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Acute Hemodynamic Effects of Nebulised Furosemide in Stable Heart Failure
The 13th Annual Scientific Meeting
HFSA
S5
Nursing Research Award 011 Comparison of the Impact of PHQ-9 Scores with and without Physical Symptom Items on Event-Free Survival in Patients with Heart Failure Kyoung Suk Lee1, Terry A. Lennie1, Seongkum Heo2, Jia-Rong Wu1, Misook L. Chung1, Debra K. Moser1; 1College of Nursing, University of Kentucky; 2School of Nursing, Indiana University Background: It is critical to evaluate levels of depressive symptoms in patients with heart failure (HF) because they have a substantial impact on outcomes. Because there are shared physical symptoms between HF and depression, depressive symptom instruments that include physical symptoms of depression might artificially inflate scores in HF patients. One way to assess the accuracy of measurement of depressive symptoms is to explore the iimpact of physical symptom on outcomes using a depression instrument with physical symptoms, and then to use it again with the physical symptoms removed. The purpose of this study was to compare the predictive ability for event-free survival between the full Patient Health Questionnaire-9 (PHQ-9) and the PHQ-9 with the physical symptom items removed. Hypothesis: The full PHQ-9 will account for a greater amount of variance in event-free survival of HF patients than the PHQ-9 with the physical symptom items removed after controlling for relevant variables. Methods: Data from 214 patients with HF (mean age: 61 6 12, female: 33%, NYHA III/IV: 60%) were collected. The PHQ-9 was used to assess levels of depressive symptoms. Event-free survival (mortality, rehospitalization, or emergency department visit for cardiac reasons) was collected for a median follow-up of 335 days. To examine predictive ability on event-free survival after adjusting for relevant variables, of the two versions of the PHQ-9, the scores of each of the two instruments were entered in two separate hierarchical Cox proportional hazard regression analysis. Because the scores of PHQ-9 were skewed, the scores were transformed. Results: After controlling for age, gender, ethnicity, body mass index, comorbidity scores, and NYHA class, scores from the full PHQ-9 predicted event-free survival (HR51.32, 95% CI51.05e1.66). Subsequent analysis was done to evaluate the impact of physical symptoms in the PHQ-9 by excluding 3 physical symptoms. Scores of the PHQ-9 without physical symptoms were an independent predictor of first cardiac event (HR51.12, 95% CI51.02e1.23). Conclusion: Although the hazard ratio is lower for the prediction of event-free survival, removal of physical symptom items from the PHQ-9 does not eliminate the association of depressive symptoms with event-free survival. It is possible to obtain an accurate assessment of depressive symptoms in HF patients using an instrument that includes physical symptoms.
012 Acute Hemodynamic Effects of Nebulised Furosemide in Stable Heart Failure Phillip J. Newton1,2, Patricia M. Davidson1, Henry Krum3, Richard Ollerton2, Peter Macdonald4; 1Centre for Cardiovascular & Chronic Care, Curtin University of Technology, Chippendale, NSW, Australia; 2University of Western Sydney, Penrith, NSW, Australia; 3Centre of Cardiovascular Research & Education, Monash University, Melbourne, VIC, Australia; 4Cardiology Department, St Vincent’s Hospital, Darlinghutst, NSW, Australia Purpose: Dyspnoea is a common and burdensome symptom in heart failure (HF). Nebulised furosemide has been proposed as a novel therapeutic for relieving dyspnoea. This mode of administration is potentially useful in community based settings. However, to date mechanisms of action are unclear. This study sought to measure the acute hemodynamic effects of nebulised furosemide in patients with stable, advanced HF. Methods: In this randomised, double blind, placebo controlled trial, participants undergoing scheduled, right heart catheterisation were randomized to receive either 40mg (4mls) of nebulised furosemide or 4mls of normal saline. Following baseline pulmonary pressure measurement and inhalation of the study medication, subjects’ pulmonary pressures were recorded every 15 minutes for one hour. The volume of urine in the bladder was measured at baseline and at 60 minutes using ultrasound methods. Results: There were no significant differences in the hemodynamic weighted average time course data of the subjects in either group over the study period. Weighted average pulmonary capillary wedge pressure after 60 minutes in the furosemide group was 22.5 6 6.5 mmHg (n514) compared to the placebo group’s 24.0 6 7.3 mmHg (n518), p50.55. No other significant differences were observed in hemodynamic parameters between the two groups. This dose of nebulised furosemide was sufficient to produce a significant change in the median volume of urine in the bladder at 60 minutes 186 ml (124.5 to 247.5) (n58) compared to placebo 76 ml (21.5 to 130.5) ml (n513), p 5 0.02. Conclusions: This study showed that 40mg of nebulised furosemide had no significant effect on the hemodynamic parameters of the participants. Despite this, this dose was able to produce a diuretic effect in these subjects after one hour. Inhalation of furosemide may provide a novel method for drug delivery and requires further investigation.
