Updates in heart failure 30-day readmission prevention.

Heart failure (HF) and HF 30-day readmission rates have been a major focus of efforts to reduce health care cost in the recent era. Since the implementation of the Affordable Care Act (ACA) in 2012 and the Hospital Readmission Reduction Program (HRRP), concerted efforts have focused on reduction of 30-day HF readmissions and other admission diagnoses targeted by the HRRP. Hospitals and organizations have instituted wide-ranging programs to reduce short-term readmissions, but the data supporting these programs is often mixed. In this review, we will discuss the challenges associated with reducing HF readmissions and summarize the rationale and effect of specific programs on HF 30-day readmission rates, ranging from medical therapy and adherence to remote hemodynamic monitoring. Finally, we will review the effect that the focus on reducing 30-day HF readmissions has had on the care of the HF patient.

Acoustic speech analysis of patients with decompensated heart failure: A pilot study.

This pilot study used acoustic speech analysis to monitor patients with heart failure (HF), which is characterized by increased intracardiac filling pressures and peripheral edema. HF-related edema in the vocal folds and lungs is hypothesized to affect phonation and speech respiration. Acoustic measures of vocal perturbation and speech breathing characteristics were computed from sustained vowels and speech passages recorded daily from ten patients with HF undergoing inpatient diuretic treatment. After treatment, patients displayed a higher proportion of automatically identified creaky voice, increased fundamental frequency, and decreased cepstral peak prominence variation, suggesting that speech biomarkers can be early indicators of HF.

Understanding the Burden of 30-Day Readmission in Patients With Both Primary and Secondary Diagnoses of Heart Failure: Causes, Timing, and Impact of Co-Morbidities.

Although efforts to reduce 30-day readmission rates have mainly focused on patients with heart failure (HF) as a primary diagnosis at index hospitalization, patients with HF as a secondary diagnosis remain common, costly, and understudied. This study aimed to determine the incidence, etiology, and patterns of 30-day readmissions after discharge for HF as a primary and secondary diagnosis and investigate the impact of co-morbidities on HF readmission. The National Readmission Database from 2014 to 2016 was used to identify HF patients with a linked 30-day readmission. Patient and hospital characteristics, admission features, and Elixhauser-related co-morbidities were compared between the 2 groups. Readmitted patients in both groups were younger, male, with lower household income, higher mortality risk, and higher hospitalization costs. Over 60% of readmissions were for reasons other than HF, and greater than 1/3 had more than 2 readmissions within 30 days, with a median time to readmission of 12 days. Both cohorts had high readmission rates and high rates of readmission for causes other than HF. Our findings suggest that efforts to reduce 30-day readmission rates should be extended to patients with secondary HF diagnosis, with surveillance extending to 2 weeks postdischarge to identify patients at risk.

Predictors of 30-Day Readmission in Patients Hospitalized With Heart Failure as a Primary Versus Secondary Diagnosis.

Short-term rehospitalizations are common, costly, and detrimental to patients with heart failure (HF). Current research and policy have focused primarily on 30-day readmissions for patients with HF as a primary diagnosis at index hospitalization, whereas a much larger population of patients are admitted with HF as a secondary diagnosis. This study aims to compare patients initially hospitalized for HF as either a primary or a secondary diagnosis, and to identify the most important factors in predicting 30-day readmission. Patients admitted with HF between 2014 and 2016 in the Nationwide Readmissions Database were included and divided into 2 cohorts: those admitted with a primary and secondary diagnosis of HF. Multivariable logistic regression was performed to predict 30-day readmission. Statistically significant predictors in multivariable logistic regression were used for dominance analysis to rank these factors by relative importance. Co-morbidities were the major driver of increased risk of 30-day readmission in both groups. Individual Elixhauser co-morbidities and the Elixhauser co-morbidity indexes were significantly associated with an increase in 30-day readmission. The 5 most important predictors of 30-day readmission according to dominance analysis were age, Elixhauser co-morbidity indexes of co-morbidity complications and readmission, number of diagnoses, and renal failure. These 5 factors accounted for 68% of the 30-day readmission risk. Measures of patient co-morbidities were among the strongest predictors of readmission risk. This study highlights the importance of expanding predictive models to include a broader set of clinical measures to create better-performing models of readmission risk for HF patients.

