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Cardiovascular Comorbidities in Patients at the Time of Their Network Entry Visit to Specialized Heart Failure Outpatient Clinics in the Canadian Heart Failure Network (CHFN) 1999 to 2007
S108 Journal of Cardiac Failure Vol. 15 No. 6S Suppl. 2009 Cardiovascular Division of Medicine, National Cardiovascular Center, Suita, Osaka, Japan Introduction: The strategies of medical therapy for acute decompensated heart failure (ADHF) should be based on systemic vascular resistance (SVR), cardiac output (CO) and ventricular filling pressures. Among these parameters, SVR, however, have been paid little attention because of its difficulty of noninvasive estimation. Hypothesis: We hypotheised that echo-doppler cardiogram derived SVR in ADHF was accurarate, feasibile and traceable. Methods: Twenty patients with ADHF were enrolled and all patients were categorized to the subset of Cold & Wet status. Pulmonary artery catheter was introduced into all patients to compare with echoderived homodynamic parameters. SVR was calculated from peak mitral regurgitant velocity (MRV) divided by left ventricular outflow tract velocity-time integral (VTILVOT). Cardiac output (CO) was calculated from VTILVOT. Various types of intravenous cardiac inotropes and vasodilators (such as dobutamine, PDE3I, nitroglycerine, natriuretic peptides.) were administered to treat ADHF. Catheter(c)-derived cSVR and cCO and their dynamic change induced by drugs (delta cSVR and delta cCO) were compared with echo(e)-derived eSVR, eCO, and delta eSVR and delta eCO, respectively. At total of 58 points, measurements were performed before and one-hour after drug initiation, up/ down-titration and/or drug exchange. Results: CO was inversely correlated with SVR (p!0.05). Catheter-derived and echo-derived SVR and CO and their dynamic changes, induced by drugs, were well correlated, regardless of types of cardio-vaso active drugs (cSVR vs. eSVR: r50.70, p!0.0001, delta cSVR vs. delta eSVR: r50.67, p!0.002, cCO vs. eCO: r50.65, p!0.0001, delta cCO vs. delta eCO: r50.73, p!0.0005). Conclusion: Echo derived measurement for systemic vascular resistance and cardiac output was feasible, accurate and traceable. These noninvasive measurements would provide the optimal drug selection in acute decompensated heart failure.
360 A Multidisciplinary Team Management Program to Decrease ReHospitalization in CHF Patients Casey Lawler, Justin Kirven, Pam Rush, Steve Bergeson; Minneapolis Heart Institute at Abbott-Northwestern Hospital, Minneapolis, MN Introduction: Congestive heart failure is the leading cause of hospitalization among the elderly and the economic burden is significant with an approximate cost of 35 billion dollars annually in the US. A substantial portion of this cost is due to readmission; with over 20% readmitted within 30 days of discharge. Hypothesis: A Multidisciplinary Team comprised of CHF cardiologists, hospitalists, home health care nurses, and hospital administrators (ANW Heart Failure Workgroup) will identify and then implement a care model which will decrease the 30 day hospitial readmission rate for CHF patients. Methods: The ANW CHF Workgroup identified three general areas of opportunity to achieve this goal: to ensure timeliness of care; to reconcile and optimize medications; and to educate and empower patient self-management. To effectively implement strategies involving these three areas a combined approach of telephone communication and in-person contact was utilized. At hospital discharge, a f/u visit within 3 to 5 days was scheduled with the patient’s primary care physician or CHF Clinc. Patients received a phone call by a triage nurse within 24 to 48 hours after hospital discharge; followed by a home health care nurse visit if the initial telephone call identified a patient at high risk (30% of patients). At these points of patient contact caregivers reconciled medications and reviewed a self management support tool (Red/Yellow/Green HF Zones) which emphasizes self knowledge regarding medications and dietary compliance as well as ‘‘warning signs’’ regarding signs and symptoms of heart failure decompensation. Patients were then directed to addtional caregiver f/u in clinic if deemed high risk of decompensation. Results: The program began in early 2008 and data collection began in April 2008. Patients with a scheduled f/u within 3 to 5 days post discharge increased from 30% to 60%. Patient understanding of CHF medications after a home health care visit increased from 21.1% to 71.5% and patient understanding of the heart failure warning signs increased from 15.6% to 83.9%. The CHF readmission rate at our institution in 2006 was 21.1% and in 2007 was 21.6%. After implementation of the program in 2008 the readmission rate dropped to 17.9% - a relative reduction of 17.5% (p ! 0.05). Conclusions: The ANW CHF Workgroup identified and implemented a management program, directed at the transition from hospital discharge to outpatient follow up, which significantly decreased the 30 day hospital readmisson for CHF patients.