013 Against Medical Advice and Improved Heart Failure Care Meriam F. Caboral, Judith E. Mitchell; Medicine/Cardiology, SUNY Downstate Medical Center, Brooklyn, NY Background: The hospital to home transition provides a critical opportunity for ensuring progressive heart failure (HF) care; absent for those patients (pts) who
signed out against medical advice (AMA). We sought to determine the characteristics of pts hospitalized with HF who leave AMA compared with pts discharged (d/c) via other modes. Method and Results: Retrospective analysis of pts admitted from April 2003 to Dec 2008 with HF. Of the 3450 pts, 91% black, mean age 68 6 34; mean ejection fraction (EF) 35%618; 2% signed out AMA. Six percent were discharged to alternate care facilities (UCF) and the remainder d/c to home. Differences by gender, EF and re-hospitalization rates separated the three d/c groups as shown in table 1. Age also differed such that the percent of pts older than 60 were 25, 69, 82 in the AMA, home, and UCF groups, respectively. The AMA group appeared sicker with lower EF, higher BNP level and more renal insufficiency. Twenty one percent of the pts who left AMA were re-hospitalized within 30 days. This is in contrast to the re-hospitalization rate of 14% for pts d/c to home and the 19% for pts d/c to an UCF. Although the number of pts signing out
AMA, D/C Home and D/C Alternate Care Facility
% Sex (female%) Age (mean) Mean EF Median BNP Creat $ 2 DM % HTN % ^CAD Re-hospitalization % (# 30 days)
AMA (2%) 25% 54 6 14 29 6 17 1769 43% 33% 77% 26% 21%
*p-value
D/C Home (92%)
**p-value
Alternate Facility (6%)
!0.001 0.003 0.023 !0.001 0.002 NS 0.013 NS 0.13
57% 68 6 35 35 6 17 1160 24% 44% 89% 20% 14%
0.013 0.021 0.11 0.009 NS NS NS 0.01 0.06
66% 74 6 14 37 6 19 1413 28% 37% 87% 29% 19%
* p-value: AMA vs. D/C Home; **p-value: Alternate Care Facility (includes nursing home, rehab, hospice) vs. Home; ^CAD: CABG, PCI, h/o MI, increased troponin. AMA is limited the overall sample size is large and the appraised period extensive, over 5 years. Conclusions: Evaluation of a predominantly black inner city population hospitalized with HF reveals that pts who leave AMA are re-hospitalized, greater than one in five, within 30 days. This may be an underestimation of the extent of the problem since a pt’s admission to another facility would not be captured in our registry. Pts leaving AMA were younger, more likely male, and with features consistent with worse systolic dysfunction and prognosis. Our study has potential policy implications and further study of these high risk pts who leave AMA is warranted.
