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1.
Am J Med ; 134(6): 797-804, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33359271

RESUMO

BACKGROUND: The effect of loop diuretics on clinical outcomes in heart failure has not been evaluated in randomized controlled trials. In hospitalized patients with heart failure, a discharge loop diuretic prescription has been shown to be associated with improved 30-day outcomes, which appears to be more pronounced in subgroups with congestion. In the current study, we examined these associations and association modifications during longer follow-up. METHODS: We assembled a propensity score-matched cohort of 2191 pairs of hospitalized heart failure patients discharged with, vs without, a prescription for loop diuretics, balanced on 74 baseline characteristics (mean age 78 years; 54% women; 11% African American). RESULTS: Hazard ratio (HR) and 95% confidence interval (CI) for 6-year combined endpoint of heart failure readmission or all-cause mortality was 1.02 (0.96-1.09). HRs and 95% CIs for this combined endpoint in patients with no, mild-to-moderate, and severe pulmonary rales were 1.19 (1.07-1.33), 0.95 (0.86-1.04), and 0.77 (0.63-0.94), respectively (P for interaction, < .001). Respective HRs (95% CIs) for no, mild-to-moderate, and severe lower extremity edema were 1.16 (1.06-1.28), 0.94 (0.85-1.04), and 0.71 (0.56-0.89; interaction P < .001). CONCLUSIONS: The association between a discharge loop diuretic prescription and long-term clinical outcomes in hospitalized patients with heart failure is modified by admission congestion with worse, neutral, and better outcomes in patients with no, mild-to-moderate, and severe congestion, respectively. If these findings can be replicated, congestion may be used to risk-stratify patients with heart failure for potential optimization of loop diuretic prescription and outcomes.


Assuntos
Insuficiência Cardíaca/tratamento farmacológico , Inibidores de Simportadores de Cloreto de Sódio e Potássio/efeitos adversos , Inibidores de Simportadores de Cloreto de Sódio e Potássio/farmacologia , Tempo , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/mortalidade , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Mortalidade/tendências , Avaliação de Resultados em Cuidados de Saúde/métodos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Pontuação de Propensão , Modelos de Riscos Proporcionais , Inibidores de Simportadores de Cloreto de Sódio e Potássio/uso terapêutico
2.
Am J Med ; 2020 Sep 30.
Artigo em Inglês | MEDLINE | ID: mdl-33010225

RESUMO

BACKGROUND: New hypertension and heart failure guidelines recommend that systolic blood pressure (SBP) in patients with heart failure with preserved ejection fraction (HFpEF) and hypertension be lowered to <130 mm Hg. METHODS: Of the 6778 hospitalized patients with HFpEF and a history of hypertension in the Medicare-linked OPTIMIZE-HF registry, 3111 had a discharge SBP <130 mm Hg. Using propensity scores for SBP <130 mm Hg, we assembled a matched cohort of 1979 pairs with SBP <130 versus ≥130 mm Hg, balanced on 66 baseline characteristics (mean age, 79 years; 69% women; 12% African American). We then assembled a second matched cohort of 1326 pairs with SBP <120 versus ≥130 mm Hg. Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with SBP <130 and <120 mm Hg were separately estimated in the matched cohorts using SBP ≥130 mm Hg as the reference. RESULTS: HRs (95% CIs) for 30-day, 12-month, and 6-year all-cause mortality associated with SBP <130 mm Hg were 1.20 (0.91-1.59; P = 0.200), 1.11 (0.99-1.26; P = 0.080), and 1.05 (0.98-1.14; P = 0.186), respectively. Respective HRs (95% CIs) associated with SBP <120 mm Hg were 1.68 (1.21-2.34; P = 0.002), 1.28 (1.11-1.48; P = 0.001), and 1.11 (1.02-1.22; P = 0.022). There was no association with readmission. CONCLUSIONS: Among older patients with HFpEF and hypertension, compared with SBP ≥130 mm Hg, the new target SBP <130 mm Hg had no association with outcomes but SBP <120 mm Hg was associated with a higher risk of death but not of readmission. Future prospective studies need to evaluate optimal SBP treatment goals in these patients.

