Ventilation-Perfusion Mismatch in a Patient With an Arteriovenous Fistula and Underlying Pulmonary Parenchymal Disease.

Many causes can result in hypoxia. We describe an interesting case of a patient with an arteriovenous fistula who had worsening hypoxia initially attributed to progression of chronic obstructive pulmonary disease and heart failure. However, after a meticulous workup, we found an interplay of complex yet common factors contributing to hypoxia.

Etiologies and predictors of readmission among obese and morbidly obese patients admitted with heart failure.

The relationship between severity of obesity and outcomes in heart failure (HF) has long been under debate. We studied index HF admissions from the 2013-14 National Readmission Database. Admissions were separated into three weight-based categories: non-obese (Non-Ob), obese (Ob), and morbidly obese (Morbid-Ob) to analyze hospital mortality and readmission at 30 days and 6 months. We investigated etiologies and predictors of 30-day readmission among these weight categories. We studied a total of 578,213 patients of whom 3.0% died during index hospitalization (Non-Ob 3.3% vs. Ob 1.9% vs. Morbid-Ob 1.9%; p < 0.01). Non-Ob comprised 79.5%, Ob 9.9%, and Morbid-Ob 10.6% of patients. Morbid-Ob patients were the youngest among age categories and more likely to be female. In-hospital mortality during readmission at 30 days and 6 months was significantly lower among Morbid-Ob and Ob compared with Non-Ob patients (all p < 0.01). Thirty-day readmission among Morbid-Ob was lower than Non-Ob and higher than Ob patients (19.6% vs. 20.5% vs. 18.6%, respectively; p < 0.01). Morbid-Ob patients were less likely to be readmitted for cardiovascular etiologies compared with both Ob and Non-Ob (45.0% vs. 50.3% vs. 50.6%; p < 0.01). Multivariable regression analysis revealed that Ob (adjusted odds ratio 0.84, 95% confidence intervals 0.82-0.86) and Morbid-Ob (aOR 0.83, 95% CI 0.81-0.85) were independently associated with lower 30-day readmission. Readmission at 6 months was highest among Morbid-Ob followed by Non-Ob and Ob (51.1% vs. 50.2% vs. 49.1%, p < 0.01). Morbid-Ob and Ob patients experience lower in-hospital mortality during index HF admission and during readmission with 30 days or 6 months compared with Non-Ob. Morbid-Ob patients experience greater readmission at 6 months despite the lower rate at 30 days post discharge. Morbid-Ob patients are most likely to be readmitted for non-cardiovascular causes.

Clinical correlates of hand-held ultrasound-guided assessments of the inferior vena cava in patients with acute decompensated heart failure.

BACKGROUND: Accurately assessing volume status in acutely decompensated heart failure (ADHF) can be challenging. Inferior vena cava (IVC) dynamics by echocardiography allow indirect assessment of volume status in these patients. Recently introduced hand-held ultrasound devices are promising. We aimed to describe the clinical correlates of volume status assessment using a hand-held ultrasound device in ADHF. METHODS: In this prospective study, we evaluated 106 patients admitted with ADHF. First scan was performed within 24 hours of admission and timed in reference to first dose of intravenous diuretic. Daily resting and inspiratory (sniff) IVC diameters were measured according to standard echocardiography methods during hospitalization including the day of discharge. IVC collapsibility index (IVC-CI = Maximum IVC diameter-Inspiratory IVC diameter/maximum diameter; <0.5 representing hypervolemia) was calculated. Primary study endpoint was 30-day readmission. Research activities were independent of clinical decision-making. RESULTS: Data for 106 patients was analyzed. Mean age was 66.7 ± 13.8 years, of which 53.8% were females, and a mean ejection fraction was 39 ± 18%. Initial scan of the IVC was obtained at an average time of 5.2 ± 8.04 hours from first diuretic dose. 81.2% of patients at admission had an IVC-CI <0.5. 63.2% patients had an IVC-CI <0.5 at discharge. There were no significant differences in age, length of stay, diuretic dose, or 30-day readmissions between patients with a discharge IVC-CI <0.5 vs ≥ 0.5. CONCLUSION: Hand-held ultrasound assessment of IVC-CI in ADHF patients, although a feasible concept, is unable to predict 30-day readmissions in our study. Further prospective studies are necessary.

Marital status and living condition as predictors of mortality and readmissions among African Americans with heart failure.

UNLABELLED: Socioeconomic factors, including social support, may partially explain why African Americans (AA) have the highest prevalence of heart failure and with worse outcomes compared to other races. AA are more likely to be hospitalized and readmitted for heart failure and have higher mortality. The purpose of this study is to determine whether the social factors of marital status and living condition affect readmission rates and all-cause mortality following hospitalization for acute decompensated heart failure (ADHF) in AA patients. METHODS: Medical records from 611 AA admitted to Einstein Medical Center Philadelphia from January, 2011 to February, 2013 for ADHF were reviewed. Patient demographics including living condition (nursing home residents, living with family or living alone) and marital status (married or non-married -including single, divorced, separated and widowed) were correlated with all-cause mortality and readmission rates. RESULTS: In this cohort (53% male, mean age 65±15, mean ejection fraction 32±16%) 25% (n=152) of subjects were unmarried. Unmarried patients had significantly higher 30-day readmission rates (16% vs. 6% p=0.0002) and higher 1-year mortality (17% vs. 11% p=0.047) compared with married patients. Fifty percent (n=303) of subjects were living with family members, while 40% (n=242) and 11% (n=66) were living alone or in a nursing facility, respectively. Patients living with family members had significantly lower 30-day readmission rates when compared with those living alone or in a nursing facility (7% vs 21% vs. 18% p=<0.0001). Furthermore, they had the lowest 1-year mortality (14% vs 32% for nursing facility patients and 17% for those living alone (p=0.0007). After controlling for traditional risk factors (age, gender, body mass index, peak troponin I, left ventricular ejection fraction, B-type natriuretic peptide, hypertension, diabetes mellitus, hyperlipidemia, and coronary artery disease), being married was an indpendent predictor of 1-year mortality (OR 0.50 p=0.019) and living alone for 30-day readmission (OR 2.86 p=<0.001). CONCLUSION: The socioeconomic factors of marital status and living condition significantly correlated with mortality and 30-day readmission rate in AA heart failure patients. Specifically, being married and living with family independently predict lower mortality and fewer readmissions. Surprisingly, living in a nursing facility was associated with significantly higher mortality than living alone or with family.