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Early Goal Directed Sepsis Management in Patients with Heart Failure and Concomitant Chronic Kidney Disease
The 23rd Annual Scientific Meeting HFSA
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Management Strategies/Adherence/Self Care 266 Pulmonary Artery Pressure-Guided Heart Failure Management is Associated with Slower Decline in Kidney Function Nour Tashtish, Sadeer Al-Kindi, Steven C. Mitchell, Guilherme H. Oliveira, Arash Rashidi, Monique Robinson; University Hospital Cleveland Medical Center, Cleveland, OH Background: Renal impairment is common among patients with heart failure and portends worse outcomes. We sought to describe the impact of euvolemia maintenance via pulmonary artery pressure-guided management of heart failure on the trajectory of kidney function. Hypothesis: We hypothesized that PAP- guided management is associated with slowing eGFR decline in heart failure patients. Methods: We retrospectively reviewed kidney function 1 year prior to implant, and 1 year after implantation of a wireless pulmonary-artery hemodynamic monitoring sensor (CardioMEMS, St Jude Medical, St Paul, MN). Glomerular filtration rate (eGFR) was estimated using standard equations (MDRD, Cockroft-Gault, and CKD-EPI). Standardized annual change in eGFR was compared prior to and after CardioMEMS implantation using related-samples Wilcoxon Signed Rank Test. Results: A total of 70 patients were included with a median age of 74 [67-79] years. Forty-two patients (60%) were male and 53 (76%) were white. Their median left ventricular ejection fraction was 41% [25-50]. Median eGFR before CardioMEMS implantation decreased from 61 [40-77] to 48 [30-64] ml/ min/1.73 m2 (P<0.001) but did not change after CardioMEMs implantation (44 [3067] ml/min/1.73 m2, P=0.17). Annualized rate of eGFR change was -6.1 [-18.6 to 2.2] ml/min/1.73 m2 before vs -1.1 [-9.6 to 4.0] ml/min/1.73 m2 after CardioMEMS (P=0.046). This difference was more pronounced among patients <74 years (P=0.009), with left ventricular ejection fraction 50% (P=0.039), RA pressure <10 mmHg (P=0.022), eGFR 60 (P=0.015), diabetes (P=0.019), not receiving ACE/ARB (P=0.025) and not receiving aldosterone antagonists (P=0.045). Conclusions: Decline in kidney function slows down after the maintenance of euvolemia with pulmonary artery pressure-guided therapy of heart failure.
P< .05). In addition, there was a trend towards a reduction in ICU transfers and inpatient mortality, as well as an increase in the use of ARNI upon discharge. However, these trends were not statistically significant. Conclusions: Management of patients with HF by a dedicated HF MDT in the inpatient and outpatient setting results in a significant reduction in morbidity; with reduced 30-day readmission rates, length of stay in hospital, number of days for follow up post-discharge and the need for inotropic support.
Table 1. Baseline Characteristics by Propensity Score Weighting Scheme for Group 1 Group 2.
Table 2. Measured Outcomes Propensity Score Weighted Group Comparisons.