3.
J Am Coll Cardiol ; 76(6): 669-679, 2020 Aug 11.
Artigo em Inglês | MEDLINE | ID: mdl-32762901

RESUMO

BACKGROUND: Heart failure (HF) is a major source of morbidity and mortality. Fluid retention and shortness of breath are its cardinal manifestations for which loop diuretics are used. Although their usefulness is well accepted, less is known about their role in improving clinical outcomes. OBJECTIVES: The purpose of this study was to determine the relationship between loop diuretics and clinical outcomes in patients with HF. METHODS: Of the 25,345 older patients hospitalized for HF in the Medicare-linked OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry, 9,866 (39%) received no pre-admission diuretics. The study excluded 1,083 patients receiving dialysis and 847 discharged on thiazide diuretics. Of the remaining 7,936 patients, 5,568 (70%) were prescribed loop diuretics at discharge. Using propensity scores for receipt of loop diuretics estimated for each of the 7,936 patients, a matched cohort of 2,191 pairs of patients was assembled balanced on 74 baseline characteristics. Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes were estimated in the matched cohort. RESULTS: Matched patients (n = 4,382) had a mean age of 78 years, 54% were women, and 11% were African American. The 30-day all-cause mortality occurred in 4.9% (107 of 2,191) and 6.6% (144 of 2,191) of patients in the loop diuretic and no loop diuretic groups, respectively (HR when the use of loop diuretics was compared with nonuse: 0.73; 95% CI: 0.57 to 0.94; p = 0.016). Patients in the loop diuretic group had a significantly lower risk of 30-day HF readmission (HR: 0.79; 95% CI: 0.63 to 0.99; p = 0.037) but not of 30-day all-cause readmission (HR: 0.89; 95% CI: 0.79 to 1.01; p = 0.081). None of the associations was statistically significant during 60 days of follow-up. CONCLUSIONS: Hospitalized older patients not taking diuretics prior to hospitalization for HF decompensation who received a discharge prescription for loop diuretics had significantly better 30-day clinical outcomes than those not discharged on loop diuretics. These findings provide new information about short-term clinical benefits associated with loop diuretic use in HF.

4.
Am J Med ; 133(12): 1460-1470, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32603789

RESUMO

BACKGROUND: Digoxin reduces the risk of heart failure hospitalization but has no effect on mortality in patients with heart failure without atrial fibrillation in the randomized controlled trial setting. Observational studies of digoxin use in patients with atrial fibrillation have suggested a higher risk for poor outcomes. Less is known about this association in patients with heart failure and atrial fibrillation, the examination of which was the objective of the current study. METHODS: We conducted an observational propensity score-matched study of predischarge digoxin initiation in 1768 hospitalized patients with heart failure and atrial fibrillation in the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry, balanced on 56 baseline characteristics (mean age, 79 years; 55% women; 7% African American). Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes were estimated for the 884 patients initiated on digoxin compared with 884 not initiated on digoxin. RESULTS: HRs (95% CIs) for 30-day, 2-year, and 4-year all-cause mortality were 0.80 (0.55-1.18; P = .261), 0.94 (0.87-1.16; P = .936), and 1.01 (0.90-1.14; P = .729), respectively. Respective HRs (95% CIs) for heart failure readmission were 0.67 (0.49-0.92; P = .014), 0.81 (0.69-0.94; P = .005), and 0.85 (0.74-0.97; P = .022), and those for all-cause readmission were 0.78 (0.64-0.96; P = .016), 0.90 (0.81-1.00; P = .057), and 0.91 (0.83-1.01; P = .603). These associations were homogeneous between patients with left ventricular ejection fraction ≤45% vs >45%. CONCLUSIONS: Among hospitalized older patients with heart failure (HFrEF and HFpEF) and atrial fibrillation, initiation of digoxin was associated with a lower risk of heart failure readmission but had no association with mortality.

5.
ESC Heart Fail ; 7(3): 794-803, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32319205

RESUMO

AIMS: Hypokalaemia is a risk factor for ventricular arrhythmias and sudden death in ambulatory patients with chronic heart failure (HF). The objective of this study was to examine the association between hypokalaemia and outcomes in hospitalized patients with decompensated HF in whom sudden death is less common. METHODS AND RESULTS: Of the 5881 hospitalized patients with HF, 1052 had consistent hypokalaemia (both admission and discharge serum potassium <4.0 mmol/L), and 2538 had consistent normokalaemia (both admission and discharge serum potassium 4.0-5.0 mmol/L). Propensity scores for consistent hypokalaemia, estimated for each of 3590 (1052 + 2538) patients, were used to assemble a matched cohort of 971 pairs of patients with consistent hypokalaemia vs. consistent normokalaemia, balanced on 54 baseline characteristics (mean age, 75 years; 60% women; 28% African American). We repeated the above process to assemble 2327 pairs of patients with discharge potassium <4.0 vs. 4.0-5.0 mmol/L and 449 pairs of patients with discharge serum potassium <3.5 vs. 4.0-5.0 mmol/L. Hazard ratios (HR) and 95% confidence intervals (CIs) associated with hypokalaemia were estimated in matched cohorts. 30 day all-cause mortality occurred in 5% and 4% of patients with consistent normokalaemia vs. consistent hypokalaemia, respectively (HR, 0.78; 95% CI, 0.52-1.18; P = 0.241). HRs (95% CI) for 30 day mortality associated with discharge serum potassium <4.0 and <3.5 mmol/L were 0.90 (0.70-1.16; P = 0.419) and 1.69 (0.94-3.04; P = 0.078), respectively. Hypokalaemia (<4.0 or <3.5 mmol/L) had no association with long-term mortality or other outcomes. CONCLUSIONS: In hospitalized older patients with HF, compared with normokalaemia (serum potassium 4.0-5.0 mmol/L), hypokalaemia (<4.0 or <3.5 mmol/L) had no significant associations with outcomes.

