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1.
Am J Med ; 2021 Jan 28.
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.

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 de Plaquetas/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.
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
10.
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
11.
Arch Med Sci ; 14(5): 995-1002, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30154880

RESUMO

Introduction: Heart failure (HF) is the leading cause of hospital readmission. Medicare home health services provide intermittent skilled nursing care to homebound Medicare beneficiaries. We examined whether discharge home health referral is associated with a lower risk of 30-day all-cause readmission in HF. Material and methods: Of the 8049 Medicare beneficiaries hospitalized for acute HF and discharged alive from 106 Alabama hospitals, 6406 (76%) patients were not admitted from nursing homes and were discharged home without discharge hospice referrals. Of these, 1369 (21%) received a discharge home health referral. Using propensity scores for home health referral, we assembled a matched cohort of 1253 pairs of patients receiving and not receiving home health referrals, balanced on 33 baseline characteristics. Results: The 2506 matched patients had a mean age of 78 years, 61% were women, and 27% were African American. Thirty-day all-cause readmission occurred in 28% and 19% of matched patients receiving and not receiving home health referrals, respectively (hazard ratio (HR) = 1.52; 95% confidence interval (CI): 1.29-1.80; p < 0.001). Home health referral was also associated with a higher risk of 30-day all-cause mortality (HR = 2.32; 95% CI: 1.58-3.41; p < 0.001) but not with 30-day HF readmission (HR = 1.28; 95% CI: 0.99-1.64; p = 0.056). HRs (95% CIs) for 1-year all-cause readmission, all-cause mortality, and HF readmission are 1.24 (1.13-1.36; p < 0.001), 1.37 (1.20-1.57; p < 0.001) and 1.09 (0.95-1.24; p = 0.216), respectively. Conclusions: Hospitalized HF patients who received discharge home health services referral had a higher risk of 30-day and 1-year all-cause readmission and all-cause mortality, but not of HF readmission.

12.
Clin Cardiol ; 41(3): 406-412, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29569405

RESUMO

BACKGROUND: Digoxin use has been associated with a lower risk of 30-day all-cause admission and readmission in patients with heart failure and reduced ejection fraction (HFrEF). HYPOTHESIS: Digoxin use will be associated with improved outcomes in patients with HFrEF receiving ß-blockers. METHODS: Of the 3076 hospitalized Medicare beneficiaries with HFrEF (EF <45%), 1046 received a discharge prescription for ß-blockers, of which 634 were not on digoxin. Of the 634, 204 received a new discharge prescription for digoxin. Propensity scores for digoxin use, estimated for each of the 634 patients, were used to assemble a matched cohort of 167 pairs of patients receiving and not receiving digoxin, balanced on 30 baseline characteristics. Matched patients (n = 334) had a mean age of 74 years and were 46% female and 30% African American. RESULTS: 30-day all-cause readmission occurred in 15% and 27% of those receiving and not receiving digoxin, respectively (hazard ratio [HR]: 0.51, 95% confidence interval [CI]: 0.31-0.83, P = 0.007). This beneficial association persisted during 4 years of follow-up (HR: 0.72, 95% CI: 0.57-0.92, P = 0.008). Digoxin use was also associated with a lower risk of the combined endpoint of all-cause readmission or all-cause mortality at 30 days (HR: 0.54, 95% CI: 0.34-0.86, P = 0.009) and at 4 years (HR: 0.76, 95% CI: 0.61-0.96, P = 0.020). CONCLUSIONS: In hospitalized patients with HFrEF receiving ß-blockers, digoxin use was associated with a lower risk of 30-day all-cause readmission but not mortality, which persisted during longer follow-up.


Assuntos
Antagonistas Adrenérgicos beta/administração & dosagem , Digoxina/administração & dosagem , Insuficiência Cardíaca/tratamento farmacológico , Ventrículos do Coração/fisiopatologia , Readmissão do Paciente/tendências , Função Ventricular Esquerda/fisiologia , Idoso , Alabama/epidemiologia , Cardiotônicos/administração & dosagem , Relação Dose-Resposta a Droga , Quimioterapia Combinada , Ecocardiografia , Feminino , Seguimentos , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/efeitos dos fármacos , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pontuação de Propensão , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Função Ventricular Esquerda/efeitos dos fármacos
13.
JAMA Cardiol ; 3(4): 288-297, 2018 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-29450487