268 Multidisciplinary Team Management in Heart Failure: Worth it? A MiddleEastern Experience Khalid A.S. Abdalla, Hussam Ghalib, Terrence Lee-St John, Richard Ferrer, Ziad G. Sadik, Bassam Atallah, Medhat Soliman, Guirguis Gabra, Mosaad Elbanna, Iman Hamour, Feras Bader; Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates Background: In recent years, there has been an emphasis on multidisciplinary team (MDT) care of the heart failure (HF) patient. A dedicated HF MDT was created on the 1stof January 2017 at Cleveland Clinic Abu Dhabi; consisting of HF cardiologists, clinical pharmacists and HF nurses. This study aims to assess the impact of a dedicated HF MDT on the mortality, length of stay and readmission rate in patients who are admitted with acute HF decompensation. Methods: A retrospective review of the patients’ charts was conducted. We identified patients who were admitted for acute exacerbation of HF between the years 2015 and 2017. Group 1 consisted of 90 patients who were admitted prior to the creation of the HF MDT, while Group 2 consisted of 94 patients who were admitted after the establishment of the team. The groups were propensity-matched in order to account for any confounding variables between the two patient populations. Results: Table 1 shows the baseline characteristics on admission of patients in both Group 1 and Group 2. The majority of patients in both groups had HFrEF. There were no significant differences between the two groups in terms of the baseline characteristics outlined. Table 2 highlights the differences in outcomes between the two groups. After the establishment of the HF MDT, there was a significant decrease in the 30 day readmission rate (25.84 % vs 5.98 %, P< .001), number of days for follow up post-discharge (16.34 §15.08 vs 7.68 §3.01 days, P< .001), length of stay in hospital (13.38 §21.81 vs 8.33 §8.01 days, P< .05) and the number of patients requiring inotropic support (23.33 % vs 11.88 %,
269 Early Goal Directed Sepsis Management in Patients with Heart Failure and Concomitant Chronic Kidney Disease Endri Ceka, Jesus E. Pino, Kai Chen, Fergie J. Ramos Tuarez, Jorge E. Saona, Andres Chacon, Gretchen De Diego, Julio Grajeda, Pedro Torres, Randy Bornmann, Samineh Sahatbakhsh, Baher Al Abbasi, Robert Chait; University of Miami Palm Beach Regional Campus, Atlantis, FL Current guidelines recommend for the use of protocolized quantitative fluid resuscitation in patients with sepsis. Limited data is available regarding optimal fluid management in patients with sepsis and concomitant heart failure (HF) and/or chronic kidney disease (CKD). Methods: This is a single center retrospective cohort study of patients diagnosed with sepsis and concomitant HF and CKD (K-HF) between January of 2015 and December of 2018. The primary outcome includes all cause in-hospital mortality. Secondary outcomes include length of stay, requirement of intravenous diuretics, need for renal replacement therapy, and 30-day heart failure readmission rate. Results: This cohort of 1116 patients included 621/1116 (55.64%) men with a mean age of 76 § 14 years (see Table I for baseline characteristics). A total of 383/ 1116 (34.31%) patients had K-HF and 733/1116 (65.68%) did not have K-HF. Patients with K-HF received an initial bolus intravenous fluid (IVF) administration of 1.63 liters vs. patients with non-K-HF and sepsis who received 1.77 liters (p=0.1766). Mortality was 121/383 (31.93%) for patients with K-HF vs. 199/733 (27.26%) for non-K-HF patients (p=0.1084). 30-day readmission was 56/383(15.73%) in patients
S100 Journal of Cardiac Failure Vol. 25 No. 8S August 2019 with K-HF vs. 112/733 (16.62) in patients with non-K-HF. In patients with sepsis with K-HF 204 (53.54%) developed AKI vs. 327 (44.61%) in non-K-HF patients. Renal replacement therapy (RRT) was required in 90/383 (23.69%) in patients with K-HF vs 327/733(44.61%) in non-K-HF patients. Conclusion: EGDT in patients with sepsis and concomitant HF and CKD shows diverse morbidity, however, with similar mortality in this special population. Table 2. Table 2. Outcomes
270 The Impact of Fluid Management in Patients with Sepsis and Heart Failure Kai Chen, Jesus E. Pino, Endri Ceka, Fergie Ramos, Jorge Saona, Julio Grajeda, Baher Al Abbasi, Andres Chacon, Pedro Torres, Gretchen De Diego, Randy Bornmann, Samineh Sehatbakhsh, Robert Chait; University of Miami Palm Beach Regional Campus, Atlantis, FL Background: Current guidelines recommend 30cc/kg of intravenous fluid (IVF) early resuscitation for patients with suspected sepsis. However, IVF resuscitation is often delayed in patients with left ventricular dysfunction due to concern of worsening heart failure. There is limited data regarding outcomes in large volume IVF in this population with various degrees of left ventricular ejection fraction (LVEF). Methods: This was a retrospective cohort study of patients with heart failure and sepsis admitted to a single cardiovascular center between January 2015 and December 2018. Heart failure was defined as preserved (EF > 50%), mid-range (40-50%), or reduced (EF < 40%). Outcomes evaluated were amount of IVF received at first encounter, 6 hours and 24 hours, in-hospital mortality, acute kidney injury, length of stay, and readmission within 30 days. Results: A total of 979 patients with diagnosis of heart failure and sepsis were included in the analysis. There were 539 (55%) males and mean age was 75.4 § 14.1. There were 590 (60.2%) patients with preserved EF, 87 (8.8%) patients with mid-range EF, and 302 (30.8%) with reduced EF. See Table 1 for baseline characteristics. There was no significant difference in amount of IVF received by either cohorts at encounter, 6 hours or 24 hours. Although not statistically significant, patients with mid-range EF appeared more likely to die during hospitalization. See Table 2 for outcomes. Conclusions: This retrospective analysis suggests the mortality in patients with heart failure and sepsis was not affected by the degree of LVEF. Larger randomized trials are needed to further investigate the impact of IVF management in these patients.
