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Nutrition Therapy Improves Outcomes in Ambulatory Heart Failure Clinic
S198
Journal of Cardiac Failure Vol. 11 No. 6 Suppl. 2005
406
408
Lack of Gender Disparity in Quality of Care in the ACC Mid-Michigan Guidelines Applied in Practice-HF Initiative Cecelia K. Montoye1, Anthony C. DeFranco2, Jianming Fang3, Kim A. Eagle3, Stephen Skorcz4, Theresa K. Aldini5, Todd M. Koelling3; 1Michigan Heart and Vascular Institute, St. Joseph Mercy Hospital, Ann Arbor, MI; 2Cardiology Associates, Edgewood, KY; 3Cardiovascular Center, University of Michigan, Ann Arbor, MI; 4 Greater Flint Health Coalition, Flint, MI; 5HCCIP, MPRO, Southfield, MI
6-Minute Walk Can Predict Peak VO2 in a Population of HF Patients Admitted for Decompensation I. L. Pina1, S. D. Russell2, M. R. Shah3, V. A. Bittner4, L. W. Stevenson5; 1Division of Cardiology, Case Western Reserve University, Cleveland, OH; 2Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD; 3Department of Medicine, Columbia University Medical Center, New York, NY; 4Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL; 5Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA
Objective: Previous studies have suggested that women hospitalized with heart failure receive lower quality of care compared to men. Methods: Data from the ACC MidMichigan HF GAP study, a quality improvement initiative in 2003–2004, were used to assess disparity in care based on gender. Analysis was completed to determine rates of LVEF assessment, medication prescription, documentation of discharge instructions and smoking counseling for women compared to men. Comparisons based on gender were made for subjects discharged to home. Results: Females were older than males (72.3 vs 70.0 years, p ⬍ 0.0001), were less likely to have CAD (61.3% vs 74.3%, p ⬍ 0.0001), but more likely to have HTN (82.7% vs 79.2%, p ⫽ 0.0166) and diabetes (50.3% vs 46.2%, p ⫽ 0.0327). Females were 36% less likely to have low LVEF compared to males (32.4% vs 50.6%, p ⬍ 0.0001) and were more than twice as likely to be discharged to a skilled nursing facility rather than to home compared to males (14.8% vs 6.1%, p ⬍ 0.0001). Despite these baseline differences, guideline-based medical care was similar for females and males (see table). Females were less likely to have LVEF documented compared to males (81.6% vs 84.9%, p ⫽ 0.0211), but were more likely to receive appropriate smoking cessation advice than males (62.4% vs 52.3%, p ⫽ 0.0191). Additionally, there were no differences in the use of study tools (heart failure standard admission orders, clinical pathways or discharge contracts) based on gender. Conclusions: While females with heart failure differ in many ways compared to male heart failure patients, there is little gender disparity in the quality of care demonstrated in the ACC Mid-Michigan HF GAP initiative.
Endpoint
Heart Failure Quality Measures and Gender Male n ⫽ 1367 (%) LVEF documented ACE-I or alternative Beta Blocker Aldosterone inhibitor D/C instructions Smoking counseling
Female n ⫽ 1412 (%)
84.9 77.3 77.2 31.3 20.6 52.3
Background: The correlation between peak (pk) VO2 and 6-min walk has not been well established in NYHA class IV pts due to safety concerns. Whether pk VO2 is predictive of mortality in this population is unknown due to limited data and concerns about exercising a pts with decompensated HF. Methods: ESCAPE randomized 433 pts with decompensated HF to treatment with PAC (n ⫽ 215) or control (n ⫽ 218). Age 56, 74% male, 85% NYHA class IV, 15% class III. A cardiopulmonary test (CPX) was done for functional capacity and a 6-min walk, if the pt was able. Of the pts randomized, 29.2% underwent CPX on admission and 30.4% at discharge. A total of 80.3% pts had a 6-min walk test at entry and 72.5% at discharge. Baseline, pk VO2 was 10.09 mL/min/kg and 6-min walk was 416.1 ft. There was a modest (but highly significant) correlation between baseline pk VO2 and 6-min walk distance, (r ⫽ 0.430; P ⬍ 0.0001); it was nearly identical at discharge. Pts who had VO2 measured at baseline were no more or less likely to have an outcome than pts who did not. Mortality for pts who had a VO2 was 18.70%. None of the outcome measures were significantly related to baseline VO2, but they trended in the same direction (Table). Included in the Table is the ability of VO2 and the 6-min walk to predict mortality in pts who had both tests. In this cohort with mostly Class IV symptoms needing hospitalization, the 6-min walk correlated modestly but significantly with pk VO2. In pts with both CPX and 6-min walk, neither predicted mortality.