6.
Am J Med ; 133(10): 1187-1194, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32272101

RESUMO

BACKGROUND: Digoxin reduces the risk of heart failure hospitalization in patients with heart failure with reduced ejection fraction. Less is known about this association in patients with heart failure with preserved ejection fraction (HFpEF), the examination of which was the objective of the current study. METHODS: In the Medicare-linked OPTIMIZE-HF registry, 7374 patients hospitalized for HF had ejection fraction ≥50% and were not receiving digoxin prior to admission. Of these, 5675 had a heart rate ≥50 beats per minute, an estimated glomerular filtration rate ≥30 mL/min/1.73 m2 or did not receive inpatient dialysis, and digoxin was initiated in 524 of these patients. Using propensity scores for digoxin initiation, calculated for each of the 5675 patients, we assembled a matched cohort of 513 pairs of patients initiated and not initiated on digoxin, balanced on 58 baseline characteristics (mean age, 80 years; 66% women; 8% African American). Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with digoxin initiation were estimated in the matched cohort. RESULTS: Among the 1026 matched patients with HFpEF, 30-day heart failure readmission occurred in 6% and 9% of patients initiated and not initiated on digoxin, respectively (HR 0.70; 95% CI, 0.45-1.10; P = .124). HRs (95% CIs) for 30-day all-cause readmission and all-cause mortality associated with digoxin initiation were 0.95 (0.73-1.23; P = .689) and 0.93 (0.55-1.56; P = .773), respectively. Digoxin initiation had no association with 6-year outcomes. CONCLUSION: Digoxin initiation prior to hospital discharge was not associated with 30-day or 6-year outcomes in older hospitalized patients with HFpEF.


Assuntos
Cardiotônicos/uso terapêutico , Digoxina/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Mortalidade , Readmissão do Paciente/estatística & dados numéricos , Volume Sistólico , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Antiarrítmicos/uso terapêutico , Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/epidemiologia , Causas de Morte , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/fisiopatologia , Hospitalização , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Masculino , Antagonistas de Receptores de Mineralocorticoides/uso terapêutico , Inibidores da Agregação Plaquetária/uso terapêutico , Pontuação de Propensão , Modelos de Riscos Proporcionais , Sistema de Registros , Inibidores de Simportadores de Cloreto de Sódio e Potássio/uso terapêutico , Varfarina/uso terapêutico
7.
Am J Ther ; 27(3): e235-e242, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-30299270

RESUMO

BACKGROUND: Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs-ARBs) improve outcomes in heart failure (HF). Less is known about this association in nursing home (NH) residents. METHODS: Of the 8024 hospitalized HF patients, 542 were NH residents, of whom 250 received ACEIs-ARBs. We assembled a propensity score-matched cohort of 157 pairs of NH residents receiving and not receiving ACEIs-ARBs balanced on 29 baseline characteristics (mean age, 83 years, 74% women, 17% African American), in which we estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with ACEI-ARB use. We then checked for interaction in a matched cohort of 5130 patients (378 were NH residents) assembled from the 8024 patients. RESULTS: Among 314 matched NH residents, HRs (95% CIs) for 30-day all-cause readmission, HF readmission, and all-cause mortality were 0.78 (0.47-1.28), 0.68 (0.29-1.60), and 1.26 (0.70-2.27), respectively. Respective HRs (95% CIs) at 1 year were 0.76 (0.56-1.02), 0.68 (0.42-1.09), and 1.04 (0.78-1.38). Among 5130 matched patients, ACEI-ARB use was associated with a significantly lower risk of all outcomes at both times, with no significant interactions, except for 1-year mortality, which was only significant in the non-NH subgroup (P for interaction, 0.026). CONCLUSIONS: We found no evidence that the use of ACEIs or ARBs is associated with improved outcomes in patients with HF in the NH setting. However, we also found no evidence that this association is different in NH residents with HF versus non-NH patients with HF. Future larger studies are needed to demonstrate effectiveness of these drugs in the NH setting.

8.
Am J Ther ; 27(4): e356-e365, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31145140

RESUMO

BACKGROUND: The use of opioids is associated with poor outcomes. Less is known about this association in patients with heart failure (HF) and whether it varies by the receipt of hospice care. METHODS: Of the 7467 patients hospitalized for HF without previous opioid use, 124 received discharge opioids. We matched 123 of these patients with 123 not receiving opioids based on their propensity scores for opioid use, thus assembling a matched cohort of 246 patients balanced on 30 baseline characteristics (mean age, 76 years, 60% women, and 11% African American). We repeated the process in hospice (n = 155; 20 received opioids) and nonhospice (n = 7298; 104 received opioids) subgroups, thus assembling 2 matched cohorts of 22 and 208 patients, respectively. Hazard ratios (HRs) and 95% confidence intervals (CIs) associated with opioid use were estimated from matched cohorts. RESULTS: During 8.6 (median, 1.4) years of follow-up, all-cause mortality occurred in 80% and 68% of matched patients in the opioid and nonopioid groups, respectively (HR, 1.49; 95% CI, 1.11-1.99; P = 0.008). There was evidence of heterogeneity in this association between hospice and nonhospice patients (P for interaction, 0.027). Among matched hospice and nonhospice patients, HRs (95% CIs) for mortality were 6.37 (2.06-19.69; P = 0.001) and 1.42 (1.03-1.96; P = 0.035), respectively. HRs (95% CIs) for 30-day and 1-year mortality were 1.98 (1.06-3.70; P = 0.033) and 1.72 (1.18-2.49; P = 0.004), respectively. HRs (95% CIs) for all-cause, HF, and non-HF readmissions were 1.31 (0.97-1.76; P = 0.079), 1.03 (0.71-1.49; P = 0.866), and 1.75 (1.05-2.91; P = 0.031), respectively. Readmission associations were similar among matched nonhospice patients. There was no readmission among matched hospice patients receiving opioids. CONCLUSIONS: In older patients with HF, opioid use is associated with a higher risk of mortality, which is greater in the hospice subgroup, and a higher risk of non-HF readmission in the nonhospice subgroup.