Table 1. Baseline Characteristics
Table 2. Outcomes
271 Quantifying Burden among Caregivers of Elderly Patients with Heart Failure Grace E. Patten1,2, Hayaan Kamran1, Karen Flynn1, Nancy Todd1, Christine Ackroyd1, Melissa Mavroides1, Michele Rybicki1, David Venesy1, Sachin Shah1, Richard D. Patten1; 1Lahey Hospital and Medical Center, Burlington, MA; 2Goucher College, Baltimore, MD Background: Heart failure (HF) patients (Pts) rely on caregivers (CGs) for assistance in many aspects of their care. While CG burden has been studied in Pts with other chronic diseases, that among CGs of HF Pts is largely unexplored. We sought to quantify CG stress to explore whether CG burden correlates with physical and emotional disability of the HF Pt. Methods: Pairs of Pts and their CGs were surveyed. CG stress was assessed using the Zarit Burden Interview (ZBI) questionnaire. HF Pts
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Management Strategies/Adherence/Self Care 266 Pulmonary Artery Pressure-Guided Heart Failure Management is Associated with Slower Decline in Kidney Function Nour Tashtish, Sadeer Al-Kindi, Steven C. Mitchell, Guilherme H. Oliveira, Arash Rashidi, Monique Robinson; University Hospital Cleveland Medical Center, Cleveland, OH Background: Renal impairment is common among patients with heart failure and portends worse outcomes. We sought to describe the impact of euvolemia maintenance via pulmonary artery pressure-guided management of heart failure on the trajectory of kidney function. Hypothesis: We hypothesized that PAP- guided management is associated with slowing eGFR decline in heart failure patients. Methods: We retrospectively reviewed kidney function 1 year prior to implant, and 1 year after implantation of a wireless pulmonary-artery hemodynamic monitoring sensor (CardioMEMS, St Jude Medical, St Paul, MN). Glomerular filtration rate (eGFR) was estimated using standard equations (MDRD, Cockroft-Gault, and CKD-EPI). Standardized annual change in eGFR was compared prior to and after CardioMEMS implantation using related-samples Wilcoxon Signed Rank Test. Results: A total of 70 patients were included with a median age of 74 [67-79] years. Forty-two patients (60%) were male and 53 (76%) were white. Their median left ventricular ejection fraction was 41% [25-50]. Median eGFR before CardioMEMS implantation decreased from 61 [40-77] to 48 [30-64] ml/ min/1.73 m2 (P<0.001) but did not change after CardioMEMs implantation (44 [3067] ml/min/1.73 m2, P=0.17). Annualized rate of eGFR change was -6.1 [-18.6 to 2.2] ml/min/1.73 m2 before vs -1.1 [-9.6 to 4.0] ml/min/1.73 m2 after CardioMEMS (P=0.046). This difference was more pronounced among patients <74 years (P=0.009), with left ventricular ejection fraction 50% (P=0.039), RA pressure <10 mmHg (P=0.022), eGFR 60 (P=0.015), diabetes (P=0.019), not receiving ACE/ARB (P=0.025) and not receiving aldosterone antagonists (P=0.045). Conclusions: Decline in kidney function slows down after the maintenance of euvolemia with pulmonary artery pressure-guided therapy of heart failure.
