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Heart Failure Database Variables Most Frequently Recorded during Followup at Specialist Heart Failure Outpatient Visits in the Canadian Heart Failure Network (CHN)
S112 Journal of Cardiac Failure Vol. 16 No. 8S August 2010 2.07 6 0.63 L/min/m2 and mean FK CO and CI 4.36 6 1.12 L/min and 2.21 6 0.58 L/min/m2, respectively. The correlations between TD and FK CO and CI were very modest at 0.42 and 0.40, respectively (Table 1). Overall, TD and FK misclassified 14 (26%) patients using CI ! 2.2 L/min/m2 as the criterion (Table 2). Patients Classified by TD and FK CI (Table 2) Classification* FK CI O 2.2 L/min/m2 FK CI ! 2.2 L/min/m2
TD CI O 2.2 L/min/m2
TD CI ! 2.2 L/min/m2
25 (27%) 8 (15%)
6 (11%) 26 (47%)
*for table, p 5 0.0005 by Chi-Square By either FK or TD, 40 patients had CI ! 2.2 L/min/m2. Using FK as the reference standard, 34 patients had CI ! 2.2 L/min/m2. FK and TD agreed in only 26 (65%) of these 34 patients. Use of TD alone would have misidentified 8 patients as having CI O 2.2 L/min/m2 and 6 patients as having CI ! 2.2 L/min/m2. In a subset of patients, contrast injection through the right atrial port (RAP) of the pulmonary artery catheter (PAC) just after TD determination demonstrated frequent RAP positioning in the internal jugular vein (internal jugular vein approach) or inferior vena cava (femoral vein approach).Conclusions: 1) In AHF patients, TD and FK CI have only a modest correlation of 0.4. 2) TD misidentifies 26% of patients using FK CI ! 2.2 L/min/m2 as the reference standard. 2) Compared to FK, TD may misidentify CI as either greater than or less than 2.2 L/min/m2. 3) The PAC RAP may not be positioned in the right atrium in some AHF patients during RHC, leading to inaccurate TD results.
370 Stroke in Children with Myocarditis: Does Anticoagulation Regimen Matter? Kimberly Lin1, Basavaraj Kerur2, Char Witmer1, Lauren Beslow1, Rebecca Ichord1, Beth Kaufman1; 1Pediatrics, Children’s Hospital of Philadelphia, Philadelphia; 2 Pediatrics, Albert Einstein M.C., Philadelphia Currently no guidelines exist regarding anticoagulation for children with myocarditis. Due to inflammation and stasis of blood in a poorly functioning heart, children with myocarditis may be at increased risk for intracardiac thrombus formation and complications including stroke. Methods: Medical records for all pts admitted to a single center pediatric cardiac intensive care unit (CICU) with newly diagnosed myocarditis from 1995-2008 were reviewed. The incidence and potential risk factors for thrombotic events (TE) including intracardiac clots were assessed. Results: We identified 30 children with myocarditis, 53% male, median age 2.2 (IQR 0.9e10.4) yrs. Myocarditis was diagnosed by endomyocardial biopsy (40%), cardiac dysfunction and viral PCR detection (23%), or high clinical suspicion (37%). Twelve (41%) required ECMO, 9 had CPR. All pts received IVIG. Length of stay in intensive care was 14 (IQR 7e21) days. Echocardiogram on admission had shortening fraction (SF) of 15.5 6 8% and left ventricular end diastolic (LVED) Z score 3.40 6 1.9. All 30 survived to hospital discharge. Anticoagulation therapy and time from admission to initiation varied for the 30 pts: therapeutic heparin (goal PTT 60-80 sec) in 8 (44%) non ECMO pts initiated at 4.1 6 3 days, low dose heparin (10 units/kg/min without PTT measurement) in 15 (50%) pts at 3.6 6 11 days, enoxaparin in 2 pts at 11.0 6 11 days, warfarin in 2 pts at 17.5 6 10 days, and aspirin in 16 pts (53%) at 13.81 6 10 days post CICU admission. Pts could have O1 regimen during the hospital stay. No differences were detected between pts prescribed different anticoagulation regimens (except all pts received heparin on ECMO). Two pts (7%) had thrombotic events during initial CICU admission. Neither pt was on ECMO, experienced CPR, or arrhythmia. Case 1: Asymptomatic LV thrombus detected via echo on CICU day #10, SF 21%, on low dose heparin at time of TE. Case 2: Stroke on CICU day #4, SF 19%, on no anticoagulation at time of stroke. No thrombotic events occurred in the 12 pts (40%) not treated with therapeutic heparin, enoxaparin, or warfarin at any time during CICU stay. Conclusions: Variation exists regarding the use of prophylactic anticoagulation in pediatric myocarditis. Thrombotic events occurred in 7% of pts and may have been preventable. The risk vs. benefit of prophylactic anticoagulation and choice of therapy in children critically ill with myocarditis requires systematic investigation.