of their practice and referral requirements according to local resources which may differ across the country. We analyzed the characteristics of heart failure patients referred to CHFN clinics from January 1999 to December 2007 and describe some of the cardiovascular comorbidities at the time of first database entry when referral to a specialized clinic was considered necessary or desirable by the referring physician. Over that period of time, data from the first CHFN visit were recorded on 10,449 patients by 26 active CHFN clinics. In the full referred population, the mean LVEF was 31.9%, the mean age was 64.7 6 2 (sd), 69.2 6 2% were male, and 89% were Caucasian. The NYHA class was I 14%, II 39%, IIIa 40%, IIIb 2%, IV 5%. The etiology was attributed as ischemic in 54%. Other selected co-morbidities are provided in the Table comparing data over the last 4 years. Comorbidities in CHFN Heart Failure Patients 2004-07
Patients (n) Hypertension % Diabetes % Dyslipidemia % Curr/Ex Smoker % Renal dysfunction %
Total
2004
2005
2006
2007
5344 40.1 55.1 35.8 70.7 17.6
1357 36.2 62.1 34.9 72.4 18.2
1327 38.7 53.2 36.0 72.0 17.7
1245 41.6 51.7 35.7 70.9 19.0
1415 43.8 54.0 36.4 67.8 15.6
Compared to some published reports of patients admitted with acute heart failure in Canada, the US and Europe, patients referred to the outpatient heart failure clinics of the CHFN appear to be younger with less hypertension but more diabetes. These differences may reflect referral bias to specialized clinics or could indicate assessment differences in an acute vs chronic setting and differences in individual treatments or diagnosis thresholds.
362 ß-Blocker Therapy Is Associated with Increased Re-Hospitalization for Heart Failure in Women with Heart Failure and Preserved Ejection Fraction S. Morteza Farasat1, Dennis T. Bolger2, Veena Shetty1, Elizabeth P. Menachery2, Gary Gerstenblith2, Edward K. Kasper2, Samer S. Najjar3; 1NIA-ASTRA at Harbor Hospital, MedStar Research Institute, Baltimore, MD; 2Department of Medicine, Johns Hopkins University, Baltimore, MD; 3Laboratory of Cardiovascular Science, National Institute on Aging, NIH, Baltimore, MD Background: b-blockers are empirically used in many patients with heart failure (HF) and preserved ejection fraction (HFpEF) because they allow more time for diastolic filling and because they improve outcomes in patients with systolic HF. However, recent data suggest that impaired chronotropic and vasodilator responses to exercise, which can worsen with b-blockade, may play a key role in the pathophysiology of HFpEF. Methods and Results: We prospectively examined the association between b-blocker therapy after hospitalization for decompensated HF and HF re-hospitalization at 6 months in 66 consecutive HFpEF patients (Framingham criteria for HF and EF $50%). Subjects (age571 6 13 years, 68% women, 42% Black) were stratified based on receiving (BBþ; 15 men, 28 women) or not receiving (BB-) b-blockers at hospital discharge. We also compared the improvement in NYHA class at 6 months (DNYHA) between the 2 study groups. At 6 months, 30 subjects (24 women) experienced at least one HF re-hospitalization. In men, HF re-hospitalization occurred less frequently in the BBþ than in the BB- group, albeit non-significantly (20% vs. 50%; P50.29), with no differences in DNYHA (-1.20 6 0.17 vs. -1.50 6 0.22, respectively; P50.35). In women, HF re-hospitalization occurred more frequently in the BBþ than in the BB- group (75% vs. 18%; P!0.001) and the BBþ group had a smaller DNYHA than the BB- group (-0.54 6 0.20 vs. -1.63 6 0.15; P!0.001). In univariate analyses, discharge b-blocker was associated with HF re-hospitalization in women (OR514.00, 95% CI53.09-63.51; P50.001), but not in men (OR50.25, 95% CI50.03-1.92; P50.18). In a forward logistic regression model that offered all univariate predictors of HF re-hospitalization, discharge b-blocker remained an independent predictor of HF re-hospitalization in women (OR511.06, 95% CI51.98-61.67, P50.006), even after adjusting for the propensity to receive discharge b-blocker (OR516.39, 95% CI52.11-127.53, P50.008). Conclusion: This observational study suggests that bblocker therapy may be associated with a significantly higher risk of HF re-hospitalization in women with HFpEF. Randomized, controlled trials are needed to evaluate the risks and benefits of b-blockade in HFpEF patients.
