Precipitating Clinical Factors, Heart Failure Characterization, and Outcomes in Patients Hospitalized With Heart Failure With Reduced, Borderline, and Preserved Ejection Fraction.

OBJECTIVES: This study assessed the comparative frequency of precipitating clinical factors leading to hospitalization among heart failure (HF) patients with reduced, borderline, and preserved ejection fraction (EF) BACKGROUND: There are few data assessing the comparative frequency of clinical factors leading to HF among hospitalized among patients with reduced, borderline, and preserved EF. METHODS: We analyzed the factors potentially contributing to HF hospitalization among 99,825 HF admissions from 305 hospitals in the Get With The Guidelines-HF (GWTG-HF) database between January 2005 and September 2013 and assessed their association with length of stay and in-hospital mortality. RESULTS: Mean patient age was 72.6 ± 14.2 years, 49% were female, and mean EF was 39.3 ± 17.2%. Common factors included pneumonia/respiratory process (28.2%), arrhythmia (21.7%), medication noncompliance (15.8%), worsening renal failure (14.7%), and uncontrolled hypertension (14.5%). In patients with borderline EF (EF 40% to 49%), pneumonia was associated with longer hospital stay, whereas dietary and medication noncompliance were associated with reduced length of stay. In patients with preserved EF (EF ≥50% or qualitative assessment of normal or mild dysfunction), pneumonia, weight gain, and worsening renal function were independently associated with longer lengths of stay. Worsening renal function and pneumonia were independently associated with higher in-hospital mortality in all HF groups, and acute pulmonary edema was associated with higher mortality in reduced EF. Dietary noncompliance (14.7%) was associated with reduced mortality for all groups but reached statistical significance in the subgroups of reduced (odds ratio [OR]: 0.65; 95% confidence interval [CI]: 0.46 to 0.91) and preserved systolic function (OR: 0.52; 95% CI: 0.33 to 0.83). Patients presenting with ischemia had a higher mortality rate (OR: 1.31; 95% CI: 1.02 to 1.69; and 1.72; 95% CI: 1.27 to 2.33, respectively, in the 2 groups). CONCLUSIONS: Potential precipitating factors among patients hospitalized with HF vary by EF group and are independently associated with clinical outcomes.

Role of heart rate as a marker and mediator of poor outcome for patients with heart failure.

Tachycardia has been associated with worse outcomes for patients with heart failure and is also thought to have a direct adverse impact on the myocardium. This report highlights the current evidence for heart rate as both a risk factor and mediator for poor outcome for patients with heart failure. We summarize the large number of studies evaluating heart rate in patients with systolic dysfunction and newer studies that examine patients with preserved systolic function. The effect on outcomes in heart failure of medications known to slow the heart rate such as ß-blockers and the more recently developed drug ivabradine are discussed. The data clearly show that a high heart rate is a marker of increased mortality. There is also a strong suggestion that a higher heart rate directly worsens outcome and that this can be mitigated by heart rate-reducing medications.

Orthostatic hypotension among outpatients with ischemic stroke.

BACKGROUND: The treatment of hypertension is an essential component of stroke prevention; however, the clinical management of patients with cerebrovascular disease is complicated by orthostatic hypotension (OH). The primary objectives were to: determine the prevalence of OH in a stroke outpatient clinic; describe categories of OH; and identify factors independently associated with the presence of OH. METHODS: Veterans with stroke, cared for in a multidisciplinary stroke clinic, were included. OH was defined as a ≥20 mmHg fall in systolic blood pressure (BP), a ≥10 mmHg fall in diastolic BP, or a ≥10 mmHg fall in systolic BP with symptoms. Multivariable logistic regression was used to identify factors associated with OH including demographics, comorbidites, stroke severity, and baseline BP. RESULTS: Among 60 patients with stroke, 16 (27%) patients had OH. Among those with OH, half were hypertensive, seven were normotensive, and one was hypotensive. A history of coronary artery disease was independently associated with the presence of OH. CONCLUSIONS: Orthostatic hypotension is present in about one quarter of outpatients with stroke, and coronary artery disease appears to be a risk factor. Stroke patients should be screened for OH given that the presence of positional BP changes may alter clinical management.

