Differences in epaAC© in heart failure patients with or without readmission: a retrospective case-control study

Improving Heart Failure Patient Transitions of Care and Reducing Readmissions with a Structured Hand-off Process

Many patients with severe obstructive sleep apnea (OSA) do not complain of excessive daytime sleepiness (EDS), possibly due to increased sympathetic nervous activity (SNA) and accompanying heightened alertness. We hypothesized that in patients with OSA, those without subjective EDS (Epworth Sleepiness Scale, ESS score < 11) would have higher very low frequency (VLF) heart rate variability (HRV) during sleep, reflecting greater sympathetic heart rate modulation than patients with an ESS score ≥ 11. Patients with severe OSA (AHI ≥ 30: 26 with and 65 without heart failure) were divided into those with and without EDS. Heart rate (HR) signals were acquired in stage 2 sleep during periods of recurrent apneas and hypopneas and submitted to coarse graining spectral analysis, which extracts harmonic, neurally mediated contributions to HRV from total spectral power. Because the apnea-hyperpnea cycle entrains muscle SNA at VLF (0 to 0.04 Hz), VLF power was our principal between-group comparison. Subjects without EDS had higher harmonic VLF power (944 ± 839 vs 447 ± 461 msec(2), p = 0.003) than those with EDS, irrespective of the presence or absence of heart failure (1218 ± 944 vs 426 ± 299 msec(2), p = 0.043, and 1029 ± 873 vs 503 ± 533 msec(2), p = 0.003, respectively). ESS scores correlated inversely with VLF power in all (r = -0.294, p = 0.005) and in heart failure subjects (r = -0.468, p = 0.016). Patients with severe OSA but without EDS have higher VLF-HRV than those with EDS. This finding suggests that patients with severe OSA but without EDS have greater sympathetic modulation of HRV than those with EDS that may reflect elevated adrenergically mediated alertness. Taranto Montemurro L; Floras JS; Picton P; Kasai T; Alshaer H; Gabriel JM; Bradley TD. Relationship of heart rate variability to sleepiness in patients with obstructive sleep apnea with and without heart failure.

Transitions in Care From Acute Care Telemetry Unit to Home: An Evidence-Based Quality Improvement Project.

ObjectivesUp to 50% of heart failure (HF) patients may be frail and have worse clinical outcomes than non-frail patients. The benefits of HF-specific pharmacotherapy (beta-blockers, ACE-inhibitors/angiotensin-receptor-blockers and mineralocorticoid-receptor-antagonist) in this...

Rehospitalization Rates in Hypertensive Emergency.

Aim. To analyze clinical and echocardiographic characteristics and prognosis in patients with heart failure mid-range ejection fraction.&#x0D; Methods. The study included 76 patients with stable heart failure IIV functional class, with a mean age of 66.110.4 years. All patients were divided into 3 subgroups based on the left ventricular ejection fraction: the first group heart failure patients with reduced ejection fraction (below 40%), 21.1%; the second group patients with mid-range ejection fraction (from 40 to 49%), 23.7%; the third group patients with preserved ejection fraction (50%), 55.3%. The clinical characteristics of all groups were compared. The quality of life was assessed by the Minnesota Satisfaction Questionnaire (MSQ), the clinical condition was determined by using the clinical condition assessment scale (Russian Shocks). The prognosis was studied according to the onset of cardiovascular events one year after enrollment in the study. The endpoints were cardiovascular mortality, myocardial infarction (MI), stroke, hospitalization for acutely decompensated heart failure, thrombotic complications. Statistical analysis was performed by using IBM SPSS Statistics 20 software. Normal distribution of the data was determined by the ShapiroWilk test, nominal indicators were compared between groups by using chi-square tests, normally distributed quantitative indicators by ANOVA. The KruskalWallis test was performed to comparing data with non-normal distribution.&#x0D; Results. Analysis showed that the most of clinical characteristics (etiological structure, age, gender, quality of life, results on the clinical condition assessment scale for patients with chronic heart failure and a 6-minute walk test, distribution by functional classes of heart failure) in patients with mid-range ejection fraction (HFmrEF) were similar to those in patients with reduced ejection fraction (HFrEF). At the same time, they significantly differed from the characteristics of patients with preserved ejection fraction (HFpEF). Echocardiographic data from patients with mid-range ejection fraction ranks in the middle compared to patients with reduced and preserved ejection fraction. In heart failure patients with mid-range ejection fraction, the incidence of adverse outcomes during the 1st year also was intermediate between heart failure patients with preserved ejection fraction and patients with reduced ejection fraction: for all cardiovascular events in the absence of significant differences (17.6; 10.8 and 18.8%, respectively), myocardial infarction (5,9; 0 and 6.2%), thrombotic complications (5.9; 5.4 and 6.2%). Heart failure patients with mid-range ejection fraction in comparison to patients with preserved ejection fraction and reduced ejection fraction had significantly lower cardiovascular mortality (0; 2.7 and 12.5%, p 0.05) and the number of hospitalization for acutely decompensated heart failure (0; 2,7 and 6.2%).&#x0D; Conclusion. Clinical characteristics of heart failure patients with mid-range and heart failure patients with reduced ejection fraction are similar but significantly different from those in the group of patients with preserved ejection fraction; echocardiographic data in heart failure patients with mid-range ejection fraction is intermediate between those in patients with reduced ejection fraction and patients with preserved ejection fraction; the prognosis for all cardiovascular events did not differ significantly in the groups depending on the left ventricular ejection fraction.