81.6 79.9 76.2 30.0 21.9 62.4
p value 0.0211 0.3033 0.6963 0.6436 0.3935 0.0191
Outcome Estimate
Days well (primary) Mortality Survival Death/rehospitalization
HR OR HR HR
0.947 0.833 0.888 0.886
VO2 6 MW (per 100 ft)
OR OR
0.883 0.976
95% CI
0.748, 1.043 0.851, 1.119
Chi-square
P value
3.48 2.14 2.25 2.13
0.062 0.144 0.134 0.145
2.14 0.12
0.1435 0.7281
407 Nutrition Therapy Improves Outcomes in Ambulatory Heart Failure Clinic Sonya Page1, Iwona Rudkowska2, Nadia Giannetti1, Hugues Plourde2; 1Cardiology, McGill University Health Centre, Montreal, QC, Canada; 2School of Dietetics and Human Nutrition, McGill University, Montreal, QC, Canada Introduction: Sodium and fluid restriction are essential in the management of symptomatic heart failure. To our knowledge no randomized controlled trials have examined the effectiveness of medical nutrition therapy on pertinent heart failure outcomes. Hypothesis: Nutrition therapy will improve nutritional status and quality of life and decrease number of emergency room admissions in ambulatory heart failure clinic patients. Methods: A three-month prospective randomized clinical trial was conducted to evaluate the effectiveness of nutrition therapy in heart failure. Inclusion criteria included NYHA functional class II to IV. A total of 60 subjects (30 treatment; 30 controls) were recruited. Control subjects were taught sodium and fluid restrictions by the clinic nurse. The treatment group received comprehensive nutrition therapy and follow-up from a nutritionist in addition to the care provided by the clinic nurse. This included implementing sodium and fluid restrictions and establishing weight goals. Measurable outcomes included usual intake questionnaires, weight loss, Minnesota Living With Heart Failure Quality of Life Questionnaire, and emergency room admissions. Results: Functional Outcomes Control (n ⫽ 23) Treatment (n ⫽ 22) p-value ⫺3.5 6
Quality of Life Score Number of subjects with ER Visits
⫺5.6 0
0.536 0.029
Nutritional Outcomes Control (n ⫽ 23) Weight Calories Sodium intake Fluid intake
Units
Before
kg kcal mg liter
89.8 2057 2746 2.3
After 89.5 2014 4025 2.2
Treatment (n ⫽ 22)
p-value
Before
0.765 0.783 0.057 0.218
84.0 2307 4120 2.3
After 82.7 1709 2657 1.8
p-value 0.036 0.005 0.001 0.001
Conclusion: Nutrition therapy improves important outcomes in ambulatory heart failure clinic patients. Improvements were observed in reduced sodium and fluid intakes; improved weight status; and fewer emergency room admissions. Medical nutrition therapy should be part of every heart failure clinic.
409 Do Elderly Patients with Chronic Left Ventricular Systolic Dysfunction Benefit from Aerobic Training and Supervised Cardiac Rehabilitation? Robert M. Siegel, Ambika Bhaskaran, Lawrence Cook, Jennifer Vermillion, James Romo, John Johnson, Greta Koehnemann; Division of Research, Advanced Cardiac Specialists, Gilbert, AZ; Department of Cardiology, Mesa General Hospital, Mesa, AZ Cardiac rehabilitation is an important factor in reducing morbidity and mortality in patients with chronic LV systolic dysfunction (LVSD) due to cardiovascular disease. It improves functional capacity, modifies LV geometry, reduces ischemic burden, and reduces the risk for future coronary events. The benefits of cardiac rehabilitation in elderly patients remains undefined. We evaluated the effects of a 12-week physical training program in patients age ⱖ70 years with significant chronic LVSD (LVEF ⱕ40%). From 1/00 to 12/04, 1,263 patients (mean age 76 years; 39% female) were enrolled in a supervised exercise program. Of these, 32% had recent acute coronary syndrome and 62.5% had multivessel chronic CAD. The aerobic exercise prescription used a preset protocol consisting of ECG-monitored, symptom-limited cycle ergometry and treadmill walking up to 60 minutes/session, 3 days/week. The intensity of exercise was set at 60–70% of HR reserve. Multiple indices of exercise tolerance, echo-based LVEF and metabolic parameters were recorded at time of entry into and at completion of cardiac rehabilitation.