371 SERIOUS Medication Reconciliation Clinic: Improving Transitions of Care Sherry LaForest1, Julie Gee2, Adam Pugacz1, Julio Barcena2, Danielle Hoover3, Aubrey Guthrie1, Sharon Sabatka1, Catherine Ortiz1, William Salem1, Jose Ortiz2; 1 Pharmacy Department, Cleveland VA Medical Center, Cleveland, OH; 2 Cardiology Division, Cleveland VA Medical Center, Cleveland, OH; 3VA National Center for Patient Safety, Ann Arbor, MI Hypothesis: Early follow-up for patients discharged after a HF exacerbation using the ‘‘SERIOUS’’ medication reconciliation (MedRec) model improves care. Methods: Heart failure patients attended a clinic staffed by pharmacists and a nurse practitioner (NP). The goal was to see patients within 7e10 days of discharge. Patients were asked to bring all medication bottles. MedRec was performed using the ‘‘SERIOUS’’ model developed by the Cleveland VA. Components of the model are: to solicit, examine, reconcile, inform, optimize, update, and share the medication regimen. A pharmacist reviewed medications and made initial recommendations for changes. If a patient was symptomatic, experienced a weight change, or had abnormal vital signs, the NP examined the patient and further
optimized the regimen. A templated note standardized the approach to care. Education included medications, daily weights, low sodium diet, recognition of symptoms, and contact information if symptoms or weight change occurred. Self-care tools including weight logs, scales, BP cuffs and pill boxes were given. An updated medication list was printed. All patients were given a follow-up appointment. Results: Between March 2008 and December 2009, 122 patients were seen. Most patients (61%, n 5 74) were referred following a HF hospitalization. The mean age in the post-discharge cohort was 69 years. Left ventricular systolic dysfunction (EF 40%) was present in 50% of patients. Patients were seen a median of 9 days after discharge. All patients had access to medications through the VA. Of the 74 post-discharge patients, 64% had medication errors identified during MedRec. The mean number of prescriptions (including diabetic supplies, over-thecounter products, topical agents) was 18. Medication regimens were optimized in 57% of patients. The 30-day all-cause readmission rate in this cohort was 8%. The Cleveland VA 30-day readmission rate was 19% in 2008. Conclusion: A substantial number of patients make medication errors following hospital discharge, in spite of discharge education. Systems encouraging early follow-up and MedRec post-discharge may impact 30-day readmission rates. Use of a MedRec model incorporating communication, education, and medication optimization early after discharge improves HF care.
