Feasibility and accuracy of linking a heart failure registry to the national claims database using indirect identifiers.

BACKGROUND: Heart failure (HF) registries include rich data on patient inclusion characteristics, but follow-up information is often incomplete. Medicoadministrative databases may provide less clinical information than registries, e.g. on left ventricular ejection fraction (LVEF), but long-term data are exhaustive and reliable. The combination of the two types of database is therefore appealing, but the feasibility and accuracy of such linking are largely unexplored. AIMS: To assess the feasibility and accuracy of linking an HF registry (FRESH; FREnch Survey on Heart Failure) with the French National Healthcare System database (SNDS). METHODS: A probabilistic algorithm was developed to link and match patient data included in the FRESH HF registry with anonymized records from the SNDS, which include: hospitalizations and diagnostic codes; all care-related reimbursements by national health system; and deaths. Consistency was assessed between deaths recorded in the registry and in the SNDS. A comparison between the two databases was carried out on several identifiable clinical characteristics (history of HF hospitalization, diabetes, atrial fibrillation, chronic bronchopneumopathy, severe renal failure and stroke) and on events during 1-year follow-up after inclusion. RESULTS: Of 2719 patients included in the FRESH registry (1049 during decompensation; 1670 during outpatient follow-up), 1885 could be matched with a high accuracy of 94.3% for deaths. Mortality curves were superimposable, including curves according to type of HF and LVEF. The rates of missing data in the FRESH registry were 2.3-8.4% for clinical characteristics and 17.5% for hospitalizations during follow-up. The discrepancy rate for clinical characteristics was 3-13%. Hospitalization rates were significantly higher in the SNDS than in the registry cohort. CONCLUSIONS: The anonymous matching of an HF research cohort with a national health database is feasible, with a significant proportion of patients being accurately matched, and facilitates combination of clinical data and a reduced rate of losses to follow-up.

Early and short-term intensive management after discharge for patients hospitalized with acute heart failure: a randomized study (ECAD-HF).

AIMS: Hospitalization for acute heart failure (HF) is followed by a vulnerable time with increased risk of readmission or death, thus requiring particular attention after discharge. In this study, we examined the impact of intensive, early follow-up among patients at high readmission risk at discharge after treatment for acute HF. METHODS AND RESULTS: Hospitalized acute HF patients were included with at least one of the following: previous acute HF < 6 months, systolic blood pressure ≤ 110 mmHg, creatininaemia ≥ 180 µmol/L, or B-type natriuretic peptide ≥ 350 pg/mL or N-terminal pro B-type natriuretic peptide ≥ 2200 pg/mL. Patients were randomized to either optimized care and education with serial consultations with HF specialist and dietician during the first 2-3 weeks, or to standard post-discharge care according to guidelines. The primary endpoint was all-cause death or first unplanned hospitalization during 6-month follow-up. Among 482 randomized patients (median age 77 and median left ventricular ejection fraction 35%), 224 were hospitalized or died. In the intensive group, loop diuretics (46%), beta-blockers (49%), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (39%) and mineralocorticoid receptor antagonists (47%) were titrated. No difference was observed between groups for the primary endpoint (hazard ratio 0.97; 95% confidence interval 0.74-1.26), nor for mortality at 6 or 12 months or unplanned HF rehospitalization. Additionally, no difference between groups according to age, previous HF and left ventricular ejection fraction was found. CONCLUSIONS: In high-risk HF, intensive follow-up early post-discharge did not improve outcomes. This vulnerable post-discharge time requires further studies to clarify useful transitional care services.

Baseline subendocardial viability ratio influences left ventricular systolic improvement with cardiac rehabilitation.

OBJECTIVE: Subendocardial viability ratio (SEVR), defined as diastolic to systolic pressure-time integral ratio, is a useful tool reflecting the balance between coronary perfusion and arterial load. Suboptimal SEVR creating a supply-demand imbalance may limit favorable cardiac response to cardiac rehabilitation (CR). To explore this hypothesis, we designed a study to analyze the relationship between baseline SEVR and response to CR in patients with coronary artery disease (CAD). METHODS: In this prospectively study, after baseline arterial tonometry, echocardiography, and cardiopulmonary exercise tests (CPETs), patients undergone 20 sessions of CR. Post-CR echocardiographic and CPET measurements were obtained for comparison. RESULTS: Final study population was comprised of fifty subjects. Study population was divided into two subgroups by median SEVR value (1.45, interquartile range 0.38). Although both groups showed significant improvements in peak VO2, significant improvements in oxygen pulse (πO2) (from 16.1±3.4 to 19.1±4.8 mL O2.kg-1.beat-1; p<0.001) and stroke volume index (from 31±5 to 35±6 mL; p=0.008) were observed in only the patients in the above-median subgroup. The change in πO2 was also significantly higher in the above-median SEVR subgroup (2.9±3.3 vs. 0.5±2.4; p=0.007). CONCLUSION: Our study shows that baseline supply-demand imbalance may limit systolic improvement response to CR in patients with CAD.