9.
Am J Med ; 133(2): e25-e31, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31401165

RESUMO

BACKGROUND: In the Studies of Left Ventricular Dysfunction (SOLVD) treatment trial, similar clinical benefits were observed between starting doses of enalapril and the target dose achieved by postrandomization up-titration. In our current analysis, protecting the randomization, we examined the early effects of starting doses of enalapril. METHODS: There were 2569 patients with mild-to-moderate chronic heart failure with reduced ejection fraction (ejection fraction ≤35%) randomized to receive starting doses (5-10 mg/day) of placebo (n = 1284) or enalapril (n = 1285). At day 14, both study drugs were blindly up-titrated to the target dose (20 mg/day). Overall, 96% (2458/2569) of the patients returned for dose up-titration, which was achieved in 59% (1444/2458), 48% (696/1444) of whom were in the enalapril group. Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes in the enalapril group were estimated. RESULTS: HRs (95% CIs) for all-cause mortality, heart failure hospitalization, and the combined endpoint of heart failure hospitalization or all-cause mortality at 14 days after randomization were 0.80 (0.32-2.03), 0.63 (0.35-1.12), and 0.65 (0.39-1.06), respectively. Corresponding HRs (95% CIs) at 30 days were 0.82 (0.41-1.67), 0.43 (0.27-0.68), and 0.43 (0.27-0.68), respectively. The magnitude of these early effects of starting doses of enalapril is similar to its previously reported long-term effects at the target dose. CONCLUSION: These data suggest that in stable ambulatory patients with heart failure with reduced ejection fraction, the magnitude of the early effect of starting doses of enalapril is similar to that observed during longer-term therapy with the target doses of the drug.


Assuntos
Enalapril/administração & dosagem , Enalapril/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Idoso , Doença Crônica/tratamento farmacológico , Relação Dose-Resposta a Droga , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
10.
Am J Med ; 133(1): 84-94, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31336093

RESUMO

BACKGROUND: A prior hospitalization resulting from heart failure is associated with poor outcomes in ambulatory patients with heart failure. Less is known about this association in hospitalized patients with heart failure and whether it varies by ejection fraction. METHODS: Of the 25,345 hospitalized patients in the Medicare-linked OPTIMIZE-HF registry, 22,491 had known heart failure, of whom 7648 and 9558 had heart failure with preserved (≥50%) and reduced (≤40%) ejection fraction (HFpEF and HFrEF), respectively. Overall, 927 and 1862 patients with HFpEF and HFrEF had hospitalizations for heart failure during the 6 months before the index hospitalization, respectively. Using propensity scores for prior heart failure hospitalization, we assembled two matched cohorts of 924 pairs and 1844 pairs of patients with HFpEF and HFrEF, respectively, each balanced for 58 baseline characteristics. Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes during 6 years of follow-up. RESULTS: Among 1848 matched patients with HFpEF, HRs (95% CIs) for all-cause mortality, all-cause readmission, and heart failure readmission were 1.35 (1.21-1.50; P <0.001), 1.34 (1.21-1.47; P <0.001), and 1.90 (1.67-2.16; P <0.001), respectively. Respective HRs (95% CIs) in 3688 matched patients with HFrEF were 1.17 (1.09-1.26; P <0.001), 1.32 (1.23-1.41; P <0.001), and 1.48 (1.37-1.61; P <0.001). CONCLUSIONS: Among hospitalized patients with heart failure, a previous hospitalization for heart failure is associated with higher risks of mortality and readmission in both HFpEF and HFrEF. The relative risks of death and heart failure readmission appear to be higher in HFpEF than in HFrEF.


Assuntos
Insuficiência Cardíaca/terapia , Hospitalização/estatística & dados numéricos , Mortalidade , Readmissão do Paciente/estatística & dados numéricos , Volume Sistólico , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Causas de Morte , Feminino , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Pontuação de Propensão , Modelos de Riscos Proporcionais , Sistema de Registros
11.
J Am Coll Cardiol ; 74(5): 617-627, 2019 08 06.
Artigo em Inglês | MEDLINE | ID: mdl-31370952