014 Depressive Symptoms, Poor Nutritional Intake and Event-Free Survival in Patients with Heart Failure: A Deadly Chain of Events Eun Kyeung Song1, Debra K. Moser1, Heather Payne-Emerson1, Seongkum Heo2, Sandra B. Dunbar3, Susan J. Pressler4, Terry A. Lennie1; 1University of Kentucky; 2 Indiana University; 3Emory University; 4University of Michigan Introduction: Depressive symptoms and malnutrition have been associated with higher risk for hospitalization or death in patients with heart failure (HF). Although depressive symptoms may contribute to poor nutritional intake, the relationship among depressive symptoms, nutritional intake, and event-free survival has not been examined. Hypotheses: 1) Depressive symptoms are associated with poor nutritional intake; 2) Poor nutritional intake predicts event-free survival; 3) Co-existence of depressive symptoms and poor nutritional intake predicts the shortest event-free survival. Methods: A total of 190 patients with HF (age 61 6 12 years, 67% male, 50% NYHA class III/IV, ejection fraction [EF] 34 6 13%) completed the Beck Depression Inventory II (BDI-II). Nutritional intake was defined as the total number of micronutrient deficiencies (range 0 to 15) measured by detailed 4-day food diaries verified by a registered dietitian. Nutrition Data System software was used to determine intake of phosphate, calcium, magnesium, niacin, zinc, folate, selenium, vitamin B1, B2, B6, B12, C, D, E and K. Micronutrient deficiencies corrected for age and gender were defined using methods specified by the Institute of Medicine. Time to hospitalization or death was followed up for 1-year. Hypotheses were tested by hierarchical Cox hazard regression. Results: Worse depressive symptoms were correlated with higher number of micronutrient deficiencies (r 5 0.20, p 5 .007). Severe depressive symptoms (hazard ratio [HR] 5 1.05, 95% CI 5 1.01-1.09) and higher number of micronutrient deficiencies (HR 5 1.13, 95% CI 5 1.02-1.26) independently predicted event-free survival after controlling for age, gender, BMI, etiology of HF, NYHA class, EF, and comorbidities. When stratified into 4 groups, patients with higher number of micronutrient deficiencies (O median split) and depressive symptoms (BDI-II O13) had the shortest event-free survival. Conclusions: Depressive symptoms were associated with shorter event-free survival particularly when paired with poorer nutritional intake in patients with HF.
HFSA
S5
Nursing Research Award 011 Comparison of the Impact of PHQ-9 Scores with and without Physical Symptom Items on Event-Free Survival in Patients with Heart Failure Kyoung Suk Lee1, Terry A. Lennie1, Seongkum Heo2, Jia-Rong Wu1, Misook L. Chung1, Debra K. Moser1; 1College of Nursing, University of Kentucky; 2School of Nursing, Indiana University Background: It is critical to evaluate levels of depressive symptoms in patients with heart failure (HF) because they have a substantial impact on outcomes. Because there are shared physical symptoms between HF and depression, depressive symptom instruments that include physical symptoms of depression might artificially inflate scores in HF patients. One way to assess the accuracy of measurement of depressive symptoms is to explore the iimpact of physical symptom on outcomes using a depression instrument with physical symptoms, and then to use it again with the physical symptoms removed. The purpose of this study was to compare the predictive ability for event-free survival between the full Patient Health Questionnaire-9 (PHQ-9) and the PHQ-9 with the physical symptom items removed. Hypothesis: The full PHQ-9 will account for a greater amount of variance in event-free survival of HF patients than the PHQ-9 with the physical symptom items removed after controlling for relevant variables. Methods: Data from 214 patients with HF (mean age: 61 6 12, female: 33%, NYHA III/IV: 60%) were collected. The PHQ-9 was used to assess levels of depressive symptoms. Event-free survival (mortality, rehospitalization, or emergency department visit for cardiac reasons) was collected for a median follow-up of 335 days. To examine predictive ability on event-free survival after adjusting for relevant variables, of the two versions of the PHQ-9, the scores of each of the two instruments were entered in two separate hierarchical Cox proportional hazard regression analysis. Because the scores of PHQ-9 were skewed, the scores were transformed. Results: After controlling for age, gender, ethnicity, body mass index, comorbidity scores, and NYHA class, scores from the full PHQ-9 predicted event-free survival (HR51.32, 95% CI51.05e1.66). Subsequent analysis was done to evaluate the impact of physical symptoms in the PHQ-9 by excluding 3 physical symptoms. Scores of the PHQ-9 without physical symptoms were an independent predictor of first cardiac event (HR51.12, 95% CI51.02e1.23). Conclusion: Although the hazard ratio is lower for the prediction of event-free survival, removal of physical symptom items from the PHQ-9 does not eliminate the association of depressive symptoms with event-free survival. It is possible to obtain an accurate assessment of depressive symptoms in HF patients using an instrument that includes physical symptoms.