Value of Baseline Cardiovascular Mechanics in Predicting Exercise Training Success.

PURPOSE: Despite being repeatedly shown that exercise training (ET) increases exercise capacity and decreases mortality in many cardiac conditions, not all patients enjoy the benefits of ET programs. We hypothesized that baseline cardiovascular mechanic properties, including cardiac systolic and diastolic functions, arterial mechanics and ventriculoarterial interaction, may have a role in predicting response to ET. METHODS: Full left ventricular pressure-volume loops were constructed and arterial mechanics were evaluated using echocardiographic and tonometric measurements. A cardiopulmonary exercise (CPX) test was performed before and after the ET program. RESULTS: Sixty of the 75 patients with coronary artery disease or heart failure diagnoses completed the study. All of the CPX parameters showed a significant improvement with ET. The change in oxygen uptake correlated only with arterial parameters, such as compliance (r = 0.399, P = .002), end-systolic arterial elastance (r = -0.293, P = .02), aortic pulse pressure (r = -0.302, P = .02), and brachial pulse pressure (r = -0.312, P = .01). Receiver-operating characteristics analysis demonstrated that baseline arterial compliance and brachial pulse pressure predicted a significantly positive ET result with reasonable sensitivity and specificity. CONCLUSIONS: Patients with a more compliant arterial system improved their exercise capacity more with ET. Evaluation of baseline arterial compliance may facilitate proper patient selection and may define patients who need optimizing measures for the arterial system before commencing ET. Even a simple blood pressure measurement may give clues in this regard.

Association between baseline cardiovascular mechanics and exercise capacity in patients with coronary artery disease.

OBJECTIVE: Functional capacity is one of the cardinal determinants of morbidity and mortality in patients with coronary artery disease (CAD). We hypothesized that baseline cardiovascular mechanics, including cardiac systolic and diastolic functions, arterial mechanics, and ventriculoarterial interaction, may play a role in predicting exercise capacity in patients with CAD. METHODS: Fifty consecutive patients with CAD who were referred to cardiac rehabilitation were prospectively included in the study. Patients with non-sinus rhythms or severe valvular disease were excluded. Full left ventricular pressure-volume loops were constructed and arterial mechanics was evaluated using echocardiographic and tonometric measurements. Cardiopulmonary exercise tests were performed to measure exercise capacity. RESULTS: Fifty patients were enrolled in the study. Ventriculo-arterial coupling showed a moderate correlation with peak oxygen consumption (VO2) (r=0.410, p=0.04) in patients with reduced left ventricular ejection fraction (LVEF). Only left ventricular volume at 15 mm Hg (r=0.514, p<0.01) in diastolic parameters (stiffness constant, p=0.75; ventricular compliance, p=0.17) and arterial compliance (r=0.467, p=0.01) in arterial parameters [arterial elastance, p=0.27; systemic vascular resistance, p=0.45; augmentation pressure, p=0.85; augmentation index (AIx), p=0.63; heart rate-corrected AIx, p=0.68] emerged as significant factors correlated with peak VO2 in patients with normal LVEF. CONCLUSION: Comprehensive evaluation of resting cardiovascular mechanics can give clues about exercise-recruited reserves of the cardiovascular system. Optimization of ventriculo-arterial coupling in patients with reduced LVEF and arterial compliance in patients with normal LVEF should be the main target in patients with CAD and limited functional capacity.

Can mortality due to circulatory failure in comatose out-of-hospital cardiac arrest patients be predicted on admission? A study in a retrospective derivation cohort validated in a prospective cohort.