372 Heart Failure Database Variables Most Frequently Recorded during Followup at Specialist Heart Failure Outpatient Visits in the Canadian Heart Failure Network (CHN) Malcolm Arnold1, Andrew Ignaszewski2, Peter Liu3, Marie Helene LeBlanc4, Jonathan Howlett5, Anne Marie Kaan2, Gordon Marchiori1; 1University Hospital, London, Canada; 2St Paul’s Hospital, Vancouver, Canada; 3University Health Network, Toronto, Canada; 4Quebec Heart and Lung Institute, Quebec City, Canada; 5Foothills Hospital, Calgary, Canada Introduction: Outpatient heart failure clinics have proliferated over the last decade based on early studies showing additional benefit for patients. Many models exist depending on local staffing and resources, both of which can vary considerably. Recommendations for establishing and maintaining a heart failure clinic have been published recently by the HFSA but there is little information on which data are most commonly collected by existing clinics. The Canadian Heart Failure Network (CHFN) links 28 member clinics across Canada through a common longitudinal database of 17,942 patients since 1998. While the database provides a construct, each clinic can also choose data fields they wish to collect for the clinical management of their patients. Hypothesis and Methods: We wished to determine which data are collected most often and therefore reflect the clinical priorities of these heart failure clinics. The database was analyzed by identifying major clinical data groupings and then ranking the frequency order of only the top five variables (#1 reflects the most frequently recorded) for the recent years 2004e2009. Rank Order
1
2
Comorbidities HF, year of Etiology onset Physical SBP, sitting DBP, sitting Exam. & standing & standing Actions Blood work Medication change Test Results Creatinine Serum clearance potassium Change since NYHA class Fatigue last visit
3
4
5
Smoking Hypertension Diabetes Weight
Heart rate
EKG
ECHO
Weight change Chest X Ray
Serum Serum LVEF sodium creatinine Dyspnea Hospital Orthopnea admission
HF, heart failure; EKG, electrocardiogram; ECHO, echocardiogram; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association Conclusion: In patient data collected in heart failure clinics of the CHFN over the last six years, the clinic physicians and nurses prioritized clinical history and widely available tests, from over 150 data field options, in their assessment of outpatients. While more sophisticated tests are helpful and necessary for select patients, heart failure databases might be expanded to non-specialists and primary care using a simple but informative smaller core data set that includes the most frequently collected data representative of specialist heart failure outpatient clinics.
373 Beta-Blocker Pretreatment Does Not Affect the Renoprotective Effects of LowDose Dopamine in Patients with Acute Decompensated Heart Failure G. Giamouzis1,2, J. Butler2, R.C. Starling3, G. Karayannis1, D. Rovithis1, C. Parisis1, J. Nastas4, T. Tsaknakis4, J. Skoularigis1, F. Triposkiadis1; 1Larissa University Hospital, Larissa, Greece; 2Emory University Hospital, Atlanta, GA; 3Cleveland Clinic Foundation, Cleveland, OH; 4Volos General Hospital, Volos, Greece Background: Recent studies suggest that low-dose dopamine (3 to 5 mg. kg-1. min-1) decreases renal vascular resistance and promotes an increase in renal blood flow in patients with acute decompensated heart failure (ADHF). Whether these beneficial effects are attenuated if pretreated with a beta-blocker (BB) is not known. Methods: Forty one consecutive ADHF patients (75.8 6 11.1 years; 56.1% female; EF 36.5 6 13.0%) received either
TD CI O 2.2 L/min/m2
TD CI ! 2.2 L/min/m2
25 (27%) 8 (15%)
6 (11%) 26 (47%)
*for table, p 5 0.0005 by Chi-Square By either FK or TD, 40 patients had CI ! 2.2 L/min/m2. Using FK as the reference standard, 34 patients had CI ! 2.2 L/min/m2. FK and TD agreed in only 26 (65%) of these 34 patients. Use of TD alone would have misidentified 8 patients as having CI O 2.2 L/min/m2 and 6 patients as having CI ! 2.2 L/min/m2. In a subset of patients, contrast injection through the right atrial port (RAP) of the pulmonary artery catheter (PAC) just after TD determination demonstrated frequent RAP positioning in the internal jugular vein (internal jugular vein approach) or inferior vena cava (femoral vein approach).Conclusions: 1) In AHF patients, TD and FK CI have only a modest correlation of 0.4. 2) TD misidentifies 26% of patients using FK CI ! 2.2 L/min/m2 as the reference standard. 2) Compared to FK, TD may misidentify CI as either greater than or less than 2.2 L/min/m2. 3) The PAC RAP may not be positioned in the right atrium in some AHF patients during RHC, leading to inaccurate TD results.