Diabetes, quality of care, and in-hospital outcomes in patients hospitalized with heart failure.

BACKGROUND: Diabetes mellitus is frequently comorbid with heart failure (HF). It is unclear if comorbid diabetes is associated with quality of care and in-hospital mortality. METHODS: We analyzed 133,971 HF admissions from 431 hospitals between January 2005 and January 2010 comparing patients with and without diabetes. RESULTS: There were 54,352 (41%) patients hospitalized with HF with a history or newly diagnosed diabetes. After adjustment, patients with diabetes were as likely as patients without diabetes to appropriately receive the composite of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and ß-blockers (odds ratio [OR] 0.99, 95% CI 0.94-1.04), angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (OR 0.98, 95% CI 0.92-1.05), evidence-based ß-blockers (OR 1.04, 95% CI 0.98-1.1), and hydralazine/nitrates (OR 1.09, 95% CI 0.99-1.2). However, patients with diabetes were less likely to receive smoking cessation counseling (OR 0.89, 95% CI 0.81-0.98) and blood pressure control (OR 0.81, 95% CI 0.78-0.84) and to attain the all-or-none composite measure (OR 0.96, 95% CI 0.93-0.99). Patients with diabetes were more likely to receive an aldosterone antagonist for reduced left ventricular ejection fraction (OR 1.05, 95% CI 1.00-1.11), lipid-lowering agent (OR 1.33, 95% CI 1.26-1.41), and influenza vaccination (OR 1.05, 95% CI 1.01-1.09). Diabetes was independently associated with longer hospital stay but not within-hospital mortality. CONCLUSIONS: With few exceptions, the application of evidence-based care and in-hospital outcomes were similar whether or not diabetes was present in this large contemporary cohort of patients hospitalized with HF.

Payment source, quality of care, and outcomes in patients hospitalized with heart failure.

OBJECTIVES: The aim of this study was to analyze the relationship between payment source and quality of care and outcomes in heart failure (HF). BACKGROUND: HF is a major cause of morbidity and mortality. There is a lack of studies assessing the association of payment source with HF quality of care and outcomes. METHODS: A total of 99,508 HF admissions from 244 sites between January 2005 and September 2009 were analyzed. Patients were grouped on the basis of payer status (private/health maintenance organization, no insurance, Medicare, or Medicaid) with private/health maintenance organization as the reference group. RESULTS: The no-insurance group was less likely to receive evidence-based beta-blockers (adjusted odds ratio [OR]: 0.73; 95% confidence interval [CI]: 0.62 to 0.86), implantable cardioverter-defibrillator (OR: 0.59; 95% CI: 0.50 to 0.70), or anticoagulation for atrial fibrillation (OR: 0.73; 95% CI: 0.61 to 0.87). Similarly, the Medicaid group was less likely to receive evidence-based beta-blockers (OR: 0.86; 95% CI: 0.78 to 0.95) or implantable cardioverter-defibrillators (OR: 0.86; 95% CI: 0.78 to 0.96). Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and beta-blockers were prescribed less frequently in the Medicare group (OR: 0.89; 95% CI: 0.81 to 0.98). The Medicare, Medicaid, and no-insurance groups had longer hospital stays. Higher adjusted rates of in-hospital mortality were seen in patients with Medicaid (OR: 1.22; 95% CI: 1.06 to 1.41) and in patients with reduced systolic function with no insurance. CONCLUSIONS: Decreased quality of care and outcomes for patients with HF were observed in the no-insurance, Medicaid, and Medicare groups compared with the private/health maintenance organization group.

A multidisciplinary stroke clinic for outpatient care of veterans with cerebrovascular disease.