361 Cardiovascular Comorbidities in Patients at the Time of Their Network Entry Visit to Specialized Heart Failure Outpatient Clinics in the Canadian Heart Failure Network (CHFN) 1999 to 2007 Malcolm Arnold, Andrew Ignaszewski, Haissam Haddad, Jonathan Howlett, MarieHelene LeBlanc, Canadian Heart Failure Network; Cardiology, University of Western Ontario, London, ON; Cardiology, St Paul’s Hospital, Vancouver, BC; Cardiology, Ottawa Heart Institute, Ottawa, ON; Cardiology, Foothills Hospital, Calgary, AB; Cardiology, Quebec Heart Institute, Quebec City, QC The CHFN links 26 clinics across Canada which share a common longitudinal database and philosophy that a specialized heart failure physician(s) and nurse(s) can optimize care in patients referred from hospital or community physicians. The Network supports the Canadian Cardiovascular Society national guidelines for the diagnosis and management of heart failure but each clinic determines the full focus and scope
363 WITHDRAWN
364 HF Family Caregiver Outcomes and Associated Factors Sandra B. Dunbar1, Patricia C. Clark2, Rebecca A. Gary1, Christina Quinn1, Carolyn M. Reilly1, Andrew Smith3, Melinda Higgins1; 1Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA; 2Brydine Lewis School of Nursing, Georgia State University, Atlanta, GA; 3School of Medicine, Emory University, Atlanta, GA Background: Family caregivers (FCGs) provide essential social and self care support to HF patients, yet little is known about caregiving burden or factors associated with
360 A Multidisciplinary Team Management Program to Decrease ReHospitalization in CHF Patients Casey Lawler, Justin Kirven, Pam Rush, Steve Bergeson; Minneapolis Heart Institute at Abbott-Northwestern Hospital, Minneapolis, MN Introduction: Congestive heart failure is the leading cause of hospitalization among the elderly and the economic burden is significant with an approximate cost of 35 billion dollars annually in the US. A substantial portion of this cost is due to readmission; with over 20% readmitted within 30 days of discharge. Hypothesis: A Multidisciplinary Team comprised of CHF cardiologists, hospitalists, home health care nurses, and hospital administrators (ANW Heart Failure Workgroup) will identify and then implement a care model which will decrease the 30 day hospitial readmission rate for CHF patients. Methods: The ANW CHF Workgroup identified three general areas of opportunity to achieve this goal: to ensure timeliness of care; to reconcile and optimize medications; and to educate and empower patient self-management. To effectively implement strategies involving these three areas a combined approach of telephone communication and in-person contact was utilized. At hospital discharge, a f/u visit within 3 to 5 days was scheduled with the patient’s primary care physician or CHF Clinc. Patients received a phone call by a triage nurse within 24 to 48 hours after hospital discharge; followed by a home health care nurse visit if the initial telephone call identified a patient at high risk (30% of patients). At these points of patient contact caregivers reconciled medications and reviewed a self management support tool (Red/Yellow/Green HF Zones) which emphasizes self knowledge regarding medications and dietary compliance as well as ‘‘warning signs’’ regarding signs and symptoms of heart failure decompensation. Patients were then directed to addtional caregiver f/u in clinic if deemed high risk of decompensation. Results: The program began in early 2008 and data collection began in April 2008. Patients with a scheduled f/u within 3 to 5 days post discharge increased from 30% to 60%. Patient understanding of CHF medications after a home health care visit increased from 21.1% to 71.5% and patient understanding of the heart failure warning signs increased from 15.6% to 83.9%. The CHF readmission rate at our institution in 2006 was 21.1% and in 2007 was 21.6%. After implementation of the program in 2008 the readmission rate dropped to 17.9% - a relative reduction of 17.5% (p ! 0.05). Conclusions: The ANW CHF Workgroup identified and implemented a management program, directed at the transition from hospital discharge to outpatient follow up, which significantly decreased the 30 day hospital readmisson for CHF patients.
of their practice and referral requirements according to local resources which may differ across the country. We analyzed the characteristics of heart failure patients referred to CHFN clinics from January 1999 to December 2007 and describe some of the cardiovascular comorbidities at the time of first database entry when referral to a specialized clinic was considered necessary or desirable by the referring physician. Over that period of time, data from the first CHFN visit were recorded on 10,449 patients by 26 active CHFN clinics. In the full referred population, the mean LVEF was 31.9%, the mean age was 64.7 6 2 (sd), 69.2 6 2% were male, and 89% were Caucasian. The NYHA class was I 14%, II 39%, IIIa 40%, IIIb 2%, IV 5%. The etiology was attributed as ischemic in 54%. Other selected co-morbidities are provided in the Table comparing data over the last 4 years. Comorbidities in CHFN Heart Failure Patients 2004-07
Patients (n) Hypertension % Diabetes % Dyslipidemia % Curr/Ex Smoker % Renal dysfunction %
Total
2004
2005
2006
2007
5344 40.1 55.1 35.8 70.7 17.6
1357 36.2 62.1 34.9 72.4 18.2
1327 38.7 53.2 36.0 72.0 17.7
1245 41.6 51.7 35.7 70.9 19.0
1415 43.8 54.0 36.4 67.8 15.6
Compared to some published reports of patients admitted with acute heart failure in Canada, the US and Europe, patients referred to the outpatient heart failure clinics of the CHFN appear to be younger with less hypertension but more diabetes. These differences may reflect referral bias to specialized clinics or could indicate assessment differences in an acute vs chronic setting and differences in individual treatments or diagnosis thresholds.