RESUMO

Importance: Lower systolic blood pressure (SBP) levels are associated with poor outcomes in patients with heart failure. Less is known about this association in heart failure with preserved ejection fraction (HFpEF). Objective: To determine the associations of SBP levels with mortality and other outcomes in HFpEF. Design, Setting, and Participants: A propensity score-matched observational study of the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry included 25 354 patients who were discharged alive; 8873 (35.0%) had an ejection fraction of at least 50%, and of these, 3915 (44.1%) had stable SBP levels (≤20 mm Hg admission to discharge variation). Data were collected from 259 hospitals in 48 states between March 1, 2003, and December 31, 2004. Data were analyzed from March 1, 2003, to December 31, 2008. Exposure: Discharge SBP levels less than 120 mm Hg. A total of 1076 of 3915 (27.5%) had SBP levels less than 120 mm Hg, of whom 901 (83.7%) were matched by propensity scores with 901 patients with SBP levels of 120 mm Hg or greater who were balanced on 58 baseline characteristics. Main Outcomes and Measures: Thirty-day, 1-year, and overall all-cause mortality and heart failure readmission through December 31, 2008. Results: The 1802 matched patients had a mean (SD) age of 79 (10) years; 1147 (63.7%) were women, and 134 (7.4%) were African American. Thirty-day all-cause mortality occurred in 91 (10%) and 45 (5%) of matched patients with discharge SBP of less than 120 mm Hg vs 120 mm Hg or greater, respectively (hazard ratio [HR], 2.07; 95% CI, 1.45-2.95; P < .001). Systolic blood pressure level less than 120 mm Hg was also associated with a higher risk of mortality at 1 year (39% vs 31%; HR, 1.36; 95% CI, 1.16-1.59; P < .001) and during a median follow-up of 2.1 (overall 6) years (HR, 1.17; 95% CI, 1.05-1.30; P = .005). Systolic blood pressure level less than 120 mm Hg was associated with a higher risk of heart failure readmission at 30 days (HR, 1.47; 95% CI, 1.08-2.01; P = .02) but not at 1 or 6 years. Hazard ratios for the combined end point of heart failure readmission or all-cause mortality associated with SBP level less than 120 mm at 30 days, 1 year, and overall were 1.71 (95% CI, 1.34-2.18; P < .001), 1.21 (95% CI, 1.07-1.38; P = .004), and 1.12 (95% CI, 1.01-1.24; P = .03), respectively. Conclusions and Relevance: Among hospitalized patients with HFpEF, an SBP level less than 120 mm Hg is significantly associated with poor outcomes. Future studies need to prospectively evaluate optimal SBP treatment goals in patients with HFpEF.


Assuntos
Pressão Sanguínea/fisiologia , Insuficiência Cardíaca/fisiopatologia , Volume Sistólico/fisiologia , Idoso , Feminino , Insuficiência Cardíaca/mortalidade , Humanos , Estimativa de Kaplan-Meier , Masculino , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Pontuação de Propensão , Sistema de Registros , Fatores de Risco
14.
Eur J Heart Fail ; 20(2): 359-369, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28980368

RESUMO

AIMS: To examine associations of below-target and target dose of enalapril, an angiotensin-converting enzyme (ACE) inhibitor, with outcomes in patients with heart failure and reduced ejection fraction (HFrEF) in the Studies of Left Ventricular Dysfunction (SOLVD) Treatment trial. METHODS AND RESULTS: Two thousand five hundred and sixty-nine patients with HFrEF (ejection fraction ≤35%) were randomized to below-target (5-10 mg/day) dose placebo (n = 1284) or enalapril (n = 1285). One month post-randomization, blind up-titration to target (20 mg/day) dose was attempted for both study drugs in 2458 patients. Among the 1444 patients who achieved dose up-titration (placebo, n = 748; enalapril, n = 696; mean dose for both groups, 20.0 mg/day), target dose enalapril (vs. target dose placebo) was associated with a 9% absolute lower risk of the combined endpoint of heart failure hospitalization or all-cause mortality [adjusted hazard ratio (HR) 0.70; 95% confidence interval (CI) 0.60-0.81; P < 0.001] during 4 years of follow-up. Among the 1014 patients who could not achieve target dose (placebo, n = 486; enalapril, n = 528; mean dose for both groups, 8.8 mg/day), below-target dose enalapril (vs. below-target dose placebo) was associated with a 12% absolute lower risk of the combined endpoint of heart failure hospitalization or all-cause mortality (adjusted HR 0.68; 95% CI 0.57-0.81; P < 0.001). Among the 1224 patients receiving enalapril, target (vs. below-target) dose had no association with the combined endpoint of heart failure hospitalization or all-cause mortality (adjusted HR 1.04; 95% CI 0.87-1.23; P = 0.695). CONCLUSION: In patients with HFrEF, the clinical benefits of ACE inhibitors appear to be similar at both below-target and target doses.