RESUMO

BACKGROUND: The deleterious effects of discontinuation of digoxin on outcomes in ambulatory patients with chronic heart failure (HF) with reduced ejection fraction (HFrEF) receiving angiotensin-converting enzyme inhibitors are well-documented. OBJECTIVES: The authors sought to determine the relationship between digoxin discontinuation and outcomes in hospitalized patients with HFrEF receiving more contemporary guideline-directed medical therapies including beta-blockers and mineralocorticoid receptor antagonists. METHODS: Of the 11,900 hospitalized patients with HFrEF (EF ≤45%) in the Medicare-linked OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry, 3,499 received pre-admission digoxin, which was discontinued in 721 patients. Using propensity scores for digoxin discontinuation, estimated for each of the 3,499 patients, a matched cohort of 698 pairs of patients, balanced on 50 baseline characteristics (mean age 76 years; mean EF 28%; 41% women; 13% African American; 65% on beta-blockers) was assembled. RESULTS: Four-year post-discharge, digoxin discontinuation was associated with significantly higher risks of HF readmission (hazard ratio [HR]: 1.21; 95% confidence interval [CI]: 1.05 to 1.39; p = 0.007), all-cause readmission (HR: 1.16; 95% CI: 1.04 to 1.31; p = 0.010), and the combined endpoint of HF readmission or all-cause mortality (HR: 1.20; 95% CI: 1.07 to 1.34; p = 0.002), but not all-cause mortality (HR: 1.09; 95% CI: 0.97 to 1.24; p = 0.163). Discontinuation of digoxin was associated with a significantly higher risk of all 4 outcomes at 6 months and 1 year post-discharge. At 30 days, digoxin discontinuation was associated with higher risks of all-cause mortality (HR: 1.80; 95% CI: 1.26 to 2.57; p = 0.001) and the combined endpoint (HR: 1.36; 95% CI: 1.09 to 1.71; p = 0.007), but not of HF readmission (HR: 1.19; 95% CI: 0.90 to 1.59; p = 0.226) or all-cause readmission (HR: 1.03; 95% CI: 0.84 to 1.26; p = 0.778). CONCLUSIONS: Among hospitalized older patients with HFrEF on more contemporary guideline-directed medical therapies, discontinuation of pre-admission digoxin therapy was associated with poor outcomes.


Assuntos
Digoxina/administração & dosagem , Insuficiência Cardíaca/tratamento farmacológico , Sistema de Registros , Volume Sistólico/fisiologia , Idoso , Cardiotônicos/administração & dosagem , Causas de Morte , Feminino , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pacientes Ambulatoriais , Readmissão do Paciente/tendências , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Resultado do Tratamento , Estados Unidos/epidemiologia , Suspensão de Tratamento
12.
Am J Med ; 132(11): 1311-1319, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31150644

RESUMO

BACKGROUND: Heart failure is a leading cause for hospital readmission. Digoxin use may lower this risk in patients with heart failure with reduced ejection fraction (HFrEF), but data on contemporary patients receiving other evidence-based therapies are lacking. METHODS: Of the 11,900 patients with HFrEF (ejection fraction ≤45%) in Medicare-linked OPTIMIZE-HF, 8401 were not on digoxin, of whom 1571 received discharge prescriptions for digoxin. We matched 1531 of these patients with 1531 not receiving digoxin by propensity scores for digoxin use. The matched cohort (n = 3062; mean age, 76 years; 44% women; 14% African American) was balanced on 52 baseline characteristics. We assembled a second matched cohort of 2850 patients after excluding those with estimated glomerular filtration rate <15 mL/min/1.73 m2 and heart rate <60 beats/min. Hazard ratios (HRs) and 95% confidence intervals (CIs) for digoxin-associated outcomes were estimated in the matched cohorts. RESULTS: Among the 3062 matched patients, digoxin use was associated with a significantly lower risk of heart failure readmission at 30 days (HR, 0.74; 95% CI, 0.59-0.93), 1 year (HR, 0.81; 95% CI, 0.72-0.92), and 6 years (HR, 0.90; 95% CI 0.81-0.99). The association with all-cause readmission was significant at 1 and 6 years but not 30 days. There was no association with mortality. Similar associations were observed among the 2850 matched patients without bradycardia or renal insufficiency. CONCLUSIONS: Among hospitalized older patients with HFrEF receiving contemporary treatments for heart failure, digoxin use is associated with a lower risk of hospital readmission but not all-cause mortality.


Assuntos
Cardiotônicos/uso terapêutico , Digoxina/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Hospitalização , Idoso , Causas de Morte , Feminino , Insuficiência Cardíaca/mortalidade , Humanos , Masculino , Medicare , Readmissão do Paciente/estatística & dados numéricos , Pontuação de Propensão , Volume Sistólico , Estados Unidos
13.
J Am Coll Cardiol ; 73(24): 3054-3063, 2019 06 25.
Artigo em Inglês | MEDLINE | ID: mdl-31221253