Clinical Overlap Between Myopericarditis and Stress Induced Cardiomyopathy: A Diagnostic and Therapeutic Challenge.

BACKGROUND Stress induced cardiomyopathy (SIC) is characterized by non-obstructive coronary arteries and characteristic ventricular apical ballooning. The exact pathogenesis of SIC is not well recognized. We present an unusual case of SIC that mimicked acute myopericarditis and discuss the effect of this masquerading presentation of SIC in recognizing pathophysiological association between myopericarditis and SIC and limitations of current diagnostic criteria. CASE REPORT A 47-year-old female presented with flu-like illness and pleuritic chest pain. An electrocardiogram (ECG) showed diffuse PR depressions and ST elevations, troponin 5 ng/mL, hemoglobin 14.2 mg/dL, leukocytosis (white blood cell count of 15.1×103/uL) and erythrocyte sedimentation rate (ESR) of 22.4 mm/hour. Echocardiogram showed reduced ejection fraction (EF) with apical ballooning. Catheterization showed non-obstructive coronary disease. The patient was given colchicine and ibuprofen for 1 day with symptom resolution over the next 2 days and repeat echocardiogram with preserved EF. Troponin trended down to 3.24 ng/mL and 0.44 ng/mL, 6 hours apart. ECG showed resolution of PR depressions and subsequent T wave inversions in 1, AVl, V1-V6 by day 3. The diagnosis of myopericarditis was favored by viral prodrome, fever, pleuritic pain, pericardial rub, ECG findings, and elevated ESR. History of emotional stress, characteristic ballooning of left ventricle apex with rapid resolution favored SIC. CONCLUSIONS This case showed that SIC and myocarditis need not be mutually exclusive and differentiating clinically between these 2 entities can be difficult. Alternatively, SIC can accompany other cardiac conditions like myocardial infarction, pericarditis, and myocarditis making diagnosis and management challenging. Clinicians need to be cautious while making this differentiation as duration and type of therapy may be significantly different. SIC can be considered a variant of regional inflammatory myocarditis wherein pericarditis may result secondary to extension of myocardial inflammation to overlying pericardium. The current Mayo Clinic criteria for diagnosis of SIC appears to be outdated, not accounting for such atypical presentations, and therefore needs to be revised.

Impaired right ventricular reserve predicts adverse cardiac outcomes in adults with congenital right heart disease.

OBJECTIVE: The prevalence of heart failure (HF) among adult patients with congenital heart disease (ACHD) is rising. Right ventricle (RV) exercise reserve and its relationship to outcomes have not been characterised. We aim to evaluate the prognostic impact of impaired RV reserve in an ACHD population referred for cardiopulmonary exercise testing (CPET). METHODS: This retrospective study evaluates patients with ACHD who underwent CPET (n=147) with first-pass radionuclide ventriculography at a single tertiary care centre. RV reserve was categorised as normal, mild to moderately or severely impaired. The primary composite clinical outcome included clinical right HF, arrhythmia, transplantation or death. RESULTS: Patients were median age 41±13 years, 50% were female and median follow-up was 1.1 (IQR: 0.7-2.0) years. Exercise RV reserve was impaired in 103 patients (70%), of whom 32% were asymptomatic. Resting RV systolic function poorly predicted RV reserve, with 52% of patients with severe impairment having a qualitatively normal echocardiographic assessment. The severely impaired reserve group had lower peak oxygen consumption (VO2)(17.2 vs 22.5 mL/kg/min, p<0.0001) compared with the normal reserve group, and was more likely to develop the composite outcome (48% vs 9%, log-rank p<0.001). Severely impaired RV reserve predicted event-free survival after adjusting for peak VO2, age, sex, RV pathology, QRS duration, New York Heart Association class, resting RV ejection fraction and RV dilation by echocardiography or MRI (HR 3.7, 95% CI 1.1 to 13.0, p=0.039). CONCLUSION: Impaired RV reserve, occurred in asymptomatic patients, was not well predicted by resting systolic function assessment, and strongly predicted adverse cardiovascular outcomes.

National Trends in Hospitalizations of Adults With Tetralogy of Fallot.