362 ß-Blocker Therapy Is Associated with Increased Re-Hospitalization for Heart Failure in Women with Heart Failure and Preserved Ejection Fraction S. Morteza Farasat1, Dennis T. Bolger2, Veena Shetty1, Elizabeth P. Menachery2, Gary Gerstenblith2, Edward K. Kasper2, Samer S. Najjar3; 1NIA-ASTRA at Harbor Hospital, MedStar Research Institute, Baltimore, MD; 2Department of Medicine, Johns Hopkins University, Baltimore, MD; 3Laboratory of Cardiovascular Science, National Institute on Aging, NIH, Baltimore, MD Background: b-blockers are empirically used in many patients with heart failure (HF) and preserved ejection fraction (HFpEF) because they allow more time for diastolic filling and because they improve outcomes in patients with systolic HF. However, recent data suggest that impaired chronotropic and vasodilator responses to exercise, which can worsen with b-blockade, may play a key role in the pathophysiology of HFpEF. Methods and Results: We prospectively examined the association between b-blocker therapy after hospitalization for decompensated HF and HF re-hospitalization at 6 months in 66 consecutive HFpEF patients (Framingham criteria for HF and EF $50%). Subjects (age571 6 13 years, 68% women, 42% Black) were stratified based on receiving (BBþ; 15 men, 28 women) or not receiving (BB-) b-blockers at hospital discharge. We also compared the improvement in NYHA class at 6 months (DNYHA) between the 2 study groups. At 6 months, 30 subjects (24 women) experienced at least one HF re-hospitalization. In men, HF re-hospitalization occurred less frequently in the BBþ than in the BB- group, albeit non-significantly (20% vs. 50%; P50.29), with no differences in DNYHA (-1.20 6 0.17 vs. -1.50 6 0.22, respectively; P50.35). In women, HF re-hospitalization occurred more frequently in the BBþ than in the BB- group (75% vs. 18%; P!0.001) and the BBþ group had a smaller DNYHA than the BB- group (-0.54 6 0.20 vs. -1.63 6 0.15; P!0.001). In univariate analyses, discharge b-blocker was associated with HF re-hospitalization in women (OR514.00, 95% CI53.09-63.51; P50.001), but not in men (OR50.25, 95% CI50.03-1.92; P50.18). In a forward logistic regression model that offered all univariate predictors of HF re-hospitalization, discharge b-blocker remained an independent predictor of HF re-hospitalization in women (OR511.06, 95% CI51.98-61.67, P50.006), even after adjusting for the propensity to receive discharge b-blocker (OR516.39, 95% CI52.11-127.53, P50.008). Conclusion: This observational study suggests that bblocker therapy may be associated with a significantly higher risk of HF re-hospitalization in women with HFpEF. Randomized, controlled trials are needed to evaluate the risks and benefits of b-blockade in HFpEF patients.
361 Cardiovascular Comorbidities in Patients at the Time of Their Network Entry Visit to Specialized Heart Failure Outpatient Clinics in the Canadian Heart Failure Network (CHFN) 1999 to 2007 Malcolm Arnold, Andrew Ignaszewski, Haissam Haddad, Jonathan Howlett, MarieHelene LeBlanc, Canadian Heart Failure Network; Cardiology, University of Western Ontario, London, ON; Cardiology, St Paul’s Hospital, Vancouver, BC; Cardiology, Ottawa Heart Institute, Ottawa, ON; Cardiology, Foothills Hospital, Calgary, AB; Cardiology, Quebec Heart Institute, Quebec City, QC The CHFN links 26 clinics across Canada which share a common longitudinal database and philosophy that a specialized heart failure physician(s) and nurse(s) can optimize care in patients referred from hospital or community physicians. The Network supports the Canadian Cardiovascular Society national guidelines for the diagnosis and management of heart failure but each clinic determines the full focus and scope
363 WITHDRAWN
364 HF Family Caregiver Outcomes and Associated Factors Sandra B. Dunbar1, Patricia C. Clark2, Rebecca A. Gary1, Christina Quinn1, Carolyn M. Reilly1, Andrew Smith3, Melinda Higgins1; 1Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA; 2Brydine Lewis School of Nursing, Georgia State University, Atlanta, GA; 3School of Medicine, Emory University, Atlanta, GA Background: Family caregivers (FCGs) provide essential social and self care support to HF patients, yet little is known about caregiving burden or factors associated with