P< .05). In addition, there was a trend towards a reduction in ICU transfers and inpatient mortality, as well as an increase in the use of ARNI upon discharge. However, these trends were not statistically significant. Conclusions: Management of patients with HF by a dedicated HF MDT in the inpatient and outpatient setting results in a significant reduction in morbidity; with reduced 30-day readmission rates, length of stay in hospital, number of days for follow up post-discharge and the need for inotropic support.
Table 1. Baseline Characteristics by Propensity Score Weighting Scheme for Group 1 Group 2.
Table 2. Measured Outcomes Propensity Score Weighted Group Comparisons.
268 Multidisciplinary Team Management in Heart Failure: Worth it? A MiddleEastern Experience Khalid A.S. Abdalla, Hussam Ghalib, Terrence Lee-St John, Richard Ferrer, Ziad G. Sadik, Bassam Atallah, Medhat Soliman, Guirguis Gabra, Mosaad Elbanna, Iman Hamour, Feras Bader; Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates Background: In recent years, there has been an emphasis on multidisciplinary team (MDT) care of the heart failure (HF) patient. A dedicated HF MDT was created on the 1stof January 2017 at Cleveland Clinic Abu Dhabi; consisting of HF cardiologists, clinical pharmacists and HF nurses. This study aims to assess the impact of a dedicated HF MDT on the mortality, length of stay and readmission rate in patients who are admitted with acute HF decompensation. Methods: A retrospective review of the patients’ charts was conducted. We identified patients who were admitted for acute exacerbation of HF between the years 2015 and 2017. Group 1 consisted of 90 patients who were admitted prior to the creation of the HF MDT, while Group 2 consisted of 94 patients who were admitted after the establishment of the team. The groups were propensity-matched in order to account for any confounding variables between the two patient populations. Results: Table 1 shows the baseline characteristics on admission of patients in both Group 1 and Group 2. The majority of patients in both groups had HFrEF. There were no significant differences between the two groups in terms of the baseline characteristics outlined. Table 2 highlights the differences in outcomes between the two groups. After the establishment of the HF MDT, there was a significant decrease in the 30 day readmission rate (25.84 % vs 5.98 %, P< .001), number of days for follow up post-discharge (16.34 §15.08 vs 7.68 §3.01 days, P< .001), length of stay in hospital (13.38 §21.81 vs 8.33 §8.01 days, P< .05) and the number of patients requiring inotropic support (23.33 % vs 11.88 %,
269 Early Goal Directed Sepsis Management in Patients with Heart Failure and Concomitant Chronic Kidney Disease Endri Ceka, Jesus E. Pino, Kai Chen, Fergie J. Ramos Tuarez, Jorge E. Saona, Andres Chacon, Gretchen De Diego, Julio Grajeda, Pedro Torres, Randy Bornmann, Samineh Sahatbakhsh, Baher Al Abbasi, Robert Chait; University of Miami Palm Beach Regional Campus, Atlantis, FL Current guidelines recommend for the use of protocolized quantitative fluid resuscitation in patients with sepsis. Limited data is available regarding optimal fluid management in patients with sepsis and concomitant heart failure (HF) and/or chronic kidney disease (CKD). Methods: This is a single center retrospective cohort study of patients diagnosed with sepsis and concomitant HF and CKD (K-HF) between January of 2015 and December of 2018. The primary outcome includes all cause in-hospital mortality. Secondary outcomes include length of stay, requirement of intravenous diuretics, need for renal replacement therapy, and 30-day heart failure readmission rate. Results: This cohort of 1116 patients included 621/1116 (55.64%) men with a mean age of 76 § 14 years (see Table I for baseline characteristics). A total of 383/ 1116 (34.31%) patients had K-HF and 733/1116 (65.68%) did not have K-HF. Patients with K-HF received an initial bolus intravenous fluid (IVF) administration of 1.63 liters vs. patients with non-K-HF and sepsis who received 1.77 liters (p=0.1766). Mortality was 121/383 (31.93%) for patients with K-HF vs. 199/733 (27.26%) for non-K-HF patients (p=0.1084). 30-day readmission was 56/383(15.73%) in patients
