Trends in heart failure hospitalizations, patient characteristics, in-hospital and 1-year mortality: A population study, from 2000 to 2012 in Lombardy

BACKGROUND

This study was undertaken to evaluate trends in heat failure hospitalizations (HFHs) and 1-year mortality of HFH in Lombardy, the largest Italian region, from 2000 to 2012.

METHODS

Hospital discharge forms with HF-related ICD-9 CM codes collected from 2000 to 2012 by the regional healthcare service (n=699797 in 370538 adult patients), were analyzed with respect to in-hospital and 1-year mortality; Group (G) 1 included most acute HF episodes with primary cardiac diagnosis (70%); G2 included cardiomyopathies without acute HF codes (17%); and G3 included non-cardiac conditions with HF as secondary diagnosis (13%). Patients experiencing their first HFH since 2005 were analyzed as incident cases (n=216782).

RESULTS

Annual HFHs number (mean 53830) and in-hospital mortality (9.4%) did not change over the years, the latter being associated with increasing age (p<0.0001) and diagnosis Group (G1 9.1%, G2 5.6%, G3 15.9%, p<0.0001). Incidence of new cases decreased over the years (3.62 [CI 3.58-3.67] in 2005 to 3.13 [CI 3.09-3.17] in 2012, per 1000 adult inhabitants/year, p<0.0001), with an increasing proportion of patients aged ≥85y (22.3% to 31.4%, p<0.0001). Mortality lowered over time in <75y incident cases, both in-hospital (5.15% to 4.36%, p<0.0001) and at 1-year (14.8% to 12.9%, p=0.0006).

CONCLUSIONS

The overall burden and mortality of HFH appear stable for more than a decade. However, from 2005 to 2012, there was a reduction of new, incident cases, with increasing age at first hospitalization. Meanwhile, both in-hospital and 1-year mortality decreased in patients aged <75y, possibly due to improved prevention and treatment.

Methodological issues on the use of administrative data in healthcare research: the case of heart failure hospitalizations in Lombardy region, 2000 to 2012

BACKGROUND

Administrative data are increasingly used in healthcare research. However, in order to avoid biases, their use requires careful study planning. This paper describes the methodological principles and criteria used in a study on epidemiology, outcomes and process of care of patients hospitalized for heart failure (HF) in the largest Italian Region, from 2000 to 2012.

METHODS

Data were extracted from the administrative data warehouse of the healthcare system of Lombardy, Italy. Hospital discharge forms with HF-related diagnosis codes were the basis for identifying HF hospitalizations as clinical events, or episodes. In patients experiencing at least one HF event, hospitalizations for any cause, outpatient services utilization, and drug prescriptions were also analyzed.

RESULTS

Seven hundred one thousand, seven hundred one heart failure events involving 371,766 patients were recorded from 2000 to 2012. Once all the healthcare services provided to these patients after the first HF event had been joined together, the study database totalled about 91 million records. Principles, criteria and tips utilized in order to minimize errors and characterize some relevant subgroups are described.

CONCLUSIONS

The methodology of this study could represent the basis for future research and could be applied in similar studies concerning epidemiology, trend analysis, and healthcare resources utilization.

Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction

BACKGROUND

A normally contracting right ventricular apex associated to a severe hypokinesia of the mid-free wall ('McConnell sign') has been considered a distinct echocardiographic pattern of acute pulmonary embolism.

OBJECTIVE

To evaluate the clinical utility of the 'McConnell sign' in the bedside diagnostic work-up of patients presenting to the Emergency Department with an acute right ventricular dysfunction due to pulmonary embolism or right ventricular infarction.

DESIGN

Among 201 patients, consecutively selected from our clinical database and diagnosed as having massive or submassive pulmonary embolism or right ventricular infarction, 161 were suitable for an echocardiographic review of regional right ventricular contraction and were included in the study. There were 107 cases with pulmonary embolism (group 1) and 54 cases with right ventricular infarction (group 2). All echocardiographic studies were randomly examined by two experienced and independent echocardiographers, blinded to the patient diagnosis and without Doppler informations.