Hospital readmission is common among patients with diabetes. Some readmissions, particularly for hypoglycemia and hyperglycemia, may be avoidable with better care transitions and post-discharge management. To ascertain the most common reasons and risk factors for readmission among adults with diabetes, with specific consideration of severe dysglycemia. Retrospective analysis of data from the OptumLabs Data Warehouse, an administrative data set of commercially insured and Medicare Advantage beneficiaries across the U.S. Adults ≥18years of age with diabetes, discharged from a hospital between January 1, 2009, and December 31, 2014 (N=342,186). Principal diagnoses and risk factors for 30-day unplanned readmissions, subset as being for severe dysglycemia vs. all other causes. We analyzed 594,146 index hospitalizations among adults with diabetes: mean age 68.2years (SD, 13.0), 52.9% female, and 67.8% white. The all-cause 30-day readmission rate was 10.8%. Heart failure was the most common cause for index hospitalization (5.5%) and readmission (8.9%). Severe dysglycemia accounted for 2.6% of index hospitalizations (48.1% hyperglycemia, 50.4% hypoglycemia, 1.5% unspecified) and 2.5% of readmissions (38.3% hyperglycemia, 61.0% hypoglycemia, 0.7% unspecified). Younger patient age, severe dysglycemia at index or prior hospitalization, and the Diabetes Complications Severity Index (DCSI) were the strongest risk factors predisposing patients to severe dysglycemia vs. other readmissions. Prior episodes of severe dysglycemia and the DCSI were also independent risk factors for other-cause readmissions, irrespective of the cause of the index hospitalization. Adults with diabetes are hospitalized and readmitted for a wide range of health conditions, and hospitalizations for severe hypoglycemia and hyperglycemia remain common, with high rates of recurrence. Severe dysglycemia is most likely to occur among younger patients with multiple diabetes complications and prior history of such events.

Summary : Lifelong exercise training maintains a youthful compliance of the left ventricle (LV), whereas a year of exercise training started later in life fails to reverse LV stiffening, possibly because of accumulation of irreversible advanced glycation end products. Alagebrium is a novel drug that breaks advanced glycation end product crosslinks and improves LV stiffness in aged animals. In this study, the authors prescribed alagebrium (200 mg daily) or placebo combined with aerobic exercise training or contact control in healthy, sedentary older individuals for 1 year. The authors evaluated overall cardiac function by the use of several modalities, including invasive pressure–volume measurements, exercise testing, and cardiac MRI before and after the training. To the authors’ knowledge, this is the first study to evaluate the effects of alagebrium and exercise training in healthy aged humans. After intervention, exercise training significantly increased exercise capacity, LV mass, and LV end-diastolic volume. Conversely, alagebrium had little effect on exercise capacity or LV geometry. However, alagebrium showed a modest improvement in LV stiffness compared with placebo. This favorable effect of alagebrium on LV stiffness was most prominent in individuals with combined alagebrium and exercise training. Conclusions : Alagebrium had no effect on hemodynamics, LV geometry, or exercise capacity in healthy, previously sedentary seniors. However, it did show a modestly favorable effect on age-associated LV stiffening.1 Summary : Maximum oxygen consumption (peak VO2) and efficiency of ventilation (VE) during exercise (VE/VCO2 slope) are known to stratify adults in heart failure for 1-year survival. On the basis of adult data, a recent American Heart Association scientific statement suggested that peak VO2<50% predicted for age and sex should be considered substantial impairment in exercise performance in children with heart disease and therefore a class I indication for heart transplant listing. This single-center study examined the association of …

