. CONCLUSIONS Although treatment of the conventional modifiable risk factors is important, stroke survivors with a prolonged QTc in lead V6 are still at a high risk of cardiac death and may need more intensive investigations and treatments than are currently routine practice.
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Affiliation(s)
- K Y K Wong
- The Cardiovascular Research Group, Department of Clinical Pharmacology and Therapeutics, University of Dundee Medical School, Ninewells Hospital, Dundee, UK.
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Abstract
AIMS To test the hypothesis that urate predicts cardiac death after stroke independent of conventional risk factors of atherosclerosis, creatinine and diuretic use. METHODS AND RESULTS Serum urate concentration was measured in an unselected cohort of 354 stroke survivors who were followed-up for a median of 2.8 years. Cardiac death was the primary end-point. Urate was associated with a statistically significant threefold increase in relative risk of cardiac death even after adjustment for other conventional risk factors. In the subgroup of patients who were not on diuretics, raised urate was associated with a 12-fold significant increase in relative risk of cardiac death after adjusting for renal function and other conventional risk factors. A urate concentration of greater than 0.31 mmol. l(-1) was 78% sensitive at predicting cardiac death within 5 years after stroke, but was only 54% specific. If urate exceeded 0.38 mmol. l(-1), specificity of predicting cardiac death within 5 years after stroke was 88%. CONCLUSIONS Elevated serum urate concentration may be used to stratify risk of future cardiac death after stroke. This appeared to be true even in stroke survivors who were not on diuretic therapy.
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Affiliation(s)
- K Y K Wong
- The Cardiovascular Research Group, Department of Clinical Pharmacology & Therapeutics, University of Dundee Medical School, Dundee, UK
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