Assuntos
Enalapril/administração & dosagem , Insuficiência Cardíaca/tratamento farmacológico , Volume Sistólico/efeitos dos fármacos , Inibidores da Enzima Conversora de Angiotensina/administração & dosagem , Canadá/epidemiologia , Causas de Morte/tendências , Relação Dose-Resposta a Droga , Método Duplo-Cego , Europa (Continente)/epidemiologia , Seguimentos , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Humanos , Volume Sistólico/fisiologia , Taxa de Sobrevida/tendências , Resultado do Tratamento , Estados Unidos/epidemiologia
15.
J Am Coll Cardiol ; 70(15): 1861-1871, 2017 Oct 10.
Artigo em Inglês | MEDLINE | ID: mdl-28982499

RESUMO

BACKGROUND: A lower heart rate is associated with better outcomes in patients with heart failure (HF) with reduced ejection fraction (EF). Less is known about this association in patients with HF with preserved ejection fraction (HFpEF). OBJECTIVES: The aims of this study were to examine associations of discharge heart rate with outcomes in hospitalized patients with HFpEF. METHODS: Of the 8,873 hospitalized patients with HFpEF (EF ≥50%) in the Medicare-linked OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry, 6,286 had a stable heart rate, defined as ≤20 beats/min variation between admission and discharge. Of these, 2,369 (38%) had a discharge heart rate of <70 beats/min. Propensity scores for discharge heart rate <70 beats/min, estimated for each of the 6,286 patients, were used to assemble a cohort of 2,031 pairs of patients with heart rate <70 versus ≥70 beats/min, balanced on 58 baseline characteristics. RESULTS: The 4,062 matched patients had a mean age of 79 ± 10 years, 66% were women, and 10% were African American. During 6 years (median 2.8 years) of follow-up, all-cause mortality was 65% versus 70% for matched patients with a discharge heart rate <70 versus ≥70 beats/min, respectively (hazard ratio [HR]: 0.86; 95% confidence interval [CI]: 0.80 to 0.93; p < 0.001). A heart rate <70 beats/min was also associated with a lower risk for the combined endpoint of HF readmission or all-cause mortality (HR: 0.90; 95% CI: 0.84 to 0.96; p = 0.002), but not with HF readmission (HR: 0.93; 95% CI: 0.85 to 1.01) or all-cause readmission (HR: 1.01; 95% CI: 0.95 to 1.08). Similar associations were observed regardless of heart rhythm or receipt of beta-blockers. CONCLUSIONS: Among hospitalized patients with HFpEF, a lower discharge heart rate was independently associated with a lower risk of all-cause mortality, but not readmission.


Assuntos
Insuficiência Cardíaca , Frequência Cardíaca , Readmissão do Paciente/estatística & dados numéricos , Volume Sistólico , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Medicare/estatística & dados numéricos , Mortalidade , Avaliação de Processos e Resultados em Cuidados de Saúde , Gravidade do Paciente , Alta do Paciente/estatística & dados numéricos , Modelos de Riscos Proporcionais , Sistema de Registros , Medição de Risco , Estados Unidos/epidemiologia
16.
J Am Med Dir Assoc ; 18(9): 761-765, 2017 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-28501416

RESUMO

BACKGROUND: Digoxin use has been shown to be associated with a lower risk of 30-day all-cause hospital readmissions in older patients with heart failure (HF). In the current study, we examined this association among long-term care (LTC) residents hospitalized for HF. METHODS: Of the 8049 Medicare beneficiaries discharged alive after hospitalization for HF from 106 Alabama hospitals, 545 (7%) were LTC residents, of which 227 (42%) received discharge prescriptions for digoxin. Propensity scores for digoxin use, estimated for each of the 545 patients, were used to assemble a matched cohort of 158 pairs of patients receiving and not receiving digoxin who were balanced on 29 baseline characteristics. Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with digoxin among matched patients were estimated using Cox regression models. RESULTS: Matched patients (n = 316) had a mean age of 83 years, 74% were women, and 18% African American. Thirty-day all-cause readmission occurred in 21% and 20% of patients receiving and not receiving digoxin, respectively (HR, 1.02; 95% CI, 0.63-1.66). Digoxin had no association with all-cause mortality (HR, 0.90; 95% CI, 0.48-1.70), HF readmission (HR, 0.90; 95% CI, 0.38-2.12), or a combined endpoint of all-cause readmission or all-cause mortality (HR, 0.97; 95% CI, 0.65-1.45) at 30 days. These associations remained unchanged at 1 year postdischarge. CONCLUSIONS: The lack of an association between digoxin and 30-day all-cause readmission in older nursing home residents hospitalized for HF is intriguing and needs to be interpreted with caution given the small sample size.