Journal of Cardiac Failure Vol. 11 No. 6 Suppl. 2005
406
408
Lack of Gender Disparity in Quality of Care in the ACC Mid-Michigan Guidelines Applied in Practice-HF Initiative Cecelia K. Montoye1, Anthony C. DeFranco2, Jianming Fang3, Kim A. Eagle3, Stephen Skorcz4, Theresa K. Aldini5, Todd M. Koelling3; 1Michigan Heart and Vascular Institute, St. Joseph Mercy Hospital, Ann Arbor, MI; 2Cardiology Associates, Edgewood, KY; 3Cardiovascular Center, University of Michigan, Ann Arbor, MI; 4 Greater Flint Health Coalition, Flint, MI; 5HCCIP, MPRO, Southfield, MI
6-Minute Walk Can Predict Peak VO2 in a Population of HF Patients Admitted for Decompensation I. L. Pina1, S. D. Russell2, M. R. Shah3, V. A. Bittner4, L. W. Stevenson5; 1Division of Cardiology, Case Western Reserve University, Cleveland, OH; 2Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD; 3Department of Medicine, Columbia University Medical Center, New York, NY; 4Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL; 5Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA
Objective: Previous studies have suggested that women hospitalized with heart failure receive lower quality of care compared to men. Methods: Data from the ACC MidMichigan HF GAP study, a quality improvement initiative in 2003–2004, were used to assess disparity in care based on gender. Analysis was completed to determine rates of LVEF assessment, medication prescription, documentation of discharge instructions and smoking counseling for women compared to men. Comparisons based on gender were made for subjects discharged to home. Results: Females were older than males (72.3 vs 70.0 years, p ⬍ 0.0001), were less likely to have CAD (61.3% vs 74.3%, p ⬍ 0.0001), but more likely to have HTN (82.7% vs 79.2%, p ⫽ 0.0166) and diabetes (50.3% vs 46.2%, p ⫽ 0.0327). Females were 36% less likely to have low LVEF compared to males (32.4% vs 50.6%, p ⬍ 0.0001) and were more than twice as likely to be discharged to a skilled nursing facility rather than to home compared to males (14.8% vs 6.1%, p ⬍ 0.0001). Despite these baseline differences, guideline-based medical care was similar for females and males (see table). Females were less likely to have LVEF documented compared to males (81.6% vs 84.9%, p ⫽ 0.0211), but were more likely to receive appropriate smoking cessation advice than males (62.4% vs 52.3%, p ⫽ 0.0191). Additionally, there were no differences in the use of study tools (heart failure standard admission orders, clinical pathways or discharge contracts) based on gender. Conclusions: While females with heart failure differ in many ways compared to male heart failure patients, there is little gender disparity in the quality of care demonstrated in the ACC Mid-Michigan HF GAP initiative.
Endpoint
Heart Failure Quality Measures and Gender Male n ⫽ 1367 (%) LVEF documented ACE-I or alternative Beta Blocker Aldosterone inhibitor D/C instructions Smoking counseling
Female n ⫽ 1412 (%)
84.9 77.3 77.2 31.3 20.6 52.3
Background: The correlation between peak (pk) VO2 and 6-min walk has not been well established in NYHA class IV pts due to safety concerns. Whether pk VO2 is predictive of mortality in this population is unknown due to limited data and concerns about exercising a pts with decompensated HF. Methods: ESCAPE randomized 433 pts with decompensated HF to treatment with PAC (n ⫽ 215) or control (n ⫽ 218). Age 56, 74% male, 85% NYHA class IV, 15% class III. A cardiopulmonary test (CPX) was done for functional capacity and a 6-min walk, if the pt was able. Of the pts randomized, 29.2% underwent CPX on admission and 30.4% at discharge. A total of 80.3% pts had a 6-min walk test at entry and 72.5% at discharge. Baseline, pk VO2 was 10.09 mL/min/kg and 6-min walk was 416.1 ft. There was a modest (but highly significant) correlation between baseline pk VO2 and 6-min walk distance, (r ⫽ 0.430; P ⬍ 0.0001); it was nearly identical at discharge. Pts who had VO2 measured at baseline were no more or less likely to have an outcome than pts who did not. Mortality for pts who had a VO2 was 18.70%. None of the outcome measures were significantly related to baseline VO2, but they trended in the same direction (Table). Included in the Table is the ability of VO2 and the 6-min walk to predict mortality in pts who had both tests. In this cohort with mostly Class IV symptoms needing hospitalization, the 6-min walk correlated modestly but significantly with pk VO2. In pts with both CPX and 6-min walk, neither predicted mortality.