The population of adults with tetralogy of Fallot (TOF) is growing, and it is not known how the changes in age distribution, treatment strategies, and prevalence of co-morbidities impact their interaction with the health care system. We sought to analyze the frequency and reasons for hospital admissions over the past decade. We extracted serial cross-sectional data from the United States Nationwide Inpatient Sample on hospitalizations including the diagnostic code for TOF from 2000 to 2011. From 2000 to 2011, there were 20,545 admissions for subjects with TOF, with a steady increase in annual number. The most common primary admission diagnoses were heart failure (HF; 17%), arrhythmias (atrial 10% and ventricular 6%), pneumonia (9%), and device complications (7%). The rates of co-morbidities increased significantly, particularly diabetes (4.5% to 8.1%), obesity (2.1% to 6.5%), hypertension, and renal disease. The number of pulmonic valve replacements increased (6.8% to 11.3% of TOF admissions, p <0.001), with an increase in median age at surgery from 16 to 19 years old (p = 0.036). The cost per TOF admission was more than double that of noncongenital HF admissions and rose significantly, reaching $21,800 ± 46,000 in 2011. In conclusion, hospitalized patients with TOF have become significantly more medically complex and are growing in number. The increase in the prevalence of obesity, hypertension, and diabetes in this young population supports the need for prevention efforts focused on modifiable risk factors, in addition to HF and arrhythmia treatment. The increase in cost of care calls for further analysis of areas in which efficiency can be increased to ensure high quality of care and lifelong follow-up of patients with TOF.

National Trends in Hospitalizations for Patients With Single-Ventricle Anatomy.

Patients with single-ventricle (SV) anatomy now live to adulthood. Little is known about the cost of care and outcomes for patients with SV anatomy, especially those who develop heart failure (HF) cared for in adult hospitals in the United States. We analyzed the Nationwide Inpatient Sample from 2000 to 2011 for patients >14 years admitted to adult hospitals with the International Classifications of Diseases, Ninth Revision, codes for SV anatomy. Demographics, outcomes, co-morbidities, and cost were assessed. From 2000 to 2011, the number of SV admissions was stable with a trend toward increased cost per admission over time. Coexistent hypertension, obesity, and liver, pulmonary, and renal diseases significantly increased over time. The most common reason for admission was atrial arrhythmia followed by HF. Patients with SV with HF had significantly higher inhospital mortality, length of stay, and more medical co-morbidities than those with SV and without HF. In conclusion, the cohort of patients with SV admitted to adult hospitals has changed in the modern era. Patients with SV have medical co-morbidities including renal and liver diseases, hypertension, and obesity at a surprisingly young age. Aggressive and proactive management of HF and arrhythmia may reduce cost of care for this challenging population. Patients with SV with HF have particularly high mortality, more medical co-morbidities, and increased cost of care and deserve more focused attention to improve outcomes.

Assessing mitral regurgitation in the prediction of clinical outcome after cardiac resynchronization therapy.

BACKGROUND: Cardiac resynchronization therapy (CRT) has been shown to reduce mitral regurgitation (MR), although the clinical impact of this improvement remains uncertain. OBJECTIVES: We sought to evaluate the impact of MR improvement on clinical outcome after CRT and to assess predictors and mechanism for change in MR. METHODS: This was a cohort study of patients undergoing CRT for conventional indications with baseline and follow-up echocardiography (at 6 months). MR severity was classified into 4 grades. The primary end point was time to all-cause death or time to first heart failure (HF) hospitalization assessed at 3 years. RESULTS: A total of 439 patients were included: median age was 70.2 years, 90 (20.5%) were women, 255 (58.1%) with ischemic cardiomyopathy, and mean QRS width was 162 ms. Worsening severity of baseline MR was independently predictive of HF or all-cause mortality (hazard ratio 1.33; 95% confidence interval 1.01-1.75; P = .042). Reduction in MR after CRT was significantly associated with lower HF hospitalization and improved survival (hazard ratio 0.65; 95% confidence interval 0.49-0.85; P = .002). Degree of baseline MR and longer surface QRS to left ventricular lead time were significant predictors of MR change. Patients with MR reduction exhibited lower mitral valve tenting area (P < .001) and coaptation height (P < .001) than those with stable or worsening MR, suggestive of improved ventricular geometry as a mechanism for change in MR. CONCLUSION: Degree of baseline MR and change in MR after CRT predicted all-cause mortality and HF hospitalization at 3 years. Longer surface QRS to left ventricular lead time at implant may be a means to target MR improvement.