Assuntos
Antiarrítmicos/uso terapêutico , Digoxina/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Readmissão do Paciente/tendências , Idoso , Idoso de 80 Anos ou mais , Alabama , Feminino , Instituição de Longa Permanência para Idosos , Hospitalização , Humanos , Assistência de Longa Duração , Masculino , Pontuação de Propensão
17.
Int J Cardiol ; 227: 462-466, 2017 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-27866868

RESUMO

BACKGROUND: Therapy with evidence-based heart failure (HF) medications has been shown to be associated with lower risk of 30-day all-cause readmission in patients with HF and reduced ejection fraction (HFrEF). METHODS: We examined the association of aldosterone antagonist use with 30-day all-cause readmission in this population. Of the 2443 Medicare beneficiaries with HF and left ventricular EF ≤35% discharged home from 106 Alabama hospitals during 1998-2001, 2060 were eligible for spironolactone therapy (serum creatinine ≤2.5 for men and ≤2mg/dl for women, and serum potassium <5mEq/L). After excluding 186 patients already receiving spironolactone on admission, the inception cohort consisted of 1874 patients eligible for a new discharge prescription for spironolactone, of which 329 received one. Using propensity scores for initiation of spironolactone therapy, we assembled a matched cohort of 324 pairs of patients receiving and not receiving spironolactone balanced on 34 baseline characteristics (mean age 72years, 42% women, 33% African American). RESULTS: Thirty-day all-cause readmission occurred in 17% and 19% of matched patients receiving and not receiving spironolactone, respectively (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.64-1.32; p=0.650). Spironolactone had no association with 30-day all-cause mortality (HR, 0.84; 95% CI, 0.38-1.88; p=0.678) or HF readmission (HR, 0.74; 95% CI, 0.41 1.31; p=0.301). These associations remained unchanged during 12months of post-discharge follow-up. CONCLUSION: A discharge prescription for spironolactone had no association with 30-day all-cause readmission among older, hospitalized Medicare beneficiaries with HFrEF eligible for spironolactone therapy.


Assuntos
Insuficiência Cardíaca/tratamento farmacológico , Antagonistas de Receptores de Mineralocorticoides/uso terapêutico , Readmissão do Paciente , Espironolactona/uso terapêutico , Alabama , Feminino , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Humanos , Benefícios do Seguro , Masculino , Medicare , Fatores de Risco , Volume Sistólico , Resultado do Tratamento , Estados Unidos
18.
Am J Med ; 129(11): 1178-1184, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27401949

RESUMO

BACKGROUND: Heart failure is the leading cause for 30-day all-cause readmission. We examined the impact of 30-day all-cause readmission on long-term outcomes and cost in a propensity score-matched study of hospitalized patients with heart failure. METHODS: Of the 7578 Medicare beneficiaries discharged with a primary diagnosis of heart failure from 106 Alabama hospitals (1998-2001) and alive at 30 days after discharge, 1519 had a 30-day all-cause readmission. Using propensity scores for 30-day all-cause readmission, we assembled a matched cohort of 1516 pairs of patients with and without a 30-day all-cause readmission, balanced on 34 baseline characteristics (mean age 75 years, 56% women, 24% African American). RESULTS: During 2-12 months of follow-up after discharge from index hospitalization, all-cause mortality occurred in 41% and 27% of matched patients with and without a 30-day all-cause readmission, respectively (hazard ratio 1.68; 95% confidence interval 1.48-1.90; P <.001). This harmful association of 30-day all-cause readmission with mortality persisted during an average follow-up of 3.1 (maximum, 8.7) years (hazard ratio 1.33; 95% confidence interval 1.22-1.45; P <.001). Patients with a 30-day all-cause readmission had higher cumulative all-cause readmission (mean, 6.9 vs 5.1; P <.001), a longer cumulative length of stay (mean, 51 vs 43 days; P <.001), and a higher cumulative cost (mean, $38,972 vs $34,025; P = .001) during 8.7 years of follow-up. CONCLUSIONS: Among Medicare beneficiaries hospitalized for heart failure, 30-day all-cause readmission was associated with a higher risk of subsequent all-cause mortality, higher number of cumulative all-cause readmission, longer cumulative length of stay, and higher cumulative cost.