012 Acute Hemodynamic Effects of Nebulised Furosemide in Stable Heart Failure Phillip J. Newton1,2, Patricia M. Davidson1, Henry Krum3, Richard Ollerton2, Peter Macdonald4; 1Centre for Cardiovascular & Chronic Care, Curtin University of Technology, Chippendale, NSW, Australia; 2University of Western Sydney, Penrith, NSW, Australia; 3Centre of Cardiovascular Research & Education, Monash University, Melbourne, VIC, Australia; 4Cardiology Department, St Vincent’s Hospital, Darlinghutst, NSW, Australia Purpose: Dyspnoea is a common and burdensome symptom in heart failure (HF). Nebulised furosemide has been proposed as a novel therapeutic for relieving dyspnoea. This mode of administration is potentially useful in community based settings. However, to date mechanisms of action are unclear. This study sought to measure the acute hemodynamic effects of nebulised furosemide in patients with stable, advanced HF. Methods: In this randomised, double blind, placebo controlled trial, participants undergoing scheduled, right heart catheterisation were randomized to receive either 40mg (4mls) of nebulised furosemide or 4mls of normal saline. Following baseline pulmonary pressure measurement and inhalation of the study medication, subjects’ pulmonary pressures were recorded every 15 minutes for one hour. The volume of urine in the bladder was measured at baseline and at 60 minutes using ultrasound methods. Results: There were no significant differences in the hemodynamic weighted average time course data of the subjects in either group over the study period. Weighted average pulmonary capillary wedge pressure after 60 minutes in the furosemide group was 22.5 6 6.5 mmHg (n514) compared to the placebo group’s 24.0 6 7.3 mmHg (n518), p50.55. No other significant differences were observed in hemodynamic parameters between the two groups. This dose of nebulised furosemide was sufficient to produce a significant change in the median volume of urine in the bladder at 60 minutes 186 ml (124.5 to 247.5) (n58) compared to placebo 76 ml (21.5 to 130.5) ml (n513), p 5 0.02. Conclusions: This study showed that 40mg of nebulised furosemide had no significant effect on the hemodynamic parameters of the participants. Despite this, this dose was able to produce a diuretic effect in these subjects after one hour. Inhalation of furosemide may provide a novel method for drug delivery and requires further investigation.
013 Against Medical Advice and Improved Heart Failure Care Meriam F. Caboral, Judith E. Mitchell; Medicine/Cardiology, SUNY Downstate Medical Center, Brooklyn, NY Background: The hospital to home transition provides a critical opportunity for ensuring progressive heart failure (HF) care; absent for those patients (pts) who
signed out against medical advice (AMA). We sought to determine the characteristics of pts hospitalized with HF who leave AMA compared with pts discharged (d/c) via other modes. Method and Results: Retrospective analysis of pts admitted from April 2003 to Dec 2008 with HF. Of the 3450 pts, 91% black, mean age 68 6 34; mean ejection fraction (EF) 35%618; 2% signed out AMA. Six percent were discharged to alternate care facilities (UCF) and the remainder d/c to home. Differences by gender, EF and re-hospitalization rates separated the three d/c groups as shown in table 1. Age also differed such that the percent of pts older than 60 were 25, 69, 82 in the AMA, home, and UCF groups, respectively. The AMA group appeared sicker with lower EF, higher BNP level and more renal insufficiency. Twenty one percent of the pts who left AMA were re-hospitalized within 30 days. This is in contrast to the re-hospitalization rate of 14% for pts d/c to home and the 19% for pts d/c to an UCF. Although the number of pts signing out
AMA, D/C Home and D/C Alternate Care Facility
% Sex (female%) Age (mean) Mean EF Median BNP Creat $ 2 DM % HTN % ^CAD Re-hospitalization % (# 30 days)
AMA (2%) 25% 54 6 14 29 6 17 1769 43% 33% 77% 26% 21%
*p-value
D/C Home (92%)
**p-value
Alternate Facility (6%)
!0.001 0.003 0.023 !0.001 0.002 NS 0.013 NS 0.13
57% 68 6 35 35 6 17 1160 24% 44% 89% 20% 14%
0.013 0.021 0.11 0.009 NS NS NS 0.01 0.06
66% 74 6 14 37 6 19 1413 28% 37% 87% 29% 19%
* p-value: AMA vs. D/C Home; **p-value: Alternate Care Facility (includes nursing home, rehab, hospice) vs. Home; ^CAD: CABG, PCI, h/o MI, increased troponin. AMA is limited the overall sample size is large and the appraised period extensive, over 5 years. Conclusions: Evaluation of a predominantly black inner city population hospitalized with HF reveals that pts who leave AMA are re-hospitalized, greater than one in five, within 30 days. This may be an underestimation of the extent of the problem since a pt’s admission to another facility would not be captured in our registry. Pts leaving AMA were younger, more likely male, and with features consistent with worse systolic dysfunction and prognosis. Our study has potential policy implications and further study of these high risk pts who leave AMA is warranted.
014 Depressive Symptoms, Poor Nutritional Intake and Event-Free Survival in Patients with Heart Failure: A Deadly Chain of Events Eun Kyeung Song1, Debra K. Moser1, Heather Payne-Emerson1, Seongkum Heo2, Sandra B. Dunbar3, Susan J. Pressler4, Terry A. Lennie1; 1University of Kentucky; 2 Indiana University; 3Emory University; 4University of Michigan Introduction: Depressive symptoms and malnutrition have been associated with higher risk for hospitalization or death in patients with heart failure (HF). Although depressive symptoms may contribute to poor nutritional intake, the relationship among depressive symptoms, nutritional intake, and event-free survival has not been examined. Hypotheses: 1) Depressive symptoms are associated with poor nutritional intake; 2) Poor nutritional intake predicts event-free survival; 3) Co-existence of depressive symptoms and poor nutritional intake predicts the shortest event-free survival. Methods: A total of 190 patients with HF (age 61 6 12 years, 67% male, 50% NYHA class III/IV, ejection fraction [EF] 34 6 13%) completed the Beck Depression Inventory II (BDI-II). Nutritional intake was defined as the total number of micronutrient deficiencies (range 0 to 15) measured by detailed 4-day food diaries verified by a registered dietitian. Nutrition Data System software was used to determine intake of phosphate, calcium, magnesium, niacin, zinc, folate, selenium, vitamin B1, B2, B6, B12, C, D, E and K. Micronutrient deficiencies corrected for age and gender were defined using methods specified by the Institute of Medicine. Time to hospitalization or death was followed up for 1-year. Hypotheses were tested by hierarchical Cox hazard regression. Results: Worse depressive symptoms were correlated with higher number of micronutrient deficiencies (r 5 0.20, p 5 .007). Severe depressive symptoms (hazard ratio [HR] 5 1.05, 95% CI 5 1.01-1.09) and higher number of micronutrient deficiencies (HR 5 1.13, 95% CI 5 1.02-1.26) independently predicted event-free survival after controlling for age, gender, BMI, etiology of HF, NYHA class, EF, and comorbidities. When stratified into 4 groups, patients with higher number of micronutrient deficiencies (O median split) and depressive symptoms (BDI-II O13) had the shortest event-free survival. Conclusions: Depressive symptoms were associated with shorter event-free survival particularly when paired with poorer nutritional intake in patients with HF.