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Feasibility of a home telemonitoring system for prevention of congestive heart failure exacerbation
The Third Annual Scientific Meeting
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HFSA
63
Epidemiology, Prevention 232
233
Increased Risk of Infection in Patients with Congestive Heart Failure Amir Morsi, Chun Kwan, Heather Ross, Elaine Wang, Peter Liu; The Toronto Hospital (TTH), University of Toronto, Canada
Idiopathic Cardiomyopathy Is Less Idiopathic Than You Think: An Endomyocardial Biopsy Study of 1278 Patients G. Michael Felker, ~ Weimin Hu,2 Joshua M. Hare, ~ Ralph H. Hruban, 2 Kenneth L. Baughman, 1 Edward K. Kasper~; ~Division of Cardiology, 2Department of Pathology, Johns Hopldns University School of Medicine, Baltimore, MD
Circulating cytokine levels are increased in patients with heart failure (HF), and this may imply abnormal immune modulation and immune compromise. To determine if HF patients are prone to infection, a case control study was conducted. The cases consisted of consecutive patients admitted to TTH with the primary diagnosis of heart failure during a fixed period, and the controls were consecutive patients admitted with the primary diagnosis of acute myocardial infarction (MI) without HF during precisely the same period. The presence of infection was established from clinical diagnosis by the attending medical team with documented clinical sequelae requiring antibiotic treatment and/or positive cultures. Overall, there were 75 pts with the isolated diagnosis of HF (mean age 77.3 yr), and the controls were 93 pts with MI (mean age 61.3 yr). Infection rate in the HF cases was 44% (33/75), vs. 11.8% (i 1/93) in the control group (Odds ratio 3.9, 95% CI= 1.7-5.9). In hospital mortality in HF patients with infection was 18.7% compared to 4.0% (p<0.05) in pts without infection. Interestingly, the patients with infection in the HF group showed no significant rise in leukocyte count at the time of diagnosis compared to those in the control group (9.5+8.2 vs. 23.0--10.9 × 106, p<0.05). The infections in HF pt were mainly pulmonary (63.6%) whereas the controls developed a broad spectrum of infections. We conclude that patients with HF are at clearly increased risk of infection, and this may contribute both to the high morbidity and mortality in these patients. HF pts are particularly susceptible to pulmonary infection, and may constitute a newly recognized immune compromised population.
Dilated cardiomyopathy is the final common pathway for many cardiac conditions. There are over 75 known causes of dilated cardiomyopathy, but the significance of identifying a specific cause of cardiomyopathy (CM) for a given patient is uncertain. We studied the incidence of various etiologies of CM in patients with unexplained CM referred to a tertiary care center. Between December 1982 and September 1998, 1278 patients underwent extensive clinical evaluation, including endomyocardial biopsy (EMB), for unexplained CM. A careful history and physical examination, selected laboratory studies including thyroid function testing and measurement of anti-nuclear antibodies, EMB, and right heart catheterization were performed in each patient. Coronary angiography Was performed in those patients with a history suggestive of ischemic heart disease or two or more risk factors for coronary artery disease. A final etiology of CM was prospectively deternlined for each patient based on prespecified diagnostic criteria. A specific diagnosis was made in 49% of patients previously thought to have unexplained CM. The most common specific diagnoses were myocarditis (9%) and coronary artery disease (8%). EMB established a specific histologic diagnosis in 200 of 1278 (16%) of patients. These included: ruyocarditis (n= 117), cardiac amyloidosis (n=41), doxorubicin toxicity (n=16), cardiac sarcoidosis (n=16), cardiac hemochromatosis (n-9), endomyocardiaI fibroelastosis (n-1), rheumatic carditis (n=l), thrombotic thrombocytopenic purpura (n=l), and interferoninduced cardiomyopathy (n= 1). We conclude that a specific etiology can be determined in approximately one-half of patients referred to a tertiary care center with unexplained CM. The history, physical examination, selected laboratory testing, and coronary angiography for patients at risk provide an explanation for CM in the majority of patients for whom a specific etiology is identified. EMB provides a specific histologic diagnosis in a subset of patients with unexplained CM, primarily by identifying patients with myocarditis or infiltrative diseases such as amylnidosis.