RESUMO

BACKGROUND: National guidelines recommend that systolic blood pressure (SBP) in patients with heart failure with reduced ejection fraction (HFrEF) and hypertension be maintained below 130 mm Hg. OBJECTIVES: This study sought to determine associations of SBP <130 mm Hg with outcomes in patients with HFrEF. METHODS: Of the 25,345 patients in the Medicare-linked OPTIMIZE-HF registry, 10,535 had an ejection fraction (EF) ≤40%. Of these, 5,615 had stable SBP (≤20 mm Hg admission to discharge variation), and 3,805 (68%) had a discharge SBP <130 mm Hg. Propensity scores for SBP <130 mm Hg, estimated for each of the 5,615 patients, were used to assemble a matched cohort of 1,189 pairs of patients with SBP <130 versus ≥130 mm Hg, balanced on 58 baseline characteristics (mean age 76 years; mean EF 28%, 45% women, 13% African American). This process was repeated in 3,946 patients, after excluding 1,669 patients (30% of 5,615) with a discharge SBP <110 mm Hg and assembled a second matched balanced cohort of 1,099 pairs of patients with SBP 110 to 129 mm Hg versus ≥130 mm Hg. RESULTS: Thirty-day all-cause mortality occurred in 7% and 4% of matched patients with SBP <130 mm Hg versus ≥130 mm Hg, respectively (hazard ratio [HR]: 1.76; 95% confidence interval [CI]: 1.24 to 2.48; p = 0.001). HRs (95% CIs) for all-cause mortality, all-cause readmission, and HF readmission at 1 year, associated with SBP <130 mm Hg, were 1.32 (1.15 to 1.53; p < 0.001), 1.11 (1.01 to 1.23; p = 0.030), and 1.24 (1.09 to 1.42; p = 0.001), respectively. HRs (95% CIs) for 30-day and 1-year all-cause mortality associated with SBP 110 to 129 mm Hg (vs. ≥130 mm Hg) were 1.50 (1.03 to 2.19; p = 0.035), and 1.19 (1.02 to 1.39; p = 0.029), respectively. CONCLUSIONS: Among hospitalized older patients with HFrEF, SBP <130 mm Hg is associated with poor outcomes. This association persisted when the analyses were repeated after excluding patients with SBP <110 mm Hg. There is an urgent need for randomized controlled trials to evaluate optimal SBP reduction goals in patients with HFrEF.


Assuntos
Pressão Sanguínea , Insuficiência Cardíaca , Volume Sistólico , Disfunção Ventricular Esquerda , Idoso , Determinação da Pressão Arterial/estatística & dados numéricos , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Medicare/estatística & dados numéricos , Mortalidade , Sistema de Registros , Fatores de Risco , Estados Unidos/epidemiologia , Disfunção Ventricular Esquerda/epidemiologia , Disfunção Ventricular Esquerda/fisiopatologia
14.
Am J Cardiol ; 123(11): 1840-1844, 2019 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-30928031

RESUMO

Heart failure (HF) is the leading cause for 30-day all-cause readmission in older Medicare beneficiaries and 30-day all-cause readmission is associated with a higher risk of mortality. In the current analysis, we examined if that association varied by timing of 30-day all-cause readmission. Of the 8,049 Medicare beneficiaries hospitalized for HF, 1,688 had 30-day all-cause readmissions, of whom 1,519 were alive at 30 days. Of these, 626 (41%) had early (first 10 days) 30-day readmission. Propensity scores for early 30-day readmission, estimated for all 1,519 patients, were used to assemble a matched cohort of 596 pairs of patients with early versus late (11 to 30 days) all-cause readmission balanced on 34 baseline characteristics. Two-year all-cause mortality occurred in 51% and 57% of matched patients with early versus late 30-day all-cause readmissions, respectively (hazard ratio [HR] associated with late 30-day readmission, 1.22; 95% confidence interval [CI], 1.04 to 1.42; p = 0.014). This association was not observed in the subset of 436 patients whose 30-day all-cause readmission was due to HF (HR, 1.01; 95% CI, 0.79 to 1.28; p = 0.963), but was observed in the subset of 756 patients whose 30-day all-cause readmission was not due to HF (HR, 1.37; 95% CI, 1.12 to 1.67; p = 0.002; p for interaction, 0.057). In conclusion, in a high-risk subset of older hospitalized HF patients readmitted within 30 days, readmission during 11 to 30 (vs 1 to 10) days was associated with a higher risk of death and this association appeared to be more pronounced in those readmitted for non-HF-related reasons.


Assuntos
Insuficiência Cardíaca/mortalidade , Readmissão do Paciente/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Insuficiência Cardíaca/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
15.
Gerontol Geriatr Educ ; : 1-14, 2019 Mar 06.
Artigo em Inglês | MEDLINE | ID: mdl-30839246

RESUMO

As the older adult population increases, the need to enhance medical education and training in Geriatric Medicine (GM) is essential. To enhance resident training, faculty at two southeastern universities developed a Resident Award Summit, a two-day active learning experience, designed to expose family and internal medicine residents to GM principles and the various career options available in GM. Over 10 years, 353 residents from 108 residency programs participated. Resident feedback indicated that attending the event had a positive impact on future practice (M = 4.65, SD = .58) and showed that the amount of GM training received was limited, with 83.5% and 70.2% ranking adequacy of medical student and resident training as limited, respectively. To impact practice, long-term change must occur. Experiences such as the Resident Award Summit allow GM faculty to educate and prepare residents though positive teaching experiences, providing residents with the skills needed to care for older adults in their communities.