S100 Journal of Cardiac Failure Vol. 25 No. 8S August 2019 with K-HF vs. 112/733 (16.62) in patients with non-K-HF. In patients with sepsis with K-HF 204 (53.54%) developed AKI vs. 327 (44.61%) in non-K-HF patients. Renal replacement therapy (RRT) was required in 90/383 (23.69%) in patients with K-HF vs 327/733(44.61%) in non-K-HF patients. Conclusion: EGDT in patients with sepsis and concomitant HF and CKD shows diverse morbidity, however, with similar mortality in this special population. Table 2. Table 2. Outcomes
270 The Impact of Fluid Management in Patients with Sepsis and Heart Failure Kai Chen, Jesus E. Pino, Endri Ceka, Fergie Ramos, Jorge Saona, Julio Grajeda, Baher Al Abbasi, Andres Chacon, Pedro Torres, Gretchen De Diego, Randy Bornmann, Samineh Sehatbakhsh, Robert Chait; University of Miami Palm Beach Regional Campus, Atlantis, FL Background: Current guidelines recommend 30cc/kg of intravenous fluid (IVF) early resuscitation for patients with suspected sepsis. However, IVF resuscitation is often delayed in patients with left ventricular dysfunction due to concern of worsening heart failure. There is limited data regarding outcomes in large volume IVF in this population with various degrees of left ventricular ejection fraction (LVEF). Methods: This was a retrospective cohort study of patients with heart failure and sepsis admitted to a single cardiovascular center between January 2015 and December 2018. Heart failure was defined as preserved (EF > 50%), mid-range (40-50%), or reduced (EF < 40%). Outcomes evaluated were amount of IVF received at first encounter, 6 hours and 24 hours, in-hospital mortality, acute kidney injury, length of stay, and readmission within 30 days. Results: A total of 979 patients with diagnosis of heart failure and sepsis were included in the analysis. There were 539 (55%) males and mean age was 75.4 § 14.1. There were 590 (60.2%) patients with preserved EF, 87 (8.8%) patients with mid-range EF, and 302 (30.8%) with reduced EF. See Table 1 for baseline characteristics. There was no significant difference in amount of IVF received by either cohorts at encounter, 6 hours or 24 hours. Although not statistically significant, patients with mid-range EF appeared more likely to die during hospitalization. See Table 2 for outcomes. Conclusions: This retrospective analysis suggests the mortality in patients with heart failure and sepsis was not affected by the degree of LVEF. Larger randomized trials are needed to further investigate the impact of IVF management in these patients.
Table 1. Baseline Characteristics
Table 2. Outcomes
271 Quantifying Burden among Caregivers of Elderly Patients with Heart Failure Grace E. Patten1,2, Hayaan Kamran1, Karen Flynn1, Nancy Todd1, Christine Ackroyd1, Melissa Mavroides1, Michele Rybicki1, David Venesy1, Sachin Shah1, Richard D. Patten1; 1Lahey Hospital and Medical Center, Burlington, MA; 2Goucher College, Baltimore, MD Background: Heart failure (HF) patients (Pts) rely on caregivers (CGs) for assistance in many aspects of their care. While CG burden has been studied in Pts with other chronic diseases, that among CGs of HF Pts is largely unexplored. We sought to quantify CG stress to explore whether CG burden correlates with physical and emotional disability of the HF Pt. Methods: Pairs of Pts and their CGs were surveyed. CG stress was assessed using the Zarit Burden Interview (ZBI) questionnaire. HF Pts