BACKGROUND: Managing cerebrovascular risk factors is complex and difficult. The objective of this program evaluation was to assess the effectiveness of an outpatient Multidisciplinary Stroke Clinic model for the clinical management of veterans with cerebrovascular disease or cerebrovascular risk factors. METHODS: The Multidisciplinary Stroke Clinic provided care to veterans with cerebrovascular disease during a one-half day clinic visit with interdisciplinary evaluations and feedback from nursing, health psychology, rehabilitation medicine, internal medicine, and neurology. We conducted a program evaluation of the clinic by assessing clinical care outcomes, patient satisfaction, provider satisfaction, and costs. RESULTS: We evaluated the care and outcomes of the first consecutive 162 patients who were cared for in the clinic. Patients had as many as six clinic visits. Systolic and diastolic blood pressure decreased: 137.2 ± 22.0 mm Hg versus 128.6 ± 19.8 mm Hg, P = 0.007 and 77.9 ± 14.8 mm Hg versus 72.0 ± 10.2 mm Hg, P = 0.004, respectively as did low-density lipoprotein (LDL)-cholesterol (101.9 ± 23.1 mg/dL versus 80.6 ± 25.0 mg/dL, P = 0.001). All patients had at least one major change recommended in their care management. Both patients and providers reported high satisfaction levels with the clinic. Veterans with stroke who were cared for in the clinic had similar or lower costs than veterans with stroke who were cared for elsewhere. CONCLUSION: A Multidisciplinary Stroke Clinic model provides incremental improvement in quality of care for complex patients with cerebrovascular disease at costs that are comparable to usual post-stroke care.

Heart rate predicts mortality in patients with heart failure and preserved systolic function.

BACKGROUND: Elevated resting heart rates have been associated with increased mortality and morbidity in patients with heart failure and decreased left ventricular ejection fraction (EF). It is unclear, though, if this association applies to those with heart failure and preserved EF. METHODS AND RESULTS: We determined outcome for 685 consecutive patients with a prior diagnosis of heart failure and a preserved EF (>50%) documented on echocardiography at 1 of 3 laboratories. Patients with non-sinus rhythm were excluded from the analysis. We determined adjusted mortality rates at 1 year after the echocardiogram. The mean age of the cohort was 70 ± 11 years. Of the 685 included patients, 87% had a history of hypertension, 50% had diabetes, and the mean EF was 60% ± 6%. All-cause mortality at 1 year was significantly lower in the group with heart rate below 60 beats/min (10%) when compared with the group with heart rates between 60 and 70 beats/min (18%), 71-90 beats/min (20%), and >90 beats/min (35%) (P < .0001). After adjustment for patient history, demographics, laboratory values, and echocardiographic findings, the hazard ratios for total mortality (relative to a heart rate of <60) were 1.26 (95% CI, 0.88-1.80) for HR 60-69, 1.47 (95% CI, 1.02-2.07) for HR 70-90, and 2.00 (95% CI, 1.31-3.04) for HR>90 (P = .01 across all groups). CONCLUSIONS: These data suggest that an elevated resting heart rate is a marker for increased mortality in patients with heart failure and preserved systolic function. Heart rate may be useful in these patients for improved cardiovascular risk assessment.

Divergent trends in survival and readmission following a hospitalization for heart failure in the Veterans Affairs health care system 2002 to 2006.

OBJECTIVES: This study sought to determine recent trends over time in heart failure hospitalization, patient characteristics, treatment, rehospitalization, and mortality within the Veterans Affairs health care system. BACKGROUND: Use of recommended therapies for heart failure has increased in the U.S. However, it is unclear to what extent hospitalization rates and the associated mortality have improved. METHODS: We compared rates of hospitalization for heart failure, 30-day rehospitalization for heart failure, and 30-day mortality following discharge from 2002 to 2006 in the Veterans Affairs Health Care System. Odds ratios for outcome were adjusted for patient diagnoses within the past year, laboratory data, and for clustering of patients within hospitals. RESULTS: We identified 50,125 patients with a first hospitalization for heart failure from 2002 to 2006. Mean age did not change (70 years), but increases were noted for most comorbidities (mean Charlson score increased from 1.72 to 1.89, p < 0.0001). Heart failure admission rates remained constant at about 5 per 1,000 veterans. Mortality at 30 days decreased (7.1% to 5.0%, p < 0.0001), whereas rehospitalization for heart failure at 30 days increased (5.6% to 6.1%, p = 0.11). After adjustment for patient characteristics, the odds ratio for rehospitalization in 2006 (vs. 2002) was 0.54 (95% confidence interval [CI]: 0.47 to 0.61) for mortality, but 1.21 (95% CI: 1.04 to 1.41) for heart failure rehospitalization at 30 days. CONCLUSIONS: Recent mortality and rehospitalization rates in the Veterans Affairs Health Care System have trended in opposite directions. These results have implications for using rehospitalization as a measure of quality of care.