234
235
Increasing Hospital Admissions and Decreasing Length of Hospital Stay for Heart Failure in New Zealand (1988-1997) Robert N. Doughty, Sue Wright, Greg Gamble, Norman Sharpe;
Feasibility of a Home Telemonitoring System for Prevention of Congestive Heart Failure Exacerbation Tania M. Nanevicz, ~ John D. Piette, ~ Daniella A. Zipkin] Michelle C. Serlin, 1 Stephanie C. Ennisi; IDept. of Medicine, University of Califonaia,San Francisco, CA, 2Center for Health Care Evaluation, VA Palo Alto, Menlo Park, CA
Introduction: Heart failure is a major public health problem and hospital admissions for heart failure account for 1-2% of total health budgets in developed countries. Tim aims of this study were to determine the trends in hospital admissions and length of hospital stay over 10 years in New Zealand. Methods: National statistics for hospital admission were obtained from the New Zealand Health Information Service using ICD 9 codes for heart failure both as the primary diagnosis and as a secondary diagnosis associated with either ischemic heart disease, rheumatic heart disease or valvular disease. Results: There was a total of 91,479 admissions for heart failure over 10 years. The number of admissions increased more than 50% over the 10 years, from 7576 in 1988 to 11646 in 1997. The mean length of stay halved between 1988 and 1997: from 14.8 days in 1988 to 7.4 days in 1997. The number of patients with a single admission each year increased by 45% from 4884 to 7065. The number of patients with multiple admissions each year increased by 68% from 1117 to 1877. Conclusions: Hospital admission for heart failure increased over 50%, with increases in both single and multiple admissions. Length of hospital stay decreased by 50%. Study of the factors influencing admissions and readmissions for heart failure and strategies to reduce hospital admissions are required.
A home telemonitoring system for patients with congestive heart failure (Daylink TM, Alere Medical Inc., San Francisco, CA) was studied for feasibility and efficacy in a socio-economically diverse group of patients. 50 patients were enrolled from county hospital clinics, a university-based specialty clinic, and a VA clinic. 5 patients were non-English speaking, 2 were blind and 56% were uninsured/public assistance. The mean age was 60 years with 40% Cancasion, 25% African American, 12% Hispanic and 23% Asian or Pacific Islander. 13 patients resided greater than 60 miles from the hospital. The NYHA classes were: 30% II, 64% EI, and 6% IV. Patients received the electronic monitoring device for 30 days with which they weighed themselves and answered 10 yes/no questions (in English or Spanish) about symptoms. This information was transmitted automatically via phone fines to an Alere nurse who followed-up with patients and their physicians by phone. Changes in patient weights (51b gain or 101b loss in < 5 days) or symptoms (reported for 3 consecutive days) prompted the nurse to call the patient and/or their physician. A nurse called once a week to deliver health, diet and serf-care education. To measure potential intervention effects patients were given educational and quality-of-life (QOL) surveys at enrollment and 30-day follow-up. The system was found to be feasible in terms of patient compliance. The average daily usage rate was 94% amongst patients from each hospital. Patients were contacted 57 times based on the above parameters and an additional 36 times at fire discretion of the nurse. The nurse spent an average of 1.3 hours on the phone with each patient. The monitoring system prompted 55 physician notifications, 8 medication changes, and 11 non-routine clinic visits. 2 patients were hospitalized and one patient died during the study period. Patient response to the lifestyle survey showed an improvement in QOL(p = 0.05). In the follow-up survey patients reported improved understanding of prevention measures (49% to 71% responding affirmatively). 60 % named at least one action they could take to improve their heart failure management after the study compared to 30% in the initial survey. 84% of patients and 65% of physicians (n=22) reported satisfaction with the system and 76% of patients reported that would like to continue the program after the study. This pilot study suggests that telemonitoring of weight and symptoms is feasible and has clinical utility in diverse patient groups and may improve patients' self-care knowledge and satisfaction with care.