RESULTS

The McConnell sign was detected in 75 of 107 patients in group 1 (70%) and in 36 of 54 patients in group 2 (67%); the finding was absent in 32 cases in group 1 and in 18 cases in group 2 (P=0.657). The sensitivity, specificity, positive and negative predictive values of the McConnell sign for the diagnosis of pulmonary embolism were respectively 70, 33, 67 and 36%.

CONCLUSIONS

In a clinical setting of patients with acute right ventricular dysfunction the McConnell sign cannot be considered a specific marker of pulmonary embolism.

[The cardiologist facing pulmonary embolism. The experience of 160 cases of acute cor pulmonale]

BACKGROUND

The results of recent multicenter studies dealing with pulmonary embolism often reveal remarkable discrepancies in terms of diagnosis, prognosis and treatment, partly due to the heterogeneity of study patients and of evaluation criteria. Our prospective study focused exclusively on patients affected by pulmonary embolism with a hemodynamic pattern of acute cor pulmonale, investigated at a single center. Particular attention was paid to in-hospital mortality, embolic recurrences, major bleeding and underlying pathologies.

METHODS

This study includes 160 cases (103 women with a median age of 71 years and 57 men with a median age of 65 years) in whom the clinical and echocardiographic findings suggestive of acute pulmonary embolism were confirmed by lung perfusion scan, pulmonary angiography, techniques for the detection of deep vein thrombosis and/or autopsy.

RESULTS

The most common clinical manifestations were: dyspnea (92% of cases), tachycardia (80%), syncope (44%), cardiac arrest (22%), and shock (20%). Thoracic pain was present in only 27% of patients. None of the patients showed a normal ECG; a right bundle branch block was found in 47% of cases. T-wave inversion in the precordial leads (32%) was not related to the severity and outcome of pulmonary embolism. Present or previous deep vein thrombosis was found in 53 and 26% of cases, respectively. Only in 2 patients pulmonary embolism was secondary to a deep vein thrombosis of the upper limbs. Intravenous heparin alone was used in 36% of cases, whereas 56% were treated with thrombolytic agents + heparin. Major bleeding occurred in 9% of patients treated with heparin alone, and in 16% of those who received heparin + thrombolytic drugs. Death occurred in 17% of the former, and in 27% of the latter patients. The in-hospital mortality rate was related not only to the presence of cardiac arrest and--to a lower degree--of shock, but also to the recurrence of pulmonary embolism and to the underlying heart disease. No relationship was found between mortality and age, intracardiac thrombi or malignancy. Prognosis was quite different depending on clinical presentation, with a death rate ranging from 11% in the absence of systemic hypertension, and 77% in the presence of cardiac arrest.

CONCLUSIONS

Even the "massive" pulmonary embolism that is observed in a cardiac department represents a true "spectrum" of pathological conditions, a spectrum that should be taken into account not only in order to evaluate prognosis and treatment in a particular case, but also when meta-analyses are performed.

Exercise training in mild hypertension: effects on blood pressure, left ventricular mass and coagulation factor VII and fibrinogen

The aim of this study was to assess the effects of aerobic exercise on resting and 24-hour blood pressure (BP), left ventricular mass (LVM), plasma fibrinogen and factor VII (FVII). For this purpose 14 sedentary subjects with untreated diastolic BP between 90 and 104 mm Hg completed a 12-week supervised exercise program. At the end of this period, 8 subjects resumed a sedentary life-style and were reexamined 2 months later (detraining). Baseline, posttraining and postdetraining examinations included resting BP assessment, ambulatory BP monitoring, cardiopulmonary stress test, echocardiography and measurements of plasma fibrinogen and FVII. Exercise-mediated increase in aerobic fitness (VO2 max + 24%) was associated with a significant reduction in resting systolic and diastolic BP (p < 0.01), mean systolic and diastolic 24-hour BP (p < 0.001) and LVM index. As for the coagulation parameters only the concentration of fibrinogen significantly decreased (p < 0.01) whereas FVII remained unchanged. The 8 subjects that resumed a sedentary life-style were reexamined 2 months later: their resting BP, 24-hour BP and fibrinogen concentration returned to baseline values; only the effect on LVM was conserved. Our study underlines the usefulness and safety of regular physical exercise in mild hypertension. Most of the patients (11 of 14) had their BP normalized and a significant reduction in LVM and fibrinogen concentration was observed, leading to an overall improvement in coronary risk profile.