Association between stroke severity and fall risk among stroke patients.

BACKGROUND: Falls are common after stroke. Simple, clinically practical tools are needed to easily identify patients with stroke who are at risk of falls. The objective of this study was to identify the factors associated with increased fall risk in a poststroke population. METHODS: We assessed factors associated with fall risk among poststroke patients. Fall risk was determined through a history of falls, physical examination, observations of transfers, gait, balance, strength, range of motion, and use of assistive devices. Stroke severity was evaluated using the NIH Stroke Scale (NIHSS); mild or moderate-severe stroke was defined as a NIHSS score of <4 or > or = 4, respectively. RESULTS: Among 52 poststroke patients, 26 (50%) were considered at risk of falls. Patients at risk of falls compared with those without fall risk were more likely to have greater stroke severity, decreased functional status, and to be more dependent in activities of daily living. Increased stroke severity was independently associated with higher fall risk (NIHSS > or = 4: OR = 5.73; 95% CI: 1.645-19.94). CONCLUSION: Poststroke patients at risk of falls can be identified by an NIHSS score of > or = 4. Clinicians should screen patients for fall risk so that fall prevention strategies can be instituted.

Obesity and survival in patients with heart failure and preserved systolic function: a U-shaped relationship.

BACKGROUND: Studies document better survival in heart failure patients with decreased left ventricular ejection fraction (EF) and higher body mass index (BMI; kg/m(2)) compared to those with a lower BMI. However, it is unknown if this "obesity paradox" applies to heart failure patients with preserved EF or if it extends to the very obese (BMI >35). METHODS: We determined all-cause mortality for 1,236 consecutive patients with a prior diagnosis of heart failure and a preserved EF (> or =50%). RESULTS: Obesity (BMI>30) was noted in 542 patients (44%). The mean age was 71 +/- 12 years, but this varied depending on BMI. One-year all-cause mortality decreased with increasing BMI, except at BMI >45 where mortality began to increase (55% if BMI <20, 38% if BMI 20-25, 26% if BMI 26-30, 25% if BMI 31-35, 17% if BMI 36-40, 18% if BMI 41-45, and 25% if BMI>45, P < .001). After adjustment for patient age, history, medications, and laboratory and echocardiographic parameters, the hazard ratios for total mortality (relative to BMI 26-30) were 1.68 (95% CI, 1.04-2.69) for BMI <20, 1.25 (95% CI, 0.92-1.68) for BMI 20 to 25, 0.99 (95% CI, 0.71-1.36) for BMI 31-35, 0.58 (95% CI, 0.35-0.97) for BMI 36 to 40, 0.79 (95% CI, 0.44-1.4) for BMI 41 to 45, and 1.38 (95% CI 0.74-2.6) for BMI >45 (P < .0001). CONCLUSIONS: Low BMI is associated with increased mortality in patients with heart failure and preserved systolic function. However, with a BMI of >45, mortality increased, raising the possibility of a U-shaped relationship between BMI and survival.

Survival among patients with left ventricular systolic dysfunction treated with atenolol.

Metoprolol succinate, carvedilol, and bisoprolol are approved for use in heart failure. Other beta-blockers have been found to be inferior (metoprolol tartrate) or have not been studied (atenolol). The authors compared all-cause mortality following treatment with either atenolol, carvedilol, or metoprolol tartrate for 974 patients with left ventricular function < or =40%. The unadjusted mortality at 6 months was lower with atenolol (3.2%) and carvedilol (4.2%) when compared with metoprolol tartrate (7.5%, P< or =.039). However, patients with atenolol were older but had less prior heart failure. After adjustment for the propensity to be treated with atenolol, patients actually treated with atenolol had a significantly lower risk of death compared with treatment with metoprolol tartrate and comparable outcome to those treated with carvedilol. These results suggest that atenolol may be useful for patients with heart failure treatment and highlight the need for a randomized trial comparing atenolol with established beta-blockers.