•
HFSA
63
Epidemiology, Prevention 232
233
Increased Risk of Infection in Patients with Congestive Heart Failure Amir Morsi, Chun Kwan, Heather Ross, Elaine Wang, Peter Liu; The Toronto Hospital (TTH), University of Toronto, Canada
Idiopathic Cardiomyopathy Is Less Idiopathic Than You Think: An Endomyocardial Biopsy Study of 1278 Patients G. Michael Felker, ~ Weimin Hu,2 Joshua M. Hare, ~ Ralph H. Hruban, 2 Kenneth L. Baughman, 1 Edward K. Kasper~; ~Division of Cardiology, 2Department of Pathology, Johns Hopldns University School of Medicine, Baltimore, MD
Circulating cytokine levels are increased in patients with heart failure (HF), and this may imply abnormal immune modulation and immune compromise. To determine if HF patients are prone to infection, a case control study was conducted. The cases consisted of consecutive patients admitted to TTH with the primary diagnosis of heart failure during a fixed period, and the controls were consecutive patients admitted with the primary diagnosis of acute myocardial infarction (MI) without HF during precisely the same period. The presence of infection was established from clinical diagnosis by the attending medical team with documented clinical sequelae requiring antibiotic treatment and/or positive cultures. Overall, there were 75 pts with the isolated diagnosis of HF (mean age 77.3 yr), and the controls were 93 pts with MI (mean age 61.3 yr). Infection rate in the HF cases was 44% (33/75), vs. 11.8% (i 1/93) in the control group (Odds ratio 3.9, 95% CI= 1.7-5.9). In hospital mortality in HF patients with infection was 18.7% compared to 4.0% (p<0.05) in pts without infection. Interestingly, the patients with infection in the HF group showed no significant rise in leukocyte count at the time of diagnosis compared to those in the control group (9.5+8.2 vs. 23.0--10.9 × 106, p<0.05). The infections in HF pt were mainly pulmonary (63.6%) whereas the controls developed a broad spectrum of infections. We conclude that patients with HF are at clearly increased risk of infection, and this may contribute both to the high morbidity and mortality in these patients. HF pts are particularly susceptible to pulmonary infection, and may constitute a newly recognized immune compromised population.
Dilated cardiomyopathy is the final common pathway for many cardiac conditions. There are over 75 known causes of dilated cardiomyopathy, but the significance of identifying a specific cause of cardiomyopathy (CM) for a given patient is uncertain. We studied the incidence of various etiologies of CM in patients with unexplained CM referred to a tertiary care center. Between December 1982 and September 1998, 1278 patients underwent extensive clinical evaluation, including endomyocardial biopsy (EMB), for unexplained CM. A careful history and physical examination, selected laboratory studies including thyroid function testing and measurement of anti-nuclear antibodies, EMB, and right heart catheterization were performed in each patient. Coronary angiography Was performed in those patients with a history suggestive of ischemic heart disease or two or more risk factors for coronary artery disease. A final etiology of CM was prospectively deternlined for each patient based on prespecified diagnostic criteria. A specific diagnosis was made in 49% of patients previously thought to have unexplained CM. The most common specific diagnoses were myocarditis (9%) and coronary artery disease (8%). EMB established a specific histologic diagnosis in 200 of 1278 (16%) of patients. These included: ruyocarditis (n= 117), cardiac amyloidosis (n=41), doxorubicin toxicity (n=16), cardiac sarcoidosis (n=16), cardiac hemochromatosis (n-9), endomyocardiaI fibroelastosis (n-1), rheumatic carditis (n=l), thrombotic thrombocytopenic purpura (n=l), and interferoninduced cardiomyopathy (n= 1). We conclude that a specific etiology can be determined in approximately one-half of patients referred to a tertiary care center with unexplained CM. The history, physical examination, selected laboratory testing, and coronary angiography for patients at risk provide an explanation for CM in the majority of patients for whom a specific etiology is identified. EMB provides a specific histologic diagnosis in a subset of patients with unexplained CM, primarily by identifying patients with myocarditis or infiltrative diseases such as amylnidosis.