The utilization outcomes of nurse practitioners (NPs) in the acute care setting have not been widely studied. The purpose of this study was to determine the impact on utilization outcomes of NPs on medical teams who take care of patients admitted to a cardiovascular intensive care unit. A retrospective 2-group comparative design was used to evaluate the outcomes of 185 patients with ST- or non ST-segment elevation myocardial infarction or heart failure who were admitted to a cardiovascular intensive care unit in an urban medical center. Patients received care from a medical team that included a cardiac acute care NP (n = 109) or medical team alone (n = 76). Patient history, cardiac assessment, medical interventions, discharge disposition, discharge time, and 3 utilization outcomes (ie, length of stay, 30-day readmission, and time of discharge) were compared between the 2 treatment groups. Logistic regression was used to identify predictors of 30-day readmission. Patients receiving care from a medical team that included an NP were rehospitalized approximately 50% less often compared with those receiving care from a medical team without an NP. Thirty-day hospital readmission (P = .011) and 30-day return rates to the emergency department (P = .021) were significantly lower in the intervention group. Significant predictors for rehospitalization included diagnosis of heart failure versus myocardial infarction (odds ratio [OR], 3.153, P = 0.005), treatment by a medical team without NP involvement (OR, 2.905, P = 0.008), and history of diabetes (OR, 2.310, P = 0.032). The addition of a cardiac acute care NP to medical teams caring for myocardial infarction and heart failure patients had a positive impact on 30-day emergency department return and hospital readmission rates.

Background Vancomycin is the standard of care for Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSI), but daptomycin is increasingly being used. There are few real-world outcome comparisons.Table 1:Clinical Characteristics of Patients with Methicillin-Resistant Staphylococcus aureus Bloodstream Infection Discharged on OPAT Table 1 summarizes patient demographic data, comorbidities, characteristics of index admission, and type of infection at index admission.Table 2:Factors Associated with 90-day Same-Infection Readmission in Multivariate Analysis Table 2 outlines results of logistic regression analysis used to investigate risk factors for same-infection 90-day readmission. Methods In this retrospective cohort study, adults with MRSA BSI were queried using the insurance-claim-derived Merative MarketScan® database (2013–2022). Logistic regression was used to investigate risk factors for all-cause readmission as well as 90-day hospital readmission with the same infection among patients discharged on vancomycin compared to daptomycin. Kaplan-Meier curves visually summarized differences in time to readmission.FIgure 1:(1) Adjusted Odds Ratios for Factors Associated with 90-day Same-Infection Readmission and (B) Same-Infection Readmission-Free Survival in Patients Discharged on Vancomycin versus Daptomycin Figure 1A is a Forest Plot illustrating results from univariate and multivariate analyses used to identify factors associated with 90-day same-infection readmission (red indicates multivariate analysis, blue indicates univariate analysis) . Figure 1B is a Kaplan-Meier survival curve demonstrating 90-day same-infection readmission-free survival in patients discharged on vancomycin (blue) versus daptomycin (red). Results Among 2,743 patients with MRSA BSI, 668 were discharged on Vancomycin and 570 on Daptomycin. Baseline characteristics were similar (Table 1). Readmissions with the same infection/s (primary endpoint, 14.4% vs. 10.9%, p=0.08) and all-cause readmissions were comparable (daptomycin 35.9% vs. vancomycin 38.5%, p=0.40), (Table 2). In adjusted multivariable models, heart failure (aOR, 2.03 [95% CI, 1.18-3.50]), brain abscesses (aOR, 2.06 [95% CI, 1.16-3.67]), and osteomyelitis (aOR, 1.45 [95% CI, 0.98-2.15]) were all associated with increased risk of 90-day readmission from same infection (Figure 1A), while daptomycin use was not (aOR, 1.32 [95% CI, 0.93-1.85]) . Readmission free survival was comparable between groups through day 15 (log rank test, p=0.11, Figure 1B). Conclusion Patients with MRSA BSI discharged on daptomycin had similar 90-day readmission outcomes as those discharged on vancomycin. There was a trend towards increased risk of readmissions with daptomycin after day 15 for the same infection which needs further investigation. Despite treatment advances, MRSA BSI readmission rates remain high and are influenced by infection complexity and comorbidities. Disclosures All Authors: No reported disclosures

Highlights From the Circulation Family of Journals.