16.
J Natl Med Assoc ; 111(3): 320-327, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30527966

RESUMO

OBJECTIVE: Examining cultural differences in assessment of cognitive/functional disability among older Americans is needed. This analysis examined associations between day-to-day function, measured by activities of daily living (ADL), and cognition, measured by CLOX scores, among older African American (AA) and non-Hispanic White (nHW) community-dwelling women and men. METHODS: Design- Cross-sectional. SETTING: Homes of community-dwelling older adults. Participants- 893 Medicare beneficiaries >65 living in west-central Alabama, without diagnoses of dementia, who were participants in the University of Alabama at Birmingham (UAB) Study of Aging, and who had complete data. Measurements- Physical function was assessed by self-reported ADL difficulty; cognitive function by CLOX, a clock drawing-task. Multivariable, linear regression models were used to examine associations within race/sex specific groups. RESULTS: After controlling for socio-demographic factors and comorbidities, CLOX1 scores were inversely and significantly correlated with ADL for AA men (ß = -0.205, P = 0.003). CLOX2 scores were similarly associated with ADL and IADL for the total group (ß = -0.118, P = 0.001, and ß = -0.180, P < 0.001, respectively); for ADL, significant associations were seen for AA men and nHW women (ß = -0.203, P = 0.004, and ß = -0.139, P = 0.02, respectively) and, for IADL, in AA women and men (ß = -0.156, P = 0.03, and ß = -0.24, P < 0.001, respectively). CONCLUSION: While African American women reported the highest difficulty with ADLs and IADLs among all race/sex groups, CLOX1 scores were correlated with ADL for AA men only. CLOX1 may have limitations to identify functional disability for older AA women. [Word Count = 234].


Assuntos
Atividades Cotidianas , Afro-Americanos/estatística & dados numéricos , Disfunção Cognitiva/epidemiologia , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Função Executiva , Atividades Cotidianas/psicologia , Afro-Americanos/psicologia , Idoso , Idoso de 80 Anos ou mais , Disfunção Cognitiva/etnologia , Estudos Transversais , Grupo com Ancestrais do Continente Europeu/psicologia , Feminino , Disparidades nos Níveis de Saúde , Humanos , Vida Independente/estatística & dados numéricos , Masculino , Testes Neuropsicológicos , Prevalência , Fatores Sexuais , Sudeste dos Estados Unidos/epidemiologia
17.
J Am Geriatr Soc ; 67(3): 565-569, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30536982

RESUMO

BACKGROUND/OBJECTIVES: The University of Alabama at Birmingham (UAB) Life-Space Assessment (LSA) is a widely used measure of community mobility. To assist clinicians and researchers with assessing the significance of changes in scores, we determined the minimal important change associated with a change in health status. SETTING: Homes of community-dwelling older adults. PARTICIPANTS: A total of 419 African American and non-Hispanic white adults 75 years and older participating in the UAB Study of Aging II, a longitudinal epidemiological study across the state of Alabama. INTERVENTION: None. MEASUREMENTS: Linear mixed models were used to compare change in LSA scores over 1-month intervals (N = 9712) between participants reporting improvement, no change, or decline in activities of daily living walking scores, accounting for the correlation among scores for the same participant over time. RESULTS: A decline in walking status was associated with a mean decrease in LSA scores of 2.93 points (95% confidence interval [CI] = 1.69-4.17 points), indicating lower mobility. An improvement in walking status was associated with a mean increase in LSA scores of 2.51 points (95% CI = 1.26-3.77 points), indicating higher mobility. CONCLUSION: A change in LSA scores of five or more is clinically important, exceeding the 95% CI for the change in LSA associated with change in walking status. Changes exceeding this threshold should prompt further investigation by providers with a goal of preserving mobility. J Am Geriatr Soc 67:565-569, 2019.


Assuntos
Atividades Cotidianas , Participação da Comunidade , Avaliação Geriátrica , Vida Independente , Relações Interpessoais , Desempenho Físico Funcional , Idoso , Idoso de 80 Anos ou mais , Alabama , Ambiente Construído , Feminino , Avaliação Geriátrica/métodos , Avaliação Geriátrica/estatística & dados numéricos , Disparidades nos Níveis de Saúde , Humanos , Vida Independente/psicologia , Vida Independente/normas , Vida Independente/estatística & dados numéricos , Estudos Longitudinais , Masculino , Limitação da Mobilidade , Avaliação de Resultados em Cuidados de Saúde , Projetos de Pesquisa , Velocidade de Caminhada
18.
Transplantation ; 103(7): 1425-1432, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30418427

RESUMO

BACKGROUND: Despite the increasing prevalence of end-stage liver disease in older adults, there is no consensus to determine suitability for liver transplantation (LT) in the elderly. Disparities in LT access exist, with a disproportionately lower percentage of African Americans (AAs) receiving LT. Understanding waitlist outcomes in older adults, specifically AAs, will identify opportunities to improve LT access for this vulnerable population. METHODS: All adult, liver-only white and AA LT waitlist candidates (January 1, 2003 to October 1, 2015) were identified in the Scientific Registry of Transplant Recipients. Age and race categories were defined: younger white (age <60 years), younger AA, older white (age, ≥60 years), and older AA. Outcomes were delisting, transplantation, and mortality and were modeled using Fine and Gray competing risks. RESULTS: Among 101 805 candidates, 58.4% underwent transplantation, 14.7% died while listed, and 21.4% were delisted. Among those delisted, 36.1% died, whereas 7.4% were subsequently relisted. Both older AAs and older whites were more likely than younger whites to be delisted and to die after delisting. Older whites had higher incidence of waitlist mortality than younger whites (subdistribution hazard ratio, 1.07; 95% confidence interval, 1.01-1.13). All AAs and older whites had decreased incidence of LT, compared with younger whites. CONCLUSIONS: Both older age and AA race were associated with decreased cumulative incidence of transplantation. Independent of race, older candidates had increased incidences of delisting and mortality after delisting than younger whites. Our findings support the need for interventions to ensure medical suitability for LT among older adults and to address disparities in LT access for AAs.