Assuntos
Insuficiência Cardíaca/terapia , Mortalidade , Readmissão do Paciente/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Alabama/epidemiologia , Estudos de Casos e Controles , Estudos de Coortes , Comorbidade , Doença da Artéria Coronariana/epidemiologia , Diabetes Mellitus/epidemiologia , Feminino , Seguimentos , Insuficiência Cardíaca/epidemiologia , Hospitalização , Humanos , Masculino , Medicare , Pessoa de Meia-Idade , Análise Multivariada , Prognóstico , Pontuação de Propensão , Modelos de Riscos Proporcionais , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Insuficiência Renal Crônica/epidemiologia , Resultado do Tratamento , Estados Unidos
19.
Qual Manag Health Care ; 25(1): 32-7, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26783865

RESUMO

BACKGROUND: Medication errors continue to exist despite the use of electronic health records and electronic prescribing; patient-centered medication reconciliation is important to decrease errors. OBJECTIVE: To identify whether a team-based approach with a pharmacist performing medication management and discharge medication reconciliation will reduce discharge-related medication errors in an academic tertiary care hospital already using an electronic health record and computerized physician order entry. DESIGN: Prospective nonrandomized controlled trial. PATIENTS: All patients were admitted to 2 of the 6 medicine teams from August 1, 2012, through October 31, 2012. INTERVENTION: On the intervention team, a pharmacist assisted with medication management, medication reconciliation, and medication education upon discharge. Although the physicians on the control team had access to a pharmacist, they rarely collaborated with the pharmacist. The numbers of discharge-related medication discrepancies on the intervention and control teams were compared. RESULTS: Collaboration with a pharmacist reduced discharge-related medication errors. The percentage of patients without medication errors within 72 hours of discharge was 93.8% on the intervention team compared with 40.2% on the control team (P < .0001). CONCLUSION: Pharmacist's involvement in the patient care team improved patient safety by decreasing discharge medication errors caused by using electronic health records and computerized physician order entry.


Assuntos
Registros Eletrônicos de Saúde/organização & administração , Erros de Medicação/prevenção & controle , Reconciliação de Medicamentos/organização & administração , Alta do Paciente , Serviço de Farmácia Hospitalar/organização & administração , Centros Médicos Acadêmicos/organização & administração , Idoso , Idoso de 80 Anos ou mais , Comportamento Cooperativo , Feminino , Humanos , Relações Interprofissionais , Masculino , Pessoa de Meia-Idade , Farmacêuticos , Médicos , Estados Unidos , United States Department of Veterans Affairs
20.
J Grad Med Educ ; 7(3): 407-11, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26457147

RESUMO

BACKGROUND: Medication errors during hospitalization are a major patient safety concern. Medication reconciliation is an effective tool to reduce medication errors, yet internal medicine residents rarely receive formal education on the process. OBJECTIVE: We assessed if an educational intervention on quality improvement principles and effective medication reconciliation for internal medicine residents will lead to fewer medication discrepancies and more accurate discharge medication lists. METHODS: From July 2012 to May 2013, internal medicine residents from 3 academic institutions who were rotating at the Washington DC VA Medical Center received twice-monthly interactive educational sessions on medication reconciliation, using both institutional summary metrics and data from their own discharges. Sessions were led by a faculty member or chief resident. Accuracy of discharge instructions for residents in the intervention group was compared to the accuracy of discharge data from June 2012 for a group of residents who did not receive the intervention. We used χ(2) analysis to assess for differences. RESULTS: The number of duplicate medications (23% versus 12%, P = .01); extraneous medications (14% versus 6%, P = .014); medications sorted by disease or indication (25% versus 77%, P < .001); and the number of discrepancies in discharge summaries (34% versus 11%, P < .001) statistically improved. No difference in the number of omissions was found between the 2 groups (17% versus 15%, P = .62). CONCLUSIONS: An educational intervention targeting internal medicine residents can be implemented with reasonable staff and time costs, and is effective in reducing the number of medication discrepancies at discharge.


Assuntos
Competência Clínica , Internato e Residência/normas , Reconciliação de Medicamentos/normas , Educação de Pós-Graduação em Medicina , Avaliação Educacional , Hospitais de Ensino , Humanos , Erros de Medicação/prevenção & controle , Segurança do Paciente , Melhoria de Qualidade
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