Regulatory standards for 30-day readmissions incentivize hospitals to improve quality of care. Implementing comprehensive electronic health record systems potentially decreases readmission rates by improving medication reconciliation at discharge, demonstrating the additional benefits of inpatient EHRs beyond improved safety and decreased errors. To compare 30-day all-cause readmission incidence rates within Medicare fee-for-service with heart failure discharged from hospitals with full implementation levels of comprehensive EHR systems versus those without. This retrospective cohort study uses data from the American Hospital Association Health IT survey and Medicare Part A claims to measure associations between hospital EHR implementation levels and beneficiary readmissions. Multivariable Cox regressions estimate the hazard ratio of 30-day all-cause readmissions within beneficiaries discharged from hospitals implementing comprehensive EHRs versus those without, controlling for beneficiary health status and hospital organizational factors. Propensity scores are used to account for selection bias. The proportion of heart failure patients with 30-day all-cause readmissions was 30%, 29%, and 32% for those discharged from hospitals with full, some, and no comprehensive EHR systems. Heart failure patients discharged from hospitals with fully implemented comprehensive EHRs compared to those with no comprehensive EHR systems had equivalent 30-day readmission incidence rates (HR = 0.97, 95% CI 0.73 - 1.3). Implementation of comprehensive electronic health record systems does not necessarily improve a hospital's ability to decrease 30-day readmission rates. Improving the efficiency of post-acute care will require more coordination of information systems between inpatient and ambulatory providers.

Morbidity and Mortality of Congestive Heart Failure in Trauma Patients

Oxygen consumption (VO2) has previously been used for prognosis and risk stratification in patients with heart failure. Furthermore, it has been reported that there is no difference in peak oxygen consumption between systolic and diastolic heart failure patients. More recent research has introduced VE/VCO2 slope as a prognostic measure, but these reports have been limited to systolic heart failure patients only. Risk of mortality has been shown to increase when VE/VCO2 slope values are greater than 34. PURPOSE: To cross-sectionally examine VE/VCO2 slope in systolic and diastolic heart failure populations as well as age-matched healthy controls. METHODS: Symptom limited graded exercise tests were conducted on 147 patients (59 diastolic heart failure, 60 systolic heart failure, 28 controls) using a bicycle ergometer protocol that started at 12 watts and progressed to 25 watts after two minutes. The stages continued to increase by 25 watt increments every three minutes until maximal effort was achieved. Breath-by-breath expired gas analysis was performed using a commercially available system with on-line computer calculations. VE/VCO2 slope was calculated from a regression line of minute ventilation and carbon dioxide production. One way analysis of variance with a Bonferroni post hoc test and Pearson correlations were used for statistical analysis. RESULTS: VE/VCO2 slope was significantly higher in systolic heart failure patients when compared to both diastolic heart failure patients (37.3 ± 7.5 vs. 34.1 ± 6.5, p=0.03) and controls (37.3 ± 7.5 vs. 32.1 ± 4.6, p=0.002). No significant difference was observed between diastolic heart failure and healthy controls (34.1 ± 6.5 vs. 32.1 ± 4.6, p=0.52). Furthermore, we observed that 45% of DHF and 59% had a VE/VCO2 slope greater than 34. Additional analysis resulted in significant correlations between VO2 and VE/VCO2 slope in systolic heart failure patients (r=−0.40, p=0.002), however, there was no significant relationship in diastolic heart failure patients (r=−0.09, p=0.49) or in controls (r=0.13, p=0.50). CONCLUSION: VE/VCO2 slope is significantly higher in patients with systolic heart failure compared to diastolic heart failure and healthy controls. While this study did not address prognosis, the findings are consistent with the belief that mortality rates are greater in SHF than DHF, and VE/VCO2 slope is useful in predicting this risk.

Le volume annuel de cas est un facteur de risque pour la réadmission non programmée après 30 jours suivant l’ostéosynthèse des fractures de l’acetabulum