Assuntos
Afro-Americanos , Doença Hepática Terminal/etnologia , Doença Hepática Terminal/cirurgia , Grupo com Ancestrais do Continente Europeu , Acesso aos Serviços de Saúde , Disparidades em Assistência à Saúde , Transplante de Fígado , Listas de Espera , Fatores Etários , Bases de Dados Factuais , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/mortalidade , Feminino , Humanos , Incidência , Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Masculino , Pessoa de Meia-Idade , Prevalência , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Listas de Espera/mortalidade
19.
Health Serv Res ; 53 Suppl 3: 5331-5351, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30246404

RESUMO

OBJECTIVES: To determine dementia prevalence and costs attributable to dementia using Veterans Health Administration (VHA) data with and without Medicare data. DATA SOURCES: VHA inpatient, outpatient, purchased care and other data and Medicare enrollment, claims, and assessments in fiscal year (FY) 2013. STUDY DESIGN: Analyses were conducted with VHA data alone and with combined VHA and Medicare data. Dementia was identified from a VHA sanctioned list of ICD-9 diagnoses. Attributable cost of dementia was estimated using recycled predictions. DATA COLLECTION: Veterans age 65 and older who used VHA and were enrolled in Traditional Medicare in FY 2013 (1.9 million). PRINCIPAL FINDINGS: VHA records indicated the prevalence of dementia in FY 2013 was 4.8 percent while combined VHA and Medicare data indicated the prevalence was 7.4 percent. Attributable cost of dementia to VHA was, on average, $10,950 per veteran per year (pvpy) using VHA alone and $6,662 pvpy using combined VHA and Medicare data. Combined VHA and Medicare attributable cost of dementia was $11,285 pvpy. Utilization attributed to dementia using VHA data alone was lower for long-term institutionalization and higher for supportive care services than indicated in combined VHA and Medicare data. CONCLUSIONS: Better planning for clinical and cost-efficient care requires VHA and Medicare to share data for veterans with dementia and likely more generally.


Assuntos
Demência/economia , Gastos em Saúde/estatística & dados numéricos , Medicare/economia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , United States Department of Veterans Affairs/economia , Idoso , Idoso de 80 Anos ou mais , Serviços de Saúde Comunitária/economia , Serviços de Saúde Comunitária/estatística & dados numéricos , Demência/epidemiologia , Feminino , Serviços de Assistência Domiciliar/economia , Instituição de Longa Permanência para Idosos/economia , Humanos , Revisão da Utilização de Seguros , Masculino , Medicare/estatística & dados numéricos , Casas de Saúde/economia , Fatores Socioeconômicos , Estados Unidos , United States Department of Veterans Affairs/estatística & dados numéricos
20.
Int J Chron Obstruct Pulmon Dis ; 13: 2731-2738, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30233163

RESUMO

Background: Social isolation is a common experience in patients with COPD but is not captured by existing patient-reported outcomes, and its association with clinical outcomes is unknown. Methods: We prospectively enrolled adults with stable COPD who completed the University of Alabama at Birmingham Life Space Assessment (LSA) (range: 0-120, restricted Life-Space mobility: ≤60 and a marker of social isolation in older adults); six-minute walk test (6MWT), and the University of California at San Diego Shortness of Breath Questionnaire, COPD Assessment Test, and Hospital Anxiety and Depression Scale. The occurrence of severe exacerbations (emergency room visit or hospitalization) was recorded by review of the electronic record up to 1 year after enrollment. We determined associations between Life-Space mobility and clinical outcomes using regression analyses. Results: Fifty subjects had a mean ± SD %-predicted FEV1 of 42.9±15.5, and 23 (46%) had restricted Life-Space mobility. After adjusting for age, gender, %-predicted FEV1, comorbidity count, inhaled corticosteroid/long-acting beta2-agonist use, and prior cardiopulmonary rehabilitation, subjects with restricted Life-Space had an increased risk for severe exacerbations (adjusted incidence rate ratio 4.65, 95% CI 1.19-18.23, P=0.03). LSA scores were associated with 6MWD (R=0.50, P<0.001), dyspnea (R=-0.58, P<0.001), quality of life (R=-0.34, P=0.02), and depressive symptoms (R=-0.39, P=0.005). Conclusion: Restricted Life-Space mobility predicts severe exacerbations and is associated with reduced exercise tolerance, more severe dyspnea, reduced quality of life, and greater depressive symptoms.


Assuntos
Limitação da Mobilidade , Doença Pulmonar Obstrutiva Crônica/psicologia , Isolamento Social/psicologia , Idoso , Depressão/diagnóstico , Progressão da Doença , Dispneia/diagnóstico , Feminino , Volume Expiratório Forçado , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Qualidade de Vida , Análise de Regressão , Teste de Caminhada
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