370 Stroke in Children with Myocarditis: Does Anticoagulation Regimen Matter? Kimberly Lin1, Basavaraj Kerur2, Char Witmer1, Lauren Beslow1, Rebecca Ichord1, Beth Kaufman1; 1Pediatrics, Children’s Hospital of Philadelphia, Philadelphia; 2 Pediatrics, Albert Einstein M.C., Philadelphia Currently no guidelines exist regarding anticoagulation for children with myocarditis. Due to inflammation and stasis of blood in a poorly functioning heart, children with myocarditis may be at increased risk for intracardiac thrombus formation and complications including stroke. Methods: Medical records for all pts admitted to a single center pediatric cardiac intensive care unit (CICU) with newly diagnosed myocarditis from 1995-2008 were reviewed. The incidence and potential risk factors for thrombotic events (TE) including intracardiac clots were assessed. Results: We identified 30 children with myocarditis, 53% male, median age 2.2 (IQR 0.9e10.4) yrs. Myocarditis was diagnosed by endomyocardial biopsy (40%), cardiac dysfunction and viral PCR detection (23%), or high clinical suspicion (37%). Twelve (41%) required ECMO, 9 had CPR. All pts received IVIG. Length of stay in intensive care was 14 (IQR 7e21) days. Echocardiogram on admission had shortening fraction (SF) of 15.5 6 8% and left ventricular end diastolic (LVED) Z score 3.40 6 1.9. All 30 survived to hospital discharge. Anticoagulation therapy and time from admission to initiation varied for the 30 pts: therapeutic heparin (goal PTT 60-80 sec) in 8 (44%) non ECMO pts initiated at 4.1 6 3 days, low dose heparin (10 units/kg/min without PTT measurement) in 15 (50%) pts at 3.6 6 11 days, enoxaparin in 2 pts at 11.0 6 11 days, warfarin in 2 pts at 17.5 6 10 days, and aspirin in 16 pts (53%) at 13.81 6 10 days post CICU admission. Pts could have O1 regimen during the hospital stay. No differences were detected between pts prescribed different anticoagulation regimens (except all pts received heparin on ECMO). Two pts (7%) had thrombotic events during initial CICU admission. Neither pt was on ECMO, experienced CPR, or arrhythmia. Case 1: Asymptomatic LV thrombus detected via echo on CICU day #10, SF 21%, on low dose heparin at time of TE. Case 2: Stroke on CICU day #4, SF 19%, on no anticoagulation at time of stroke. No thrombotic events occurred in the 12 pts (40%) not treated with therapeutic heparin, enoxaparin, or warfarin at any time during CICU stay. Conclusions: Variation exists regarding the use of prophylactic anticoagulation in pediatric myocarditis. Thrombotic events occurred in 7% of pts and may have been preventable. The risk vs. benefit of prophylactic anticoagulation and choice of therapy in children critically ill with myocarditis requires systematic investigation.
371 SERIOUS Medication Reconciliation Clinic: Improving Transitions of Care Sherry LaForest1, Julie Gee2, Adam Pugacz1, Julio Barcena2, Danielle Hoover3, Aubrey Guthrie1, Sharon Sabatka1, Catherine Ortiz1, William Salem1, Jose Ortiz2; 1 Pharmacy Department, Cleveland VA Medical Center, Cleveland, OH; 2 Cardiology Division, Cleveland VA Medical Center, Cleveland, OH; 3VA National Center for Patient Safety, Ann Arbor, MI Hypothesis: Early follow-up for patients discharged after a HF exacerbation using the ‘‘SERIOUS’’ medication reconciliation (MedRec) model improves care. Methods: Heart failure patients attended a clinic staffed by pharmacists and a nurse practitioner (NP). The goal was to see patients within 7e10 days of discharge. Patients were asked to bring all medication bottles. MedRec was performed using the ‘‘SERIOUS’’ model developed by the Cleveland VA. Components of the model are: to solicit, examine, reconcile, inform, optimize, update, and share the medication regimen. A pharmacist reviewed medications and made initial recommendations for changes. If a patient was symptomatic, experienced a weight change, or had abnormal vital signs, the NP examined the patient and further
optimized the regimen. A templated note standardized the approach to care. Education included medications, daily weights, low sodium diet, recognition of symptoms, and contact information if symptoms or weight change occurred. Self-care tools including weight logs, scales, BP cuffs and pill boxes were given. An updated medication list was printed. All patients were given a follow-up appointment. Results: Between March 2008 and December 2009, 122 patients were seen. Most patients (61%, n 5 74) were referred following a HF hospitalization. The mean age in the post-discharge cohort was 69 years. Left ventricular systolic dysfunction (EF 40%) was present in 50% of patients. Patients were seen a median of 9 days after discharge. All patients had access to medications through the VA. Of the 74 post-discharge patients, 64% had medication errors identified during MedRec. The mean number of prescriptions (including diabetic supplies, over-thecounter products, topical agents) was 18. Medication regimens were optimized in 57% of patients. The 30-day all-cause readmission rate in this cohort was 8%. The Cleveland VA 30-day readmission rate was 19% in 2008. Conclusion: A substantial number of patients make medication errors following hospital discharge, in spite of discharge education. Systems encouraging early follow-up and MedRec post-discharge may impact 30-day readmission rates. Use of a MedRec model incorporating communication, education, and medication optimization early after discharge improves HF care.