PURPOSE: Circulatory failure (CF) influences management of out-of-hospital cardiac arrest (OHCA) patients and the decision of circulatory assistance. We performed a study to identify on hospital admission patients at risk for CF-related death. MATERIALS AND METHODS: This is a single-center study including OHCA patients without obvious extracardiac cause and sustained return of spontaneous circulation, in a retrospective derivation (RC) and prospective validation cohort (PC). Univariate/multivariate logistic regression was used in the RC to determine a score predicting CF-related death (due to rearrest or persistent shock despite adequate fluid and catecholamine treatment). The score was validated in the PC. RESULTS: We included 207 patients in the RC and 96 in the PC. Circulatory failure occurred in 59% of RC and 63% of PC patients (P = .70); 35% in both cohorts died of CF. In multivariate regression, correlates of CF-related death making up the logistic score were arterial pH (P < .0001) and shock requiring catecholamines on admission (P = .0045). In the PC, for a logistic score cut-off of 0.5, sensitivity for CF-related death was 50%; specificity, 92%. Patients with shock and arterial pH less than or equal to 7.11 had a CF-related death probability greater than 0.5. CONCLUSION: A logistic score based on arterial pH and shock requiring catecholamines on admission can predict CF-related death in OHCA patients.

Effects of Cardiopulmonary Exercise Rehabilitation on Left Ventricular Mechanical Efficiency and Ventricular-Arterial Coupling in Patients With Systolic Heart Failure.

BACKGROUND: Success of cardiac rehabilitation (CR) is generally assessed by the objective improvement in peak volume of inhaled oxygen (VO2) measured by cardiopulmonary exercise test (CPX). However, cardiac mechanical efficiency and ventricular-arterial coupling (VAC) are the other important dimensions of the heart failure pathophysiology, which are not included in CPX-derived data. The effect of cardiac rehabilitation on left ventricular (LV) efficiency or VAC in unselected heart failure patients has not been studied thus far. METHODS AND RESULTS: Thirty patients with an ejection fraction of ≤45% were recruited for 20 sessions of exercise-based CR. Noninvasive LV pressure-volume loops were constructed and VAC was calculated with the help of applanation tonometry and echocardiography before and after CR. VAC showed an improved mechanical efficiency profile and increased significantly from 0.56±0.18 to 0.67±0.21 (P=0.02). LV mechanical efficiency improved from 43.9±9.1% to 48.8±9.1% (P=0.01). The change in peak VO2 was not in a significant correlation with the change in VAC (r=-0.18; P=0.31), mechanical efficiency (r=-0.16, P=0.39), or the change in ejection fraction (r=-0.07; P=0.68). CONCLUSIONS: CR is associated with an improvement in VAC and LV mechanical efficiency in heart failure patients. Further studies are needed to determine the incremental value of VAC and mechanical efficiency over CPX-derived data in predicting clinical outcomes.

Effects of exercise on postexercise ventricular-arterial coupling and pulsatile efficiency in patients with systolic dysfunction.

BACKGROUND: A suboptimal ventricular-arterial (VA) interaction may have a prolonged depressing effect on the failing heart after functional reserves forced to their limits under stress conditions such as exercise. The continuation of excessive load in the postexercise period may be more important than the load during exercise, because the sum of postexercise periods generally exceeds exercise time itself. We sought that exercise-induced changes in postexercise VA coupling and pulsatile efficiency in patients with heart failure (HF). METHODS: Thirty consecutive HF with reduced ejection fraction (EF) and thirty age-, sex- and peak VO2 -matched subjects with preserved EF were enrolled. Pre- and postexercise echocardiographic and tonometric measurements were taken to calculate left ventricular and arterial elastances, arterial compliance and wave reflections, and steady and pulsatile power. RESULTS: VA coupling significantly deteriorated in HF group (from 1·50 ± 0·47 to 2·00 ± 0·75 mmHg/mL, P < 0·01), but control group maintained basal favourable coupling status after exercise (from 1·04 ± 0·29 to 1·03 ± 0·24 mmHg/mL, P = 0·77). Pulsatile percentage of total power significantly increased with exercise in HF group, whereas it showed a significant decrease in control group. The change in pulsatile power fraction was correlated with the change in augmentation pressure (r = 0·41, ß = 3·00, P < 0·01) and inversely correlated with the change in total arterial compliance (r = -0·29, ß = -8·52, P = 0·02). CONCLUSION: Our data indicate that exercise-induced VA decoupling and pulsatile inefficiency extend into postexercise phase in patients with systolic dysfunction. The exact duration of these derangements requires further studies.

Changes in ventricular-arterial coupling during decongestive therapy in acute heart failure.