234
235
Increasing Hospital Admissions and Decreasing Length of Hospital Stay for Heart Failure in New Zealand (1988-1997) Robert N. Doughty, Sue Wright, Greg Gamble, Norman Sharpe;
Feasibility of a Home Telemonitoring System for Prevention of Congestive Heart Failure Exacerbation Tania M. Nanevicz, ~ John D. Piette, ~ Daniella A. Zipkin] Michelle C. Serlin, 1 Stephanie C. Ennisi; IDept. of Medicine, University of Califonaia,San Francisco, CA, 2Center for Health Care Evaluation, VA Palo Alto, Menlo Park, CA
Introduction: Heart failure is a major public health problem and hospital admissions for heart failure account for 1-2% of total health budgets in developed countries. Tim aims of this study were to determine the trends in hospital admissions and length of hospital stay over 10 years in New Zealand. Methods: National statistics for hospital admission were obtained from the New Zealand Health Information Service using ICD 9 codes for heart failure both as the primary diagnosis and as a secondary diagnosis associated with either ischemic heart disease, rheumatic heart disease or valvular disease. Results: There was a total of 91,479 admissions for heart failure over 10 years. The number of admissions increased more than 50% over the 10 years, from 7576 in 1988 to 11646 in 1997. The mean length of stay halved between 1988 and 1997: from 14.8 days in 1988 to 7.4 days in 1997. The number of patients with a single admission each year increased by 45% from 4884 to 7065. The number of patients with multiple admissions each year increased by 68% from 1117 to 1877. Conclusions: Hospital admission for heart failure increased over 50%, with increases in both single and multiple admissions. Length of hospital stay decreased by 50%. Study of the factors influencing admissions and readmissions for heart failure and strategies to reduce hospital admissions are required.
A home telemonitoring system for patients with congestive heart failure (Daylink TM, Alere Medical Inc., San Francisco, CA) was studied for feasibility and efficacy in a socio-economically diverse group of patients. 50 patients were enrolled from county hospital clinics, a university-based specialty clinic, and a VA clinic. 5 patients were non-English speaking, 2 were blind and 56% were uninsured/public assistance. The mean age was 60 years with 40% Cancasion, 25% African American, 12% Hispanic and 23% Asian or Pacific Islander. 13 patients resided greater than 60 miles from the hospital. The NYHA classes were: 30% II, 64% EI, and 6% IV. Patients received the electronic monitoring device for 30 days with which they weighed themselves and answered 10 yes/no questions (in English or Spanish) about symptoms. This information was transmitted automatically via phone fines to an Alere nurse who followed-up with patients and their physicians by phone. Changes in patient weights (51b gain or 101b loss in < 5 days) or symptoms (reported for 3 consecutive days) prompted the nurse to call the patient and/or their physician. A nurse called once a week to deliver health, diet and serf-care education. To measure potential intervention effects patients were given educational and quality-of-life (QOL) surveys at enrollment and 30-day follow-up. The system was found to be feasible in terms of patient compliance. The average daily usage rate was 94% amongst patients from each hospital. Patients were contacted 57 times based on the above parameters and an additional 36 times at fire discretion of the nurse. The nurse spent an average of 1.3 hours on the phone with each patient. The monitoring system prompted 55 physician notifications, 8 medication changes, and 11 non-routine clinic visits. 2 patients were hospitalized and one patient died during the study period. Patient response to the lifestyle survey showed an improvement in QOL(p = 0.05). In the follow-up survey patients reported improved understanding of prevention measures (49% to 71% responding affirmatively). 60 % named at least one action they could take to improve their heart failure management after the study compared to 30% in the initial survey. 84% of patients and 65% of physicians (n=22) reported satisfaction with the system and 76% of patients reported that would like to continue the program after the study. This pilot study suggests that telemonitoring of weight and symptoms is feasible and has clinical utility in diverse patient groups and may improve patients' self-care knowledge and satisfaction with care.