372 Heart Failure Database Variables Most Frequently Recorded during Followup at Specialist Heart Failure Outpatient Visits in the Canadian Heart Failure Network (CHN) Malcolm Arnold1, Andrew Ignaszewski2, Peter Liu3, Marie Helene LeBlanc4, Jonathan Howlett5, Anne Marie Kaan2, Gordon Marchiori1; 1University Hospital, London, Canada; 2St Paul’s Hospital, Vancouver, Canada; 3University Health Network, Toronto, Canada; 4Quebec Heart and Lung Institute, Quebec City, Canada; 5Foothills Hospital, Calgary, Canada Introduction: Outpatient heart failure clinics have proliferated over the last decade based on early studies showing additional benefit for patients. Many models exist depending on local staffing and resources, both of which can vary considerably. Recommendations for establishing and maintaining a heart failure clinic have been published recently by the HFSA but there is little information on which data are most commonly collected by existing clinics. The Canadian Heart Failure Network (CHFN) links 28 member clinics across Canada through a common longitudinal database of 17,942 patients since 1998. While the database provides a construct, each clinic can also choose data fields they wish to collect for the clinical management of their patients. Hypothesis and Methods: We wished to determine which data are collected most often and therefore reflect the clinical priorities of these heart failure clinics. The database was analyzed by identifying major clinical data groupings and then ranking the frequency order of only the top five variables (#1 reflects the most frequently recorded) for the recent years 2004e2009. Rank Order
1
2
Comorbidities HF, year of Etiology onset Physical SBP, sitting DBP, sitting Exam. & standing & standing Actions Blood work Medication change Test Results Creatinine Serum clearance potassium Change since NYHA class Fatigue last visit
3
4
5
Smoking Hypertension Diabetes Weight
Heart rate
EKG
ECHO
Weight change Chest X Ray
Serum Serum LVEF sodium creatinine Dyspnea Hospital Orthopnea admission
HF, heart failure; EKG, electrocardiogram; ECHO, echocardiogram; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association Conclusion: In patient data collected in heart failure clinics of the CHFN over the last six years, the clinic physicians and nurses prioritized clinical history and widely available tests, from over 150 data field options, in their assessment of outpatients. While more sophisticated tests are helpful and necessary for select patients, heart failure databases might be expanded to non-specialists and primary care using a simple but informative smaller core data set that includes the most frequently collected data representative of specialist heart failure outpatient clinics.
373 Beta-Blocker Pretreatment Does Not Affect the Renoprotective Effects of LowDose Dopamine in Patients with Acute Decompensated Heart Failure G. Giamouzis1,2, J. Butler2, R.C. Starling3, G. Karayannis1, D. Rovithis1, C. Parisis1, J. Nastas4, T. Tsaknakis4, J. Skoularigis1, F. Triposkiadis1; 1Larissa University Hospital, Larissa, Greece; 2Emory University Hospital, Atlanta, GA; 3Cleveland Clinic Foundation, Cleveland, OH; 4Volos General Hospital, Volos, Greece Background: Recent studies suggest that low-dose dopamine (3 to 5 mg. kg-1. min-1) decreases renal vascular resistance and promotes an increase in renal blood flow in patients with acute decompensated heart failure (ADHF). Whether these beneficial effects are attenuated if pretreated with a beta-blocker (BB) is not known. Methods: Forty one consecutive ADHF patients (75.8 6 11.1 years; 56.1% female; EF 36.5 6 13.0%) received either