AIMS: Coupled arterial and left ventricular properties are poorly documented in acute heart failure. The aim of this prospective noninvasive study was to document early changes in ventricular-arterial coupling in patients with acutely decompensated HF (ADHF). METHODS AND RESULTS: We studied 19 patients hospitalized for ADHF (age 62 ± 15 years, NYHA class 3 or 4). Patients with shock and sustained arrhythmias were excluded. All the patients received intravenous loop diuretics, and none received intravenous vasodilators or inotropes. Ongoing chronic treatments were maintained. Echocardiography and radial artery tonometry were performed simultaneously on admission and after clinical improvement (day 4 ± 1 after admission). Classical echocardiographic parameters were measured, including stroke volume (SV). End-systolic pressure (Pes) was derived from reconstructed central aortic pressure, and arterial elastance (Ea) was calculated as Ea = Pes/SV. End-systolic LV elastance (Ees) was calculated with the single-beat method. Ventricular-arterial coupling was quantified as the Ea/Ees ratio. Following IV diuretic therapy, mean weight loss was 5 ± 2 kg (P < 0·01) and BNP fell from 1813 (median) (IQR = 1284-2342) to 694 (334-1053) pg/mL (P < 0·01). Ea fell by 29%, from 2·46 (2·05-2·86) to 1·78 (1·55-2·00) mmHg/mL (P < 0·01), while Ees remained unchanged (1·28 (1·05-1·52) to 1·13 (0·92-1·34) mmHg/mL). The Ea/Ees ratio therefore fell, from 2·13 (1·70-2·56) to 1·81 (1·56-2·08) (P < 0·02). CONCLUSION: An early improvement in ventricular-arterial coupling was observed after diuretic-related decongestive therapy in ADHF patients and was related to a decrease in effective arterial elastance rather than to change in LV contractility.

Akt-mediated cardioprotective effects of aldosterone in type 2 diabetic mice.

Studies have shown that aldosterone would have angiogenic effects and therefore would be beneficial in the context of cardiovascular diseases. We thus investigated the potential involvement of aldosterone in triggering a cardiac angiogenic response in the context of type-2 diabetes and the molecular pathways involved. Male 3-wk-old aldosterone synthase (AS)-overexpressing mice and their control wild-type (WT) littermates were fed a standard or high-fat, high-sucrose (HFHS) diet. After 6 mo of diet treatment, mice were euthanized, and cardiac samples were assayed by RT-PCR, immunoblotting, and immunohistology. HFHS diet induced type-2 diabetes in WT (WT-D) and AS (AS-D) mice. VEGFa mRNAs decreased in WT-D (-43%, P<0.05 vs. WT) and increased in AS-D mice (+236%, P< 0.01 vs. WT-D). In WT-D mouse hearts, the proapoptotic p38MAPK was activated (P<0.05 vs. WT and AS-D), whereas Akt activity decreased (-64%, P<0.05 vs. WT). The AS mice, which exhibited a cardiac up-regulation of IGF1-R, showed an increase in Akt phosphorylation when diabetes was induced (P<0.05 vs. WT and AS-D). Contrary to WT-D mice, AS-D mouse hearts did not express inflammatory markers and exhibited a normal capillary density (P<0.05 vs. WT-D). To our knowledge, this is the first study providing new insights into the mechanisms whereby aldosterone prevents diabetes-induced cardiac disorders.

Efficacy of early clinical evaluation in predicting direct home discharge of elderly patients after hospitalization in internal medicine.

OBJECTIVES: Early evaluation of direct home discharge (DHD) after hospitalization of elderly patients is important to organize discharge planning quickly. Many scores, scales, and indices have been developed to improve discharge planning. Is clinical judgment better than functional status, comorbidity, or cognitive function scales in predicting DHD of elderly patients after hospitalization? METHODS: Ninety-seven patients, aged 75 years or older, admitted from the emergency department to an internal medicine department in a French teaching hospital between December 1, 2006 and May 1, 2007, were enrolled prospectively in the study. Demographic, clinical, and laboratory characteristics and functional status, comorbidity, and cognitive function scales were determined. The primary outcome was the percentage of correct discharge prediction made by junior and senior doctors within the first 48 hours upon admission. Univariate analysis and logistic regression were assessed to determine predictive variables of patients' discharge. RESULTS: Junior and senior doctors obtained correct prediction in 74.2% and 73.2% of cases, respectively (P > 0.99). Activities of daily living, instrumental activities of daily living, and duration of hospitalization were predictive of DHD (95% confidence interval [CI] -6.1 to 0.2, P = 0.037; 95% CI -2.1 to 9.9, P = 0.003; 95% CI -3 to 9.1, P = 0.0001, respectively) in the univariate analysis. Instrumental activities of daily living was an independent predictive variable of patients' discharge in a logistic regression. No difference between clinical evaluation and the use of an independent predictive variable regarding the prediction of DHD was found. CONCLUSIONS: Early clinical evaluation is as effective as the use of functional status scales to predict DHD of hospitalized elderly patients.