81.6 79.9 76.2 30.0 21.9 62.4
p value 0.0211 0.3033 0.6963 0.6436 0.3935 0.0191
Outcome Estimate
Days well (primary) Mortality Survival Death/rehospitalization
HR OR HR HR
0.947 0.833 0.888 0.886
VO2 6 MW (per 100 ft)
OR OR
0.883 0.976
95% CI
0.748, 1.043 0.851, 1.119
Chi-square
P value
3.48 2.14 2.25 2.13
0.062 0.144 0.134 0.145
2.14 0.12
0.1435 0.7281
407 Nutrition Therapy Improves Outcomes in Ambulatory Heart Failure Clinic Sonya Page1, Iwona Rudkowska2, Nadia Giannetti1, Hugues Plourde2; 1Cardiology, McGill University Health Centre, Montreal, QC, Canada; 2School of Dietetics and Human Nutrition, McGill University, Montreal, QC, Canada Introduction: Sodium and fluid restriction are essential in the management of symptomatic heart failure. To our knowledge no randomized controlled trials have examined the effectiveness of medical nutrition therapy on pertinent heart failure outcomes. Hypothesis: Nutrition therapy will improve nutritional status and quality of life and decrease number of emergency room admissions in ambulatory heart failure clinic patients. Methods: A three-month prospective randomized clinical trial was conducted to evaluate the effectiveness of nutrition therapy in heart failure. Inclusion criteria included NYHA functional class II to IV. A total of 60 subjects (30 treatment; 30 controls) were recruited. Control subjects were taught sodium and fluid restrictions by the clinic nurse. The treatment group received comprehensive nutrition therapy and follow-up from a nutritionist in addition to the care provided by the clinic nurse. This included implementing sodium and fluid restrictions and establishing weight goals. Measurable outcomes included usual intake questionnaires, weight loss, Minnesota Living With Heart Failure Quality of Life Questionnaire, and emergency room admissions. Results: Functional Outcomes Control (n ⫽ 23) Treatment (n ⫽ 22) p-value ⫺3.5 6
Quality of Life Score Number of subjects with ER Visits
⫺5.6 0
0.536 0.029
Nutritional Outcomes Control (n ⫽ 23) Weight Calories Sodium intake Fluid intake
Units
Before
kg kcal mg liter
89.8 2057 2746 2.3
After 89.5 2014 4025 2.2
Treatment (n ⫽ 22)
p-value
Before
0.765 0.783 0.057 0.218
84.0 2307 4120 2.3
After 82.7 1709 2657 1.8
p-value 0.036 0.005 0.001 0.001
Conclusion: Nutrition therapy improves important outcomes in ambulatory heart failure clinic patients. Improvements were observed in reduced sodium and fluid intakes; improved weight status; and fewer emergency room admissions. Medical nutrition therapy should be part of every heart failure clinic.
409 Do Elderly Patients with Chronic Left Ventricular Systolic Dysfunction Benefit from Aerobic Training and Supervised Cardiac Rehabilitation? Robert M. Siegel, Ambika Bhaskaran, Lawrence Cook, Jennifer Vermillion, James Romo, John Johnson, Greta Koehnemann; Division of Research, Advanced Cardiac Specialists, Gilbert, AZ; Department of Cardiology, Mesa General Hospital, Mesa, AZ Cardiac rehabilitation is an important factor in reducing morbidity and mortality in patients with chronic LV systolic dysfunction (LVSD) due to cardiovascular disease. It improves functional capacity, modifies LV geometry, reduces ischemic burden, and reduces the risk for future coronary events. The benefits of cardiac rehabilitation in elderly patients remains undefined. We evaluated the effects of a 12-week physical training program in patients age ⱖ70 years with significant chronic LVSD (LVEF ⱕ40%). From 1/00 to 12/04, 1,263 patients (mean age 76 years; 39% female) were enrolled in a supervised exercise program. Of these, 32% had recent acute coronary syndrome and 62.5% had multivessel chronic CAD. The aerobic exercise prescription used a preset protocol consisting of ECG-monitored, symptom-limited cycle ergometry and treadmill walking up to 60 minutes/session, 3 days/week. The intensity of exercise was set at 60–70% of HR reserve. Multiple indices of exercise tolerance, echo-based LVEF and metabolic parameters were recorded at time of entry into and at completion